We just published an interview: Dean Spears on why babies are born small in Uttar Pradesh, and how to save their lives. Listen on Spotify or click through for other audio options, the transcript, and related links. Below are the episode summary and some key excerpts.

Episode summary

I work in a place called Uttar Pradesh, which is a state in India with 240 million people. One in every 33 people in the whole world lives in Uttar Pradesh. It would be the fifth largest country if it were its own country. And if it were its own country, you’d probably know about its human development challenges, because it would have the highest neonatal mortality rate of any country except for South Sudan and Pakistan. Forty percent of children there are stunted. Only two-thirds of women are literate. So Uttar Pradesh is a place where there are lots of health challenges.

And then even within that, we’re working in a district called Bahraich, where about 4 million people live. So even that district of Uttar Pradesh is the size of a country, and if it were its own country, it would have a higher neonatal mortality rate than any other country. In other words, babies born in Bahraich district are more likely to die in their first month of life than babies born in any country around the world.

- Dean Spears

In today’s episode, host Luisa Rodriguez speaks to Dean Spears — associate professor of economics at the University of Texas at Austin and founding director of r.i.c.e. — about his experience implementing a surprisingly low-tech but highly cost-effective kangaroo mother care programme in Uttar Pradesh, India to save the lives of vulnerable newborn infants.

They cover:

• The shockingly high neonatal mortality rates in Uttar Pradesh, India, and how social inequality and gender dynamics contribute to poor health outcomes for both mothers and babies.
• The remarkable benefits for vulnerable newborns that come from skin-to-skin contact and breastfeeding support.
• The challenges and opportunities that come with working with a government hospital to implement new, evidence-based programmes.
• How the currently small programme might be scaled up to save more newborns’ lives in other regions of Uttar Pradesh and beyond.
• How targeted health interventions stack up against direct cash transfers.
• Plus, a sneak peak into Dean’s new book, which explores the looming global population peak that’s expected around 2080, and the consequences of global depopulation.
• And much more.

Producer and editor: Keiran Harris
Audio engineering lead: Ben Cordell
Technical editing: Simon Monsour, Milo McGuire, and Dominic Armstrong
Additional content editing: Katy Moore and Luisa Rodriguez
Transcriptions: Katy Moore

Highlights

Why neonatal mortality is so high in Uttar Pradesh

Dean Spears: So neonatal mortality comes from largely being low birthweight, and underweight babies largely come from underweight moms. And in this district where we work, about a third of the moms are underweight, in the sense of having a body mass index below 18.5.

So why are moms underweight? Well, some of the reasons that moms in Uttar Pradesh are underweight are the reasons that sort of everybody in Uttar Pradesh has worse net nutrition than they might, such as the disease environment and poor sanitation. So moms and babies and dads all sort of live in a place where sanitation — and yes, there’s still open defecation here — means that people are exposed to germs that use up their nutrition, that sap their nutrition and their energy through diarrhoeal disease, or just fighting infections. But it’s not just the poor sanitation and disease environment that’s causing so many moms to be underweight. Very importantly, it’s also social forces like gender inequality and the moms being socially low-ranking people.

So mothers in India tend to have their babies at younger ages. Unlike in, for example, sub-Saharan Africa, where childbearing careers are more spread out in age, a lot of the babies in India are born to moms in their early 20s. And that’s a time where women in India tend to be particularly likely to be underweight.

You might just be thinking it’s a poor country, and that’s why there’s undernutrition. But there’s more undernutrition in India amongst women of childbearing age than in, for example, sub-Saharan Africa or the rest of the developing world. And what we see in India is this distinctive pattern where, especially in a place like Uttar Pradesh, the youngest women in their early 20s are particularly likely to be underweight. And as they get older, gain more social status, have children, they become less likely to be underweight. So the likelihood that a woman is underweight falls in age in a way that we just don’t see in the same way in the rest of the developing world. So India has this double challenge, where mothers tend to have babies young and that’s when they tend to be underweight.

Luisa Rodriguez: Right. And why is it that this is happening in India and not in countries in sub-Saharan Africa, for example?

Dean Spears: I think a very big reason is social status and women’s status in the sort of hierarchy that you find, especially in traditional households. Not all households are like this, but let’s zoom in on a special case that it’s easy to learn from, which is joint households.

So Diane Coffey and Reetika Khera and I wrote a statistical paper about learning from joint households: where you have two brothers, they grew up together into adults, they got married, and they all lived together. So in a household like this, the wife of the older brother is socially higher ranking than the wife of the younger brother. And the wife of the younger brother, the lower-ranking daughter-in-law, is expected to do more work for the family, and is later in line for getting the food she needs to eat, even during pregnancy.

So that’s a situation where we can see an effect of a difference in women’s social status, even comparing cousins — their kids who live in the same family, live in the same house, live in the same village, so a lot of things would be held constant. So what do we see? Well, we do see that the lower-ranking daughters-in-law are thinner, and that’s even though they have the same height. And so it’s not about their early life nutrition; it’s about what happens to them in adulthood.

It’s like we have a little experiment here. We can look in these families as petri dishes to see, holding these other things constant, what’s the effect of mom being underweight for these social reasons? So what is the effect? Well, we see that the children of the lower-ranking daughter-in-law are more likely to die neonatal deaths. And we see that they’re more likely to be stunted and small in other ways. So in a situation where we’re pretty sure that the difference in maternal nutrition is coming from these social forces, we’re seeing it all the way through into neonatal mortality.

Evidence of KMC's effectiveness

Dean Spears: So there was a 2021 study in The New England Journal of Medicine that was the iKMC programme, or the immediate KMC programme. And basically what they were studying was the benefits of doing kangaroo mother care even sooner than it might otherwise happen. So it’s not like kangaroo mother care versus nothing; it’s kangaroo mother care versus conventional care in a radiant warmer machine.

So the control group in this study was still in a hospital, still under medical supervision, and was in a radiant warmer. And then the treatment in this iKMC study was KMC: skin-to-skin contact on the mother’s chest and all of that. And it’s in poor countries. They did it in five hospitals: four in Africa, and one that I would consider to be a relatively privileged public hospital in India because it’s in Delhi. It is in this context. What they found is that there was less neonatal death amongst the babies who got immediate KMC than amongst the babies who got conventional care — even with radiant warmers and machines and medical care.

This is so good that it’s at least holding its own against conventional care with the radiant warmer. In fact, they stopped the trial; they decided that we couldn’t ethically continue doing this experiment because the KMC was so good. And even in developed countries where there are lots of resources, a lot of the conversation right now is, “Let’s, at least for a little bit, take the baby out of the incubator or the radiant warmer and put it on mom’s chest for a little while.”

Now, I’m not a medical professor. I’m an economics professor. I’m a social scientist. And what I think is interesting, and what an economics professor can talk about, is why wasn’t this thing happening before? And how do we understand the social science of making it happen and getting families involved? But if you look at what the medical literature says, they wouldn’t be surprised that this is helping, because that’s what they find when they look at experiments for this. And the frontier that they’re asking about is: is this maybe even better than conventional care in some cases?

So, amongst the babies in this programme, 11% of them die neonatal deaths. It is possible to do better than that, and 11% is a lot better than what would have been likely to happen otherwise. So this doesn’t mean that the project of neonatal health care is done forever, but it means that we have something wonderful available, if it can be organised and brought to the babies who need it.

How cost-effective is KMC?

Dean Spears: Yeah, let’s talk about that cost-effectiveness number. The highly cost-effective things that you might be familiar with include maybe giving out insecticide-treated bed nets to save lives against malaria. And one of those nets I think costs on the order of $5. But if you give out a lot of them, then the low probability of saving a life for each one all works out that you can save a life for something in the low thousands, right?

This is a different way of getting to a cost-effectiveness number in that ballpark. It costs our programme about $5,000 a week to run. That’s the cost of staffing and management and some supplies. So when we did our cost-effectiveness computations, at that time, we were able to have about 11.5 babies a week passing through the programme. That works out to $430 per baby of average cost. So the average cost of the programme when we did the cost-effectiveness calculation is $430 per baby.

Now, how you get from that number to a cost per life saved depends on how many lives the programme is saving. Here is one sort of really basic way to think about it: a plausible bound for saving lives is that is one in 10: a 10-percentage-point difference in neonatal mortality, like on the order of one in 10 lives are being saved. I actually think it’s better than that, but that’s going to make the math easier. And a plausible bound for the cost is in the hundreds of dollars per baby. So hundreds of dollars of cost per baby times one in 10 lives saved gets you a cost in the low thousands of dollars per life saved. And that’s basically the whole story of the cost effectiveness.

But going forward, the programme is helping more babies than 11.5 per week. So that means a few things. It means that there’s an opportunity to put more funding to good use in order to really reach all of the babies who are appearing. Babies from the smaller clinics are coming instead, we’re catching more of them that pass through. We’re persuading more families to stay instead of leaving. For all of these reasons, more babies are coming. So that means we need more nurses.

Now, the good news is, in economics we have average costs and marginal costs. The average cost is the average cost per baby — that’s that $430 number that I said before. The marginal cost is the extra cost of reaching another baby. And this is a programme where there are lots of scale effects. Once we have a manager who is organising the shifts of which nurse is on home visits and which nurse is on the overnight shift — and believe me, this is a big and thankless task — but once we have that nurse doing it, that is done. So the marginal cost of helping another baby, we don’t have to hire another person to do the scheduling, so chances are the marginal cost of helping more babies is even lower than that $430 average cost.

And so we’re in a situation where, on the one hand, because the programme is successful in attracting more demand, and doing a better job of finding the babies that can be helped, we’re able to help more babies than we thought would be the case. On the other hand, we’re probably helping or treating the marginal baby for less expensively than the average baby.

So that means there’s a real opportunity here to cost effectively save lives. So if a listener out there is eager to find a way to make a cost-effective, life-saving donation in a place where there is an opportunity to absorb the funding and put it to good use, riceinstitute.org — and we think we have that right here.

Is KMC better than direct cash transfers?

Luisa Rodriguez: So we interviewed Paul Niehaus last year about the organisation he cofounded, GiveDirectly, and he made the case that, in many cases, global health and development is better served by people just directly giving people cash, rather than trying to figure out how to deliver a specific programme to them. Why do you think that is not the case here?

Dean Spears: First off, I think he’s right that that is probably often the case. So I don’t disagree with him in any sort of big-picture way. In this case, it goes back to the fact that healthcare involves a lot of market failures.

The idea behind giving someone cash is that then they’re going to be the customers who can go out and make sure they’re getting a good product, and getting the product that’s actually valuable for them. But there’s no real way you could take the $430 that on average this programme is spending per baby, and buy something like this in the market. The private providers here aren’t providing this quality of care, or even a very high-quality of care at all: babies born in private facilities in Uttar Pradesh are actually more likely to die than babies born in public facilities in Uttar Pradesh, even though their families are better off. And then there’s just the well-known market failures of, do the parents know that they need this?

So yes, it probably is true that in a lot of cases, giving cash is a good idea — but it’s not going to provide this outcome of neonatal survival. This is a case where there’s a special opportunity of these moderately underweight babies — not the very most underweight babies, but these moderately underweight babies — where this sort of intervention of low-cost neonatal care can save their lives. But it’s not going to happen if it doesn’t happen in an organised way.