Merging, de-merging, and emerging at Deaconess Billings Clinic

Complexity theory offers a powerful model for effective mergers of health care organizations that differs substantially from customary approaches. Exploring how Deaconess Billings Clinic in Montana evolved from two separate and very different cultures provides insight into how organizations can apply a complex adaptive system (CAS) model of mergers to create more truly integrated health care systems. DBC's merger illustrates the phenomenon of emergence in complex systems, whereby structures arise that are not a synthesis of the pre-existing cultures or the result of a new culture being imposed. Instead, the merger is understood as an ongoing, self-organizing process appropriately characterized by fits and starts, feelings of uncertainty, and other natural challenges of change and growth. By squarely surfacing the distinct cultures of the organizations through abundant interaction, relationship building, and information flow, differences can be creatively transformed, resulting in deep-seated change and the emergence of a genuine, shared health care system culture.     

The Impact of Labour-Force Participation on Childbearing Behaviour: Pro-Cyclical Fertility in Sweden during the 1980s and the 1990s

During the last two decades, Sweden has experienced strong fluctuations both in its economy and in its level of childbearing. A period of high employment and increasing fertility has been followed by a period of lower employment and decreasing fertility since the beginning of the 1990s. In this paper, we use register data for Swedish women in order to examine how various types of attachment to the labour market affect women's propensity to give birth at different parities. Specifically, we show what impact changes in women's employment status have had on recorded fertility trends in Sweden. We find that women who have relatively low levels of income and women who are enrolled as students generally have lower fertility than other women. We also find that a rise in the number of women with such characteristics can explain part of the decrease in fertility during the 1990s. It is evident, however, that other factors, working at the macro level, also have to be considered when one wants to explain the fluctuating fertility of Sweden. Social policy is one such factor. In sum, we find a pattern of pro-cyclical fertility, where levels of female earnings are positively related to levels of childbearing.