Health care at birth and infant mortality: evidence from nighttime deliveries in Nigeria

High rates of home births in developing countries are often linked to high rates of newborn deaths, but there is considerable debate about how much of this is causal. This paper weighs in on this question by analyzing data on the timing of birth, health care utilization, and mortality for a sample of births in 7,021 rural Nigerian households occurring between 2009 and 2014. First, we show that timing of birth is strongly linked to use of institutional care: women with a nighttime birth are significantly less likely to use a health facility because of the difficulties associated with accessing care at night. In turn, this is associated with a sharp increase in the rate of newborn mortality at night. Leveraging variation in household proximity to a health care facility that offers 24-hour coverage, we show that this increase in mortality is plausibly due to lack of formal health care at the time of birth: infants born at night to households without a nearby health care facility that offers 24-hour coverage, experience an increase in mortality equivalent to about 10 additional newborn deaths per 1,000 live births. In contrast, when households have a nearby health facility that provides care at night, there is no detectable increase in mortality. These results suggest that well-designed policies to increase access to (and quality of) formal care at birth will likely to lead to significant reductions in newborn deaths.