Russ Roberts

Emily Oster on Infant Mortality

EconTalk Episode with Emily Oster
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Emily Oster of the University of Chicago talks with EconTalk host Russ Roberts about why U.S. infant mortality is twice that in Finland and high relative to the rest of the world, given high income levels in the United States. The conversation explores the roles of measurement and definition along with culture to understand the causes of infant mortality in the United States and how it might be improved.

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0:33Intro. [Recording date: November 11, 2014.] Russ: Our topic for today is a paper you've coauthored with Alice Chen and Heidi Williams on infant mortality. In particular you are looking at why the United States higher rates of infant mortality than many European countries. And I thought it would be interesting to talk about this particular issue, which I'm very interested in, in itself; but I'm also interested in the general question of how we use health data to evaluate public policy and think about ways to make things better. So, I hope we'll get into those issues as well in today's episode. Let's start with what is to be explained. What kind of differences are we talking about, between the United States and Europe? Guest: They're very large. If you look at the baseline, like what is the World Development Indicator (WDI) say are the differences in infant mortality rates, the United States ranks something like 50th internationally. And the difference between the United States and a frontier country like Finland or Sweden is something like 3 deaths in 1000. So, the infant mortality rate in the United States is about 6 in 1000; in these other places it's about 3. And you know, if you think about that, that amounts to something like 12,000 excess deaths a year, among live-born infants, so that's a reasonably large number. It's certainly very large as a share. Russ: Right. It's double, which seems like a very large number. Three seems small; 12,000 seems horrible. Right? So it is an interesting example in itself of the challenges of trying to assess what's big and small. But I think the 100% part--the fact that our U.S. rate is double that of, say, Finland, is surprising and interesting to think about. Guest: Yeah. I think that's a lot of how people have thought of it. On the one hand, the good news is that in all of these places, the infant mortality rate is very low relative to historical norms or relative to developing countries. On the other hand, clearly there's a long way to go; there are many places, most of Europe, even places outside of there, which are doing much, much better than the United States in this dimension. There's no particular reason that we think that should have to be. Russ: And to put it into historical perspective, the number I have used in the past for infant mortality in 1900--and infant mortality, we're going to get into the definition, but usually when you just say 'infant mortality' it's death within the first year of life. In 1900, the data I have seen says it was 1 in 10; and now it's about .5 per 100, or 6 per thousand. So, it's about a 20-fold improvement in the last century. Guest: Yeah. That sounds right. Those changes should not be forgotten. There's enormous amounts of progress that have been made on this dimension, and I think that's really wonderful. Russ: So, let's start just the fact itself. Which seems like a fact, but of course all facts have context and there's issues of measurement and definition. So, how is infant mortality defined in the data that is usually used that we're talking about at the national level--say, 6 per 1000, 2 or 3 per 1000 in, say, Scandinavia? What is the definition? Guest: The definition is deaths in the first year among live-born infants. So, that is the definition. And when you see numbers that are reported by the World Development Indicators, or the CIA (Central Intelligence Agency) has some numbers, that's the number that you're going to get. And that's reported by the country. And so one of the issues that I think often comes up, that we talk about in the paper, is that how you define a live-born infant actually varies. And so, in particular, human gestation is intended to be approximately 40 weeks; infants born before 22 weeks effectively never survive. But there is a lot of variation across countries in whether you ever report infants born in that earlier period, before 22, as live births; and those kind of reporting issues actually do potentially bias some of these comparisons. So, because if you report any live births from that period, there are certainly going to--that is going to count as a death. You can inflate the numbers. So, the first thing we do in the paper, which is sort of possible because of the kind of data that we have, is limit to what we think of as a comparable sample were kind of all of the countries are reporting infants in that range as live births. And that actually turns out to make some difference. So, the difference between the United States and the comparison countries we use--which are Finland and Austria--shrinks from 3 to 2 deaths per 1000, once you adjust for these differences in reporting. So that's certainly something to start thinking about. Russ: I want to come back to that. But just to make it clear, when you say the difference shrinks from 3 to 2: so, right now, the raw difference is 6 per 1000 in the United States versus 3 per 1000 in, say, Finland; so that's a difference of 3. And a third of that difference is data-driven, is what you are saying. Guest: Exactly. A third of that difference is reporting [?]. Russ: Before we get to that, we should give listeners some feel for the range outside of the developed world. There are countries tragically with infant mortality rates over 100 per 1000, still, correct? That's the equivalent of a 1900s-level of infant mortality. Guest: Yeah. There are certainly places like that. Afghanistan would be in this category; some countries in Africa. If you take a country like India, which is of course very large, they report infant mortality rates something like 40 in 1000, so it's still very big; and then this goes all the way down to about 2 in the places that are doing the best, which would be like Sweden, maybe Japan. Russ: But I'm thinking, when you talk about the definition and how live birth is defined, in some countries, particularly the poor countries, I assume there's variation in a pre-term infant, whether it's defined as a live birth or now. Guest: Yeah, I think so. And the truth is, in these developing countries where these rates are so high, those differences are not going to be very important in this scheme of the overall level. So, part of what makes these reporting differences potentially important when you are comparing, say, the United States to Europe, is that already the rates are pretty low. And so things that kind of matter a little bit are going to matter relatively more as a share. When you are talking about a place that has an infant mortality rate of 150 per 1000, small differences in reporting are going to be vanishing in the scheme of those comparisons. Russ: Right. But I do want to mention, in my quick look at the data, there is improvement in the last 5 years, even in those poor countries. Guest: Yes. All of this has been getting better, much, much better over time; and I think that that's a function of better health care and more vaccinations, some better sanitation, and other policies. And so I think things have really been improving. Which is, again: broadly this problem is getting better, which is very encouraging. Russ: One of the challenges of thinking about this is there are specific things, like you just mentioned: sanitation, health care. But my first thought, stepping back from this is that resources generally are really important per capita. Some measure of standard of living is going to be extremely important. And that exactly is why it's such a puzzle that the United States, which is a very rich nation, still is twice the rate of, say, Finland. Guest: Yeah. In general, like almost everything, this is going to line up with income. And it broadly does line up with income. And it is puzzling that the United States is down, like next to Croatia, even though the United States is much richer than Croatia. Russ: About 3 times, if I remember correctly from your paper. Guest: About 3 times.
9:41Russ: So, let's talk about some definitions and a little bit about how data get collected in this area. So, when you talk about the World Development Indicators, I assume every hospital in the United States has some requirement to report births, deaths; and those numbers get aggregated in some way and then sent to some international source; and that's where we get the 6 from. Is that correct? Guest: Yeah, that's correct. So these are going to come, in the United States, from what are called the Natality Detail Files, which are collected and reported by the CDC (Center for Disease Control), so they are basically like short-form birth certificate data: you can actually see, not people's names and addresses, but for each birth you see the characteristics of the birth--things that happened: the gestation, the birth weight, and so on. And then that's linked to deaths in the first year. So that's like a nationally available, nationally curated data set. And that is how--those are the numbers that will then be reported as international statistics for the United States. Russ: So, that's the birth side--and that word in there was 'natality,' correct? N-a-t-a. Guest: Natality. Correct. Russ: It's a tough word--don't use it that often in everyday conversation. Guest: Yeah, it doesn't come up. Russ: But that's the birth side. How do we know that a child--if an infant dies, tragically, in the hospital, that gets counted pretty straight-forwardly, I assume. Or if it's born and doesn't survive the delivery, again there's a question about whether it was a live birth or not, depending on how many weeks it was, maybe. But an infant that dies at 6 months or 11 months, how does that get into the data? Guest: So, there are mortality reporting files in the United States, also. And so deaths get reported in the same kind of systemized way. And then in the back room somewhere at the CDC these things get linked. So, you can actually get access to the birth data linked to the information on death, including the recorded cause of death and the standard stuff that would be on a death certificate. Russ: And that's going on in every country. Guest: Well, that's going on in many developed countries. Let's put it that way. Russ: Okay. Why do you say 'many'? Guest: So, as part of this project actually we tried to get this equivalent data for as many countries as we could. And we got some. I think some of them are, like, not sort of linking this in quite the same way, such that you could use it like this. But some version of this where you are recording births and you are recording deaths, some version is happening in all developed countries, for sure. Russ: What's not happening that would make it hard to use? You say it's not happening in every country: What's going on? Guest: I think in many poor countries, births and deaths are not reported in a consistent way, and so these numbers for mortality are taken from smaller field surveys or from estimates from parts of the population, or from various kinds of inference. And I think there it's very complicated. Even in developed countries, there's no particular reason that you need to have the micro individual birth data linked to individual death data except for research purposes. And so I think in many countries that doesn't happen. Russ: Okay. So let's go to your data. You have a different kind of data. You call it 'micro data.' Describe it and, what are its advantages? Guest: So, we've got this data that I described for the United States, where we see every birth. We're looking at 2000-2005, so we see every birth linked to information about death in the first year, if the infant died. And then we have effectively the same data from Finland and Austria. So it's every birth linked to information about the birth, the birth weight, the gestation, some things about the mother; and then also linked to information about deaths in the first year, including exactly at what age the infant died and some information on cause of death. So we have quite a rich and comparable data set across all three places. Russ: Why did you choose those three? Guest: So, the truth is that we actually tried to get this data from every place that we could. So, we knew we had this from the United States--this is very commonly used. For the European countries we basically just mass called and emailed all the European countries in an attempt to get this, and these are the two that worked out. We also have some data from the United Kingdom and from Belgium, where it's a little more aggregated, so we can't do quite the same analysis, but we can do some of our analyses there. It turns out, I think--these are good comparison countries because Finland is in this frontier of places that are doing really, really well; and Austria is kind of right in the middle of the U.S. distribution, but I can't say that we did this in some way that was that well thought out. Russ: No, you took what you got. Which is fine.
14:56Russ: And let's talk about the other data that's in there, besides births and deaths. So, you have information about the mother. Is this a sample? Or is this purporting to be exhaustive. Guest: This is the universe. This is purporting to be exhaustive. Russ: So, when my wife gave birth, the hospital had a bunch of information about her. What kind of information would they have? And obviously when the baby is born they do a bunch of tests. The baby is weighed. The height, length--it's not really height because they are not standing up, but it's the length of the baby. There's Apgar scores, which--you should describe what those are. And what other stuff do we get, that's required? Guest: Yes. We have everything. So, an Apgar score is the most commonly used measure of just how is the baby doing at birth. It's on a scale from 1 to 10--or 0 to 10, I guess. And so, like, a 9 would be the sort of standard--like, everything is looking good kind of score. So that's the kind of summary of how well the baby is breathing and so on. So, we see that. We see the weight, the length. We see the gestation. We see a bunch of information about complications of labor and delivery and complications of the baby. So if the baby has a birth defect, that's recorded. A heart problem or Down's Syndrome, that goes in this data. If the labor was very fast or very slow or there was a C-section (Caesarean section), all of that stuff goes in the data. So it's quite a rich set of information about the circumstances of the birth and characteristics of the infant. Russ: What do you know about the mom? Or the dad? Guest: We know that--we know some. We know the education; we know their race; we know their birth country. Obviously we know the location of the birth and the location of residence. And assuming that there's a father around, his education is also recorded, and marital status, and that type of thing. So, what you think of as sort of basic demographic information. Russ: How do you get the education? Where does that education number come from? Because that's important, obviously. Guest: So, these is all in these natality files, and is I think intended to be reported in this monoform[?] birth certificate information. I mean, I remember being asked--when I had my daughter, I remember being asked at the hospital, like, how much education do you have? Russ: Hmm. I don't remember that. Guest: I remember writing that down. Russ: It's the kind of question I don't like. Guest: A lot of other stuff was going on, so [?] was not--you know, had I not been thinking about this research project it probably would not have been in the front of mind. Russ: Yeah. I just don't remember anything remotely like providing that information. But of course I have health insurance--but not everybody does. I'm just wondering how--you say you have the universe of all births, say, in the United States, say in 2000-2005. There must be missing data. Lots of missing data. Guest: I think it's very likely that there are births that are missed. Births are supposed--in order to get a Social Security card and be able to work and be a U.S. citizen you must have a birth certificate. This information is collected as part of the birth certificate. So, like at least some of this information. So, if you are born in a hospital, you are getting this. If you are born at home, you know, you are supposed to get this information; this information is supposed to be collected so then you can get a birth certificate. Now, what is almost certainly true is if there is a birth at home, all of the details about the medical procedures that occurred during the birth and so on are likely to be less well reported. And you know--but basically anything that happens in the hospital, most of the complicated information here would have nothing to do with the individual having to report. It would be reported by the hospital, by the doctor. In that sense. Russ: So, just out of curiosity, do you know what proportion of births are home versus hospital? I assume it's very small, the home births. Guest: Very small. It's like half of one percent. Russ: Okay.
19:22Russ: So, you have that for the United States, you have that for Finland, you have that for Austria. And so you've got a lot of micro-information about the birth that's not in the national numbers that we normally. And now, tell us what you found when you looked more carefully, given that data, about what might explain those differences. Guest: Yes. So, I think we were pretty focused on trying to think about the kind of accounting problem. And we broke it down into kind of four parts. First is this issue of reporting. And so, just kind of limiting to a sample we thought was comparable. The second issue is looking at differences in prematurities. This is an issue that gets a lot of attention in the United States. The United States has a high rate of prematurity, meaning a large share of babies born prior to what we consider a completed gestation. And so we find that both reporting and prematurity matter a fair amount. So, as I said, about a third of this gap between the United States and elsewhere are closed by this reporting issue. And we do find that also, particularly compared to Finland, but also to some extent compared to Austria, the differences in prematurity matter. And [?] the thing that's most interesting, that is most interesting, that is most different from what people have found before, is in these data where it will just separate the neo-natal period--so the very early period after birth, the first week or the first month--from what happened after that. And this distinction is kind of very central, because the things that caused death in those two periods are very different. And what we find is actually, conditional on birth weight, the United States is doing very well early on. So, in the first week or the first month, we're actually doing better than, like Finland, and very, very comparable to Austria. And then when we move from the period of a month to a year of life, when infants are typically at home and a lot of deaths occur in the household in some way, that is the period in which the United States is really lagging behind other countries and really that is like driving a lot of these differences. And I think that was sort of the most surprising thing we say. Russ: Yeah, that's fascinating. I want to come back to that. I want to start with the two issues you just mentioned, you just started with, which are the reporting issue and the prematurity issue. Let's talk about the reporting issue. I'd like to give the listeners a feel for how you actually "controlled for" that. What did you do to your data to take the reporting differences out of the measurement? Guest: So, we did--it's pretty straight-forward. So we did basically three things. We took out infants where the gestational age was less than 22 weeks. We took out infants where the weight at birth was less than 500 grams--because these are kind of standard reporting things. All countries report babies in the categories of later than 22 weeks, larger than 500 grams; and there's variation below that. And we also, in this case we took out singleton births--sorry, we took out plural births. Not so much of issues of reporting but because there are many more of those in the United States, probably due to [?] reproductive technology-- Russ: Yeah. Guest: And so in some sense because those infants are more vulnerable, you would like to compare apples to apples and look at singleton births. So, that's all we did. It was not an especially sophisticated way to approach this. We just took out things we thought where the reporting was not consistent. But what's interesting is that the United States, then, has more deliveries at less than 22 weeks, and more deliveries under 500 grams birth weight. Is that right? Guest: No, that's not so clear. So that's the issue. Because if this is supposed to be recording of live births. So I think the way you want to think about it is, if the infant is born at 20 weeks and kind of moves around a little bit, that will sometimes in the United States get reported as a live birth; but it will not get reported as a live birth in these other places. So it's not--it is possible the United States has more births in that period. But that is not something we can see in the data because we simply are not seeing those observations elsewhere, because they are getting reported as miscarriages. Or stillbirths. Russ: And 500 grams is, according to my crude effort--is that about a pound? Guest: Yeah, it's about a pound. Russ: So that's a tiny--the average birth weight of full term baby is about 7-8 pounds? Guest: It's about 7. Russ: Okay. So that's remarkably small. So, that's the first one. Did we talk about prematurity while I was doing that? Did you talk about, while I was doing my conversion, just that? Guest: We didn't. I mentioned prematurity. Russ: Yeah. Tell me what you did to deal with that. Guest: So, what we do to deal with that is we put in basically adjustments for either gestational week, or in fact what we use is birth weight. So, it turns out birth weight in these data are much better reported than gestational age. Which is not surprising. The way you record gestational age is by asking the woman, like, when was your last period? People don't--this is a hard thing to remember. Birth weight is very precise. It's measured in the hospital and the correlation is obviously very, very, very high. So, we use birth weight. And we basically--one thing is we just look at the comparison across the countries, and we see basically if the United States adopted the birth weight distribution--like magically acquired the birth weight distribution of one of these other countries, but kept the mortality conditional on birth weight the same, how much of the gap would that close? So it's sort of like a counterfactual. Like, if that was the only thing that we changed, how much of a difference would that make? And the answer there is it would close much of the gap with Finland, like 75%; but only about a third, less than a third of the gap with Austria. So, it clearly matters; but it matters a lot more relative to Scandinavia. So, state that again. If the United States--how different is the birth weight distribution? That's what's so surprising, right? Guest: It's interesting. So if you look--we have some graphs in the paper. Which of course are difficult to look at on the podcast; but you can look at them. Russ: We will put a link up to the paper, of course. Guest: Excellent. So check the [?]. One of the things you can see is actually the United States and Austria have really, really, really similar birth weights. The only place they differentiate is a little bit at the very bottom. The United States has a few more babies in the kind of 500-1000 grams, but they're very similar. The big difference is the Finnish babies are much larger than either of the other places. Like, much, much larger. And I don't think there's like not a great explanation for that one. One possibility is just like the Finns are tall and they have giant babies. That's something that's a little hard to tell. But for example they are more than 200 grams heavier on average than babies in the United States. So, that turns out to matter. And they are also--the rates of prematurity are just lower. And that's actually something we know to be true. Like, that's a commonly observed fact that is not very well understood, because we don't know really what causes infants to be born prematurely, which is making it very difficult to understand why it might differ across space. Russ: Right. So, and, you said we don't know very much. Do we know anything? Guest: Basically--we know a few things. So, for example, smoking increases the rate of prematurity. Using drugs like meth, also not good. But beyond those things, that basically--that's it. So, 12% of births or 10% of births in the United States are pre-term. And obviously 10% of women are not smoking or using methamphetamines, and so, you know, there's a tremendous amount of variation and we just have a very, very poor understanding of it. Russ: There's a random component that may be related to other things, but we don't know what they are, is what you are saying. Guest: Exactly. There's some random component; it's probably related to some other stuff. We don't know what it is. This is related to the fact that we don't know what causes women to go into labor in the first place. Or we have only a very poor understanding of that, even at term, full term. We just don't know very much about what are the biological mechanisms that prompt that to happen. Russ: There's not a switch, strangely enough. Guest: There's not a switch. Russ: Or if there is, we don't know where it is. Guest: Yeah. Probably there is, but we haven't figured out how to turn it off or not.
28:33Russ: But we do know--I guess the only thing I know about this--and I assume there's some evidence for it--and of course Emily, in her previous EconTalk appearance was talking about what we know about pregnancy, which is sometimes less than we'd like to know. The thing that I think we know, is that not being active slows it down. At least, women who are at risk of delivering earlier are told to take it easy. Is that--do we know that that actually works? Guest: No, that doesn't work. Russ: They get put on bed rest. Guest: Yeah. That doesn't work. Russ: Bed rest does not work? Guest: No. Bed rest does not work. Russ: How do we know that? Guest: Randomized trials[?]. Russ: Because people--women get put on--I say 'people'--women. Women get put on bed rest all the time. Right? Guest: No, this is one of the like--when we did this earlier, this stuff about pregnancy, this is like a very striking fact. A lot of people are put on bed rest; they think it is increasingly well accepted. Bed rest is definitely not useful for preventing premature babies, or doing anything. It's actually pretty bad. It has some other, like, negative consequences. So, systems, like, just lay around: not effective. Russ: It does have an 18th century ring to it. Which makes you nervous. Guest: Sure, yeah. I mean, everyone likes to relax. I think it turns out--it sounds great, when you're pregnant, to be like, oh-ah, just lay in the bed. But actually being forced to lay in your bed all the time-- Russ: Horrible-- Guest: It's very unpleasant. Russ: Good to know. So, let's regroup here. Let's summarize what you've told us so far. We've got, controlling for birth weight, prematurity. Is that the only two we've talked about so far? Guest: Yes. So, adjusting for reporting differences and adjusting for prematurity, you find that the United States is still substantially worse off than elsewhere. So, even if we had the same levels of birth weight as these other places, things would still be much worse in the United States. Russ: But not relative to Finland? Guest: But much less, relative to Finland. That's true. Slightly worse. Russ: Butt relative to Austria. Guest: But relative to Austria, much worse. Slightly worse relative to Finland.
30:59Russ: So let's turn to the surprising finding, which is fascinating. Which is that neonatal--which I guess means close to birth--as you said, first week or so, maybe first month: U.S. neonatal mortality is very, very good relative to these two countries, at least. Whereas the, say, months 2-12, it's where the United States is doing much worse. And this, of course is not visible in the standard national data because that just looks at any time within the first year. Is that correct? Guest: Yeah. And it's actually--and it's even in some sense harder than that. Because sometimes in these national data sets they do separate, like, the first month and the later period. But what they are not able to do is do that controlling for birth weight. So, like from a policy--so economists, like I think we're interested in what we would do about policy. And so I think then the question you want to ask is, conditional on the inputs that you are getting, conditional on the weight of the babies that are born in your hospital: How are we doing at the kind of neonatal, in the neonatal period, and then how are we doing later? Because that's how you think about identifying policies. And just reporting aggregate numbers, certainly overall in the first year, but even if you separated these time periods but you didn't think about the differences in inputs, you would still be misleading. So what we find is once we are able to adjust for differences in birth weight, which we are able to do because the data is so rich, as you say, the United States actually looks quite good in the early period. And then really, really not very good later. Russ: So, to say that a different way--let me understand that I understand what you're saying: If you don't control for birth weight, the United States might have still a very high neonatal mortality rate. But that doesn't take account of the fact that the United States has lots of small babies. Right? Guest: Yes, Russ: Which risk--increases the risk of death, when you hold that constant we are actually doing very well. But isn't there a question why we have such low birth weights? Guest: Yes, there is. But I think that is, again, related to this prematurity question; because that's being driven by a lot of high rates of prematurity. I think this doesn't say we shouldn't worry about that. We should worry about that. But I think from the standpoint of the neonatal period, the question you'd like to ask is: Is the United States having a problem because our neonatal care is really terrible? And if you looked at the aggregate statistics and you saw, look, the United States has high neonatal mortality, we might be tempted to think, well, let's invest a lot more money in necu[?]-care. In like, making sure that we have high quality hospitals and that the hospitals are [?]teched[?] up in various ways. Russ: They already are, of course. Guest: But they already are. They are doing very well. Their inputs are not very good. But once they get the inputs, things are looking very good. And I think that kind of tells you, yes, let's think about prematurity, but maybe think about that more so than we think about investing in necu[?]-care. Russ: When you say inputs, you mean the quality of the pregnancy-- Guest: Yeah, and the birth weight of the baby. Russ: So, given that--I'm going to take the one thing that we know, that we think we know. One example that, if we wanted to improve the neonatal rate, then, you are saying, mortality rate, the raw numbers, would be to reduce the smoking rate. If people stopped smoking or choose to stop smoking, that would presumably increase the number of births that come to term and would improve the survival rate. Guest: Yes. No, that's definitely true. Although, in fact though, the effects are probably pretty small. Like, even the smoking is like the one thing we know to matter--actually the impacts are not that big. But certainly that is--yes--and if we actually got people to stop--I actually think this methamphetamine thing is not a trivial problem. And so if we addressed that problem, that would improve neonatal mortality as well. Russ: Yeah. But presumably that's a hard--what's your evidence for why you think that's a serious problem? Because obviously you don't have any good data on that. Guest: I would say, the Internet. Which is probably not the best source of that. I mean, some of this is from talking to doctors who treat women in areas that have high prematurity rates, and this comes up, in certain parts of the United States, in discussions as an issue. Russ: Yeah, it's interesting. Hard to know. Guest: They made it be that it feels very salient. Russ: Sure.
35:58Russ: Let's move on to the first-year problem. So, the United States, despite the raw number, does quite well in the neonatal mortality rate. Now, what do we call the--is it post-natal? Guest: Post-neonatal. Russ: So the post-neonatal period, which is, say--is it second month? Guest: It's a month to a year. [?] Russ: So, there, the United States, if you look at the data, which as you say it's hard to show on the podcast, but it's shocking, actually. Because you see these two lines, the United States versus other countries; they are moving along together. And then all of a sudden the United States diverges dramatically in the first year as time passes in the life of the child. What do we think is going on there? Guest: You know, it's hard to--it's very hard to say. So, one of the places we tried to look for information is looking in the causes of death, to try to see if there is something that jumps out as like, this is a particular thing that's going on. One thing we can say is it doesn't seem to be differences in congenital abnormalities--which is actually a pretty common cause of death, but doesn't seem to be more common in the United States. But, it turns out most of the [?] deaths are things like SIDS (Sudden Infant Death Syndrome); accidents, to some small extent, assaults. So that's somewhat informative. But since SIDS is the most common cause of death in this period, it is not actually that informative to say that it is also accounting for the largest share of the difference. Russ: SIDS is Sudden Infant Death Syndrome, which is--go ahead-- Guest: I was just going to say, yes, it's Sudden Infant Death Syndrome. It's kind of intended to be a cause of death that refers to something specific, which is like the infant just stops breathing and died; although in practice it ends up capturing a lot of residual sort of things that happened where we don't really know what actually happened. Russ: Yeah. In a way, the way it's phrased, it's a way of saying we don't know what happened. Guest: Yes. Russ: Do we know anything--our children were all born in the 1990s, and that was right at the time when there was a great deal of anxiety about SIDS. What's the state of our knowledge about it? And what do we know about what prevents it--if anything? At the time there was a worry about babies sleeping on their stomachs. And everyone was told to have the babies sleep on their sides. And I think--well, you tell me. What do we know about it? Guest: I think that that turns out to be actually a pretty good policy: so your baby should sleep on it's back. I think in general we've moved toward a view that the infant should be sleeping on its back, with no blankets, in like a crib with no pillows or anything. And I think that's the kind of--I think the ideology of SIDS is such that basically an infant just stops breathing. And so things which just make the infant sleep less soundly tend to have some positive effects on this. So having a fan in the room-- Russ: Less soundly? Guest: Yes. Basically, if the infant is sleeping too soundly, they forget to breathe. Kind of like the--that's not the only thing that happens, but I think that's sort of part of the understanding, is that they just sort of stop breathing. And so when you are not as soundly asleep, that is less--happening to somewhat less of an extent. And so, things like having a pacifier and having a fan in the room are both things that are now, I think recommended as ways to lower the SIDS risk. But this back to sleep thing is the biggest. The biggest issue, has had quite large impacts on the rates of SIDS over time--you can see pretty clearly that campaign in the time series. Russ: But it's a very small number, right? Guest: It's a small number. Russ: Let's talk about, something about the magnitudes in general. When we are talking about this difference now, in the United States to say, Finland, or the United States to Austria, post-natal death mortality rate--what kind of numbers are we talking about here? Guest: About 1 in 1000. Russ: Right. Guest: So, the sort of difference in this period is about 1 in 1000. The absence of that [?] says that if you couldn't kind of move the United States to the rate of, say, Austria, in this period, holding constant this situation at birth and holding constant what's happening in the first month, you would decrease the overall mortality by about 1 in 1000 deaths, and that's about 4000 deaths a year. So, it's not an enormous number; but it's reasonably large. Russ: Well, every one of them is horrific. Guest: Yes. So it's a very terrible thing to happen. So-- Russ: Unbearable. The question is, and I'm sure you've thought about it: 1 in 1000 is a small number. How much of that is a random difference that might not show up year in, year out, and is due to unpredictable, unknowable things? What are your thoughts on that? Guest: These differences are pretty consistent in our data over this period. And obviously we [?] people saying which is that they are very precise--and there are an enormous number--I mean, these regressions have 25 million observations or something. So, I think, at that level, I think it's unlikely that this is driven sort of totally by chance. And that's sort of as far as we got about that, I guess.
41:58Russ: But--and let's come to this now. I mean, the other issue, obviously, is what we would call socioeconomic poverty, violence. Try to summarize--you touched on it before. Try to summarize what we know about that 1 in 1000, where it's coming from. Obviously some of it is--it's hard to believe that there's an important difference in how U.S. parents are using pillows versus Finnish parents, in terms of SIDS rates. So, what might matter that's important? Try to break it down again for that, for causes. Guest: So, what we do on the socioeconomic stuff is we basically try to ask the question: In this sort of high SES [Socio-economic status] group, which we think about as kind of college-educated--in the United States, white-- Russ: SES is 'socio-economic status'. Guest: Socio-economic Status. Right. So, you take like college educated white married women in the United States and compare them to the similar demographic in Finland and Austria, so high-educated married women, to basically see if this is a difference across countries which is kind of existing everywhere in the socioeconomic status distribution. And we find that it's not. So, these sort of white college-educated married women in the United States look, in terms of their infants' mortality rates, they look just like that comparable group elsewhere. So, it is not the case that that group is doing worse than these other countries. What's happening is that there's relatively small differences in either Finland or Austria across these parts of the socio-economic distribution, whereas in the United States there are very, very large differences across groups. And that turns out to be basically driving most of these differences. Russ: And there's a lot of different factors than socio-economic status. So, what do you find was--are some effects more important than others? Guest: It's being driven by education, basically. Now, that doesn't mean--it's not exactly the answer you are looking for because that doesn't tell you what it is about the education, but the most important variable in this is education. Russ: We don't know what that means exactly because obviously education is correlated with income. It would be great if we said 'more education women know more stuff about how to be good mothers and that therefore we just need to get that information to people who have less education.' But it's not that simple. Guest: No. No, and actually at some point we tried--this is in the current draft of the paper--to look at particular behavior: things like back to sleep or like smoking. And we found that in a lot of those cases it's true that high socioeconomic status women in the United States undertake sort of better behavior on those dimensions than lower socioeconomic status women, but that's also true elsewhere. So those differences in the United States across groups in behaviors didn't seem to be particularly large relative to the differences elsewhere. There wasn't like some behavior that stuck out like a smoking gun. Russ: But if I understand what you said correctly, you said--Finland, and to some extent Austria, is less diverse than the United States racially; it's less diverse economically. I assume. Guest: Yes. Russ: And if the United States, going back to your earlier statements, had the same birthweight and the same socioeconomic status as Finland and Austria, there would be virtually no difference between the infant mortality rates. Guest: Yeah, that's true. Now, of course, that's like, as a policy, get everyone as rich as Finland is pretty daunting. And I think part of the challenge--we're trying to think through whether we can push this forward--is thinking about: are there things you could do that are sort of smaller scale than just like, bring everybody to the income level of Finland, that would kind of ameliorate some of these problems in a kind of more micro, focusing more on this particular issue as opposed to trying to fix the whole setup. Russ: And? Guest: The one thing that we talk about in the paper is some kind of home visiting program, which I think is something that's gotten some kind of policy discussion in the United States of late. So, in all of these European countries, these two and basically all of the rest of them, they have programs where someone comes to your house after you are home with your kid and give you some advice and tells you something about how to parent. And I think those programs actually continue for some time after the birth. We don't have much of that in the United States. You can see why a program like that might be of particular use to people with limited resources, who maybe don't have as many places to go for advice and information. And you know, I don't know if you remember--but when I brought home my daughter, it was sort of like, there you are in your house with your kid, and I'm like, 'I guess it's going to wake up,' like I have to do something with it. It's very hard to figure out what exactly to be doing with a baby. And I think, you know, that problem becomes more acute as resource constraints bind. And so I think one thing people have seen in the United States in some of these home visiting programs is that they do have some effect on mortality. So I think that's one kind of policy one might imagine wrapping up. Russ: Yeah. I remember, I think desperately, to have a manual. Guest: Exactly. Russ: Especially that first night. Our daughter was crying like a baby; and we're thinking, 'What do we do now?' We know that thousands of parents have successfully negotiated this challenge, because we're here. Most of it works on its own, comes naturally.
48:53Russ: What we're talking about now is that last half of a half of a percent. Where again, even, given your breakdown before of SIDS versus violence, it's great that someone would come to my house and say--although I wouldn't want them to; I just want to say on the record; and I'm not sure I'd want to pay for it and I'm not sure it's a good idea. But if someone came to my house, such as my parent, my own parent, or a neighbor, and said, 'By the way, it's good to have the baby sleep on its back,' that seems like a good thing. Of course, implementing it is not straightforward at all. And it would seem to me that the rest of the categorization of that last bit of possible improvement we could make, seems like it could be purely cultural. You think that's a reasonable conclusion? Guest: Yeah, I think that one thing to [?] to start talking about small numbers are pockets in the United States where these numbers are bigger. So, for example, among, like, black women with less than a high school education in Cook County--which would basically be the South Side of Chicago--the infant mortality rate in this period is about 16 per 1000. Which is obviously a lot bigger. So that suggests that there may be scope in particular pockets to actually have much larger changes. And I think it's more potentially than things like your kid should sleep on your back; I think many of these programs are, some are more wholistic view of how do you think about parenting. And when it is okay to give your kid solid food, and does your kid look like they're doing okay? And I think those are the kind of things they are trying to communicate. But I agree, the implementation issues here are very, very difficult. Russ: So, that rate of 16 on the South Side, how does that break down between first month and post-- Guest: That, I don't know, actually. Russ: Okay. So, that's interesting. Have you thought about other issues? One issue I've heard people worry about is a rise in maternal mortality in the United States? Mothers dying in childbirth. Have you looked at any of that data? Those data? Guest: I haven't. Those numbers are very small; I think it's right that they've gone up a bit over time. But they are really, really, really small. Which is great; but makes it harder to pinpoint a particular cause.
51:37Russ: So, let's summarize. Step back and give me your assessment of what you've learned from this more nuanced and more complete data that you have on births and deaths. So, we started off by saying on the surface, the United States despite its relative wealth is something like Croatia--it's 51st in the world in infant mortality. Which is somewhat appalling. And we're double the countries in the world that are doing the best at keeping infants alive. Which is Finland. Given what you've looked at now, how would you summarize what we know about that picture? Guest: I think that what I would say is that what we get out of our data is a recognition that the issues that the United States is having are not issues about the kind of medical technology part of this, and I think that's--in some ways surprising that [?] I think [?] we think of infant mortality as kind of being special and about things that are happening in hospitals and [?] and how we're doing with very small babies and it's true that that is an important part of infant mortality, but it's not a place that the United States is falling down. Instead the place that the United States seems to be doing worse is in the more mundane issues of what is happening before birth, most of which is going to be about things that are happening in people's households. And then what's happening after people are home with their infants. And both of these are not unrelated to broader issues in the United States, like we in general have a higher mortality rate among children, among adults, than most other places, and sort of thinking about this a little wholistically and thinking about how we can support women with infants when they are at home, if they do something that might be of some significant policy value. Russ: Although it wouldn't be a bad idea to have everyone be as well-off as they are in Finland. We don't know how to get there. If we knew how to get there. Guest: No, I agree. Yeah, if we knew how to get to a place with less inequality I think that would also be good but I think that might be a slight [?] more complicated. Russ: I would say less poverty. I would not say less inequality. Guest: Right, less poverty. That's exactly right. It is exactly the poverty that is the issue, not the inequality per se. That's exactly right. Russ: 5414 So, close and talk about either what you feel you've learned or where you'd like to go down the road in thinking about these kinds of issues, not just infant mortality but there's a lot of, I think, noise, not much light, a lot of yelling and posturing about the U.S. health system. There are people who want us to go more toward single payer. There are those of us, like myself, who would like a less centralized system--which seems very far off. But one can always dream. And one way that people argue for these different policy positions is they try to out-data about life expectancy, they try to out-data about infant mortality, etc. To me, your story is a half-full story in the sense that access to quality medical technology at birth does not seem to be a problem in the United States. That's glorious. Maybe we pay way too much for it--I wouldn't be surprised . And I'm sure we do lots of things that are not-- Guest: Right. We pay a lot for it. Russ: But talk generally about this issue of health care data. It's a very--we've had Martha Nussbaum on recently talking about using different measures of wellbeing other than, say, Gross Domestic Product, other than, say, per capita income. And people push for health measures. And obviously it's more complicated than it might seem at first. What are your thoughts on those issues? Guest: Yeah, no, I think this is a very, as you say, this is a very complicated area. I think one of the issues that we clearly have in the United States, and this is true in this infant mortality stuff but it also comes up in research I've seen, but there are things like obesity and diabetes and a set of health issues which arise later in life. In all of these things we see these huge differences across those economic groups in the United States. And I think a lot gets made of, kind of let's look at these other places and see how much better they are doing in these various things without recognizing that the circumstances that we are facing in the United States given how much diversity there is and how large the differences are in income and in some sense how poor the poorest people in the United States are, this makes all of these problems much more difficult to tackle. And so, saying things like--for example, I read something, somebody sent me something about how, Denmark has figured out how to address childhood obesity using a comprehensive family centered plan and that's so successful and shouldn't we do this in the United States? We look [?] and, what's the plan? The plan is like the kids, the family eats a meal together every night; you make sure the kid doesn't have more than one helping; you know, like boneless, skinless chicken breasts that the mother has carefully prepared. And then the kid goes running outside. It's like, okay, why don't you try to port that model to the South Side of Chicago. Like, where is the kid going running at 73rd Street and Stony Island after dinner? This isn't a realistic thing. And I think we need to try to think about some of these problems in the context of the setup that we have, a broader setup. And I think it makes many of these problems much more intractable, and much harder to think about. It also means focusing on them in kind of a minor way outside of the context is just a very, very complicated and probably useless approach. Russ: It just strikes me that some of the things that get suggested--that's a great example. It wouldn't fly culturally in the United States; it's not going to be implemented well in the United States. Wouldn't be politically popular in the United States. Guest: Right. No. It's not going to happen. Russ: So, it seems to me that the single biggest policy thing we would like to improve in the United States is giving people ways to use their skills in the labor market. Which we are not doing a great job on. And if I could pick one thing to make health better, that would be it. Guest: Yes. I think that's right. I think fundamentally there's a lot of other things we could do around the edges but that is a very central thing, and without that it's going to be hard to make really, really large changes in any of these dimensions.


COMMENTS (22 to date)
Annie writes:

Thanks for an interesting podcast. As a European after listening to your episode on infant mortality I finally got it. It won't get better because most rich white Americans don't give a hoot. You could start a program of home visits to target poor black women in the South Side of Chicago and elsewhere, but it would cost money and might be seen as intrusive, and, really, who cares? You aren't outraged, and the episode gave me the impression that those infants are disposable. Sad.

Greg G writes:

Annie,

Individuals vary a lot in how much they care about various problems but generalizing about the attitudes of rich white Americans is probably not any more helpful than generalizing about the attitudes of poor black Americans.

The politics on this issue are complex. Many of the poorest American states have electorates that are among the most hostile to more government involvement in healthcare.

It tends to be the case that, in this country, all health care issues are seen through the lens of whether or not there should be a more or less socialized healthcare system. As a fairly wealthy white American I think the government could and should do a lot more to insure a minimum standard of healthcare for all Americans. Those who disagree with that are often sincere in their belief that the system they advocate would be best for the poor as well as the rich.

This podcast did convince me that infant mortality rates are a particularly problematic metric for comparing healthcare in the U.S. to other countries.

I think discussion should have been given to the fact that maternal mortality rates in the U.S. also compare rather poorly to the maternal death rates in many poorer countries. I am not aware of comparable issues in deciding what counts as a maternal death. I am inclined to suspect that may of the same factors that contribute to a high infant death rate also contribute to a high maternal death rate.

Fred writes:

How do the figures for low SES whites compare to those of low SES minorities in the US? Do both groups have comparable rates of infant mortality?

Ak Mike writes:

Annie - I second what Greg G says, and note additionally that Prof. Oster made it clear that neonatal death rates, which would include the poor, are just as good in the United States as in the best of European countries. The problems come later. I believe that the U.S. actually spends more for health care for the poor (as for health care generally) than do European countries, so the problem is not "who cares," but is deeper and more difficult. Your impression that infants are disposable in the U.S. was not based on anything in the podcast.

In answer to Fred, take a look at the linked paper. It appears that even non-minority poor have worse outcomes here than in Europe.

Brad F writes:

@Ak Mike
We (the US) spend more than EU on HC, but we invert ratio of hi tech to hi touch. Annie highlights utility of spending more for social service, ie, home visits. I cant say it any other way. We stink in the delivery of aftercare.

As for where we perform equally--neonatal survival, given our proclivity for waste, we could likely continue to achieve the same outcomes for less.

Brad

Ak Mike writes:

Brad - no argument from me about whether our money is well spent - I think that is a tough, tough question that could be the subject of Prof. Oster's next paper. It could be that the follow up she discusses would be entirely useless; or it could save lots of babies.

I just think Annie was way off base with her accusation that "rich white Americans don't give a hoot" or that we don't have a program because it would "cost money." In fact like other American taxpayers, rich white Americans spend huge amounts providing medical care to poor people, black and otherwise. I think Annie's prejudice against Americans caused her to hear things in this podcast that were not actually in it.

Scott Campbell writes:

I think your guest's effort are misdirected in the face of 1.06 million abortions this year. That is over 2000 thousand babies killed every day..

What's the mystery? Finland is a country of 5 million northern Europeans, with a homogeneous culture. Median age: over 43. The USA is a country of 320 million with a great deal of racial and ethnic diversity. Median age: under 38 years.

Finland has birth rate of 10.4 births/1,000 population. The USA has 13.4/1,000. Finland's net migration ratio is .62 migrants per 1,000 population, while the USA's is almost 2.5 per thousand.

At about 50 minutes in, Oster admits that Americans who most resemble Finns in race and education have the same infant mortality. Gee, I wonder where the two countries different overall rates come from?

JohnM writes:

Patrick - Thanks for pointing out the obvious. It also extends to crime, test scores, employment, teen pregnancy, income and life expectancy. Everybody knows it and no one in academics is really allowed to discuss it. Please don't kill the messenger for a lack of clarity.

Greg - Finland's per capita healthcare expenditure is roughly 1/3 of the the per capita cost in the United States. So what minimum standard of care are you referring.

Annie - my wife worked in a home healthcare program in Baltimore doing exactly what you described. Those programs already exist and are well funded. Get your facts right before you get outraged and make rash judgements about what Americans care about.

David Zetland writes:

The US indeed has more complex issues wrt SES, but I disagree with Russ's final recommendation ("we need to find better ways to help the poor work") as many poor people are the working poor, and expectant mothers are hardly in a position to work.

It would make sense -- if addressing this issue is a goal -- to improve the delivery of services to the poor. I'd prefer to replace the hodgepodge of overlapping, confusing programs with a Basic Income policy, especially as such a program is likely to delver more benefits (i.e., impact and flexibility) at a lower cost (fewer bureaucrats and less failed targeting)

The US is complex. I get it. That doesn't excuse these results...

Floccina writes:

Interestingly I have read that Hispanics have a slightly lower infant mortality than non-Hispanic whites.

It is also interesting how it lines up by state:

http://kff.org/other/state-indicator/infant-mortality-rate-by-race-ethnicity/

SaveyourSelf writes:

@~19:22 Emily Oster said, “The United States has a high rate of prematurity…And what we find is actually, conditional on birth weight, the United States is doing very well early on…And then when we move from the period of a month to a year of life…that is the period in which the United States is really lagging behind other countries.”

Outstanding, elegant work.
The question that follows, then, is why does the US do poorly in infant mortality after they leave the hospital? Perhaps the answer is breastfeeding: Breastfeeding Comparison
Note the chart on page 2, where the percentage of women who ever breastfed in Finland is about 93% whereas the US is about 74%. Breastfeeding matters because human breast milk contains antibodies to every illness the mother ever encountered. So if you are looking for policies that will decrease infant mortality or just looking for a way to boost infants' immune systems, increase breastfeeding. Some policy changes that might increase breastfeeding: 1. Remove formula from the foodstamps program and from WIC 2. Lengthen maternity leave.

@44:20 Emily Oster said that differences in natality between different socioeconomic stratifications, “are being driven by education basically. Now that does not tell you what it is about the education that is driving this, but the most important variable in this is education.”

I suspect the level of education is a distraction. My guess is the differences Emily notes between socioeconomic groups stem from different amounts of information available to the different socioeconomic groups.
97% of everything learned in school is forgotten in a single year, regardless of the socioeconomic background. The people who thrive in school, therefore, are the ones with greatest access to recorded information. So school is, at its most fundamental form, the place where humans acquire to the skills necessary to access stored information. Those skills can take the form of reading or writing or exercising or singing or painting or whatever. The information is stored in songs and on video and in textbooks and computers and the internet and in peoples’ minds etc. Missing from that list, however, is the information carried in market prices. The wealth or paucity of market price information is at least as important for determining income level as all the information taught in school combined.

@48:26 Russ Roberts said, “I remember wanting desperately to have a manual, especially that first night. Our daughter was crying like a baby and we were thinking, ‘what do we do now?’”.

Exactly! I can tell what socioeconomic group you are in simply based on that statement.

@~19:22 Emily Oster said, “smoking increases the rate of prematurity. Using drugs like meth, also not good…So, 12% of births or 10% of births in the United States are pre-term. And obviously 10% of women are not smoking or using methamphetamines”
A study in 2012 done by the Substance Abuse and Mental Health Services Administration found that 21.8% of pregnant white women smoked compared with 14.2% among African-American and 6.5% among Hispanic women. “Levels of self-reported alcohol use were fairly similar between pregnant white women (12.2%) and pregnant African-American women (12.8%). Hispanic women had the lowest rates of alcohol use during pregnancy at 7.4%.” And with regards to illegal drug use during pregnancy, the rates were 7.7% for African-Americans, 4.4% for white, and 3.1% for Hispanic women. (Source Citation)

@50:00 Emily Oster said, “So for example among black women with less than a high school education in Cook county—which is basically the south side of Chicago—the infant mortality rate in this period is about 16 per 1000.”

Percentage below poverty level in Cook county 2008-2012 = 16.4% (http://quickfacts.census.gov/qfd/states/17/17031.html).
High poverty level means high government welfare system activity. High welfare system activity means that market price signals must compete with government subsidy signals. Market price signals tell people where their skills and energy are most desired by society. Government subsidy signals tell poor people that society desires that they remain unemployed.
Additionally, the minimum wage is active at this low income level, meaning that ALL price signals from the labor market below that arbitrary number are silenced. So, below the minimum wage level, subsidy signals are the ONLY signals available to direct their productive energy. Well, subsidy signals and black market signals.

@58:00 Russ Roberts said, “The single biggest policy thing we would like to improve in the United States is giving people ways to improve their skills in the Labor Market…and if I had one thing to pick to make health better that would be it.”

Well said, Russ. Both you and Emily did a great job in this interview.

Opher Donchin writes:

Thanks for addressing this important issue.

Oster finds that Finlands larger babies also come with better neonatal survival. She and Roberts come to the conclusion that the problem in the US is not at the neonatal stage. This is a fallacy. Just because the Finns are larger people and thus have larger babies doesn't mean that the US babies are not born healthy. A healthy baby in the US may well be smaller than a healthy baby in Finland. That healthy baby may have a poorer chance in the US than in Finland. This does not mean that the difference in birth weight is causing the difference in neonatal deaths.

Dave N writes:

It’s not in the transcript yet, but I found the following exchange near the end interesting:

Russ: “Wouldn’t be a bad idea to have everyone be as well off as they are in Finland, if we knew how to get there”

Guest: “If we knew how to get to a place with less inequality, I think that that would also be good but I feel like that may be a slightly more complicated thing to address”

Russ: “I would say less poverty, I would not say less inequality”

Guest: “Less poverty is exactly right. It is exactly the poverty that is the issue, not the inequality. That’s exactly right.”

And yet in her paper we have the following statements:

"Most striking, the US has similar neonatal mortality but a substantial disadvantage in postneonatal mortality. This postneonatal mortality disadvantage is driven almost exclusively by excess inequality [emphasis mine] in the US: infants born to white, college-educated, married US mothers have similar mortality to advantaged women in Europe"

“In both Finland and Austria, postneonatal mortality rates are extremely similar across
groups with varying levels of advantage, either unconditionally or (more starkly) conditional on conditions at birth. This pattern is confirmed graphically in Appendix Figure C.1. In contrast, there is tremendous inequality in the US, with lower education groups, unmarried and African-American women having much higher infant mortality rates.”

Perhaps Russ could expand on “to have everyone be as well off as they are in Finland” as well as "less poverty, I would not say less inequality”

If the 75% ‘low education/occupation’ cohort (Table 5) which are responsible for the vast majority of infant mortality difference could manage to "use their skills in the labor market" to raise themselves up to the top 25% level that would make society more equal pretty much by definition.

So go ahead and say ‘less inequality’ Russ, because that’s an inseparable part of the issue at hand.

Russ Roberts writes:

Dave N,

Perhaps we have a semantic or interpretative disagreement. If poor people in America today became as rich as Finland, the implication of Emily Oster's work is that infant mortality rates would fall. There are two ways to get there. One is for everyone in America to get much richer. That would make the poorest Americans more like Finland and infant mortality rates would fall. Another way to get there is for poor people to get richer but not anyone else, say by an improvement of the schools that children from poor families attend. That would reduce inequality and infant mortality.

But inequality per se is not the cause of high infant mortality rates among the poor. It is their poverty. I disagree with Emily Oster's wording in her paper that "excess inequality" is the cause of infant deaths. True, eliminating inequality as I say above, would reduce infant mortality, but that masks what is really going on as my first example, I hope, illustrates.

G Alexander writes:

I would have liked to hear about breastfeeding. NIH estimated in 2004 that we could save over 700 lives per year by raising breastfeeding rates. I'm curious whether those statements still seem reasonable.

Also, no mention of differences in vaccination schedules? I realize it's a highly politicized issue, but 40+ vaccines before age 2 in the US is over 3.5x more than the 11-12 administered by age 2 in Finland and Sweden. I know we're all tiptoeing to avoid giving radical anti vaccination folks ammo, but there's a legitimate, potentially lifesaving discussion to be had about how much is too much when it comes to infant vaccinations.

Dave N writes:

Thanks for taking the time to respond Russ. I’m a recent newcomer to your podcast and I’m really enjoying the wide array of subjects and also your interviewing technique. I’ve already queued a frighteningly large reading list from your site alone.

Of course I agree that mortality rates fall as income rises. And that the differences we’re talking about here are small compared to the gains made in the last century. Still I’m continually puzzled by the outlier nature of the US. It just does so much worse, in so many areas, than you would predict based on income levels alone. This is why I don’t accept ‘poverty’ by itself as an explanation.

Unfortunately there doesn’t seem to be the data necessary to provide cross country comparisons into actual household incomes and the relationship with infant mortality. (And wouldn’t it be great to have another dozen countries to compare with?) But it seems safe to say that the advantaged group (the 25% with a ‘college degree/good occupation’) in the US would have a much higher income (PPP adjusted) than the corresponding advantaged group in Finland; and yet the mortality rates are similar. Wouldn’t you expect them to be significantly better in the US if that group is significantly richer?

Further, from the paper: “In both Finland and Austria, postneonatal mortality rates are extremely similar across groups with varying levels of advantage”. I take this to mean that the disadvantaged in Finland do much better than you would expect them to if they followed the US gradient. So my guess as to what you would find if you had the data is that mortality rates would still be higher in the US when comparing similar income cohorts, implying that increasing income alone would not fully erase the difference.

The excellent comment from SaveyourSelf above points out some unconsidered factors that could help to explain this. Finnish mothers apparently breastfeed more and are certainly home more because of extended maternity leave programs. (Note that 3 month ‘exclusively breastfeed’ rates are more than 50% higher in Finland, though UK rates are abysmally low so it’s not a magic bullet) Plus we still don’t have an answer as to why Finnish babies are higher birth weight. Better nutrition, less environmental toxins? Who knows.

But research (by Richard Wilkinson for example, who would make an excellent guest as I don’t see him in your archives) seems to be showing that inequality has many more negative externalities associated with it than previously considered. Part of the human condition is that relative status matters; just how much is the question we are now beginning to address.

Eric (Epidemiologist) writes:

Russ, love the podcast.

Glad to hear that you are interested results/conclusions based on tried and true epidemiological methods. A pleasant surprise after a comment you made in an earlier show (which I felt compelled to write down) "Epidemiology is a cesspool of intellectual failure."

Keep up the good work in your new era of enlightenment. ;-)

Harry Guiremand writes:

In Finland and Austria, the vast majority of male newborns are not subjected to unnecessary surgery. But about half of American newborn boys are subjected to such surgeries. Unsurprisingly, the states that do the most unnecessary surgery on male newborns also tend to have higher infant mortality rates. This seems worth noting. This report would have benefited from a comparison of infant mortality for male and female babies. Since, in the USA, only boys are subjected to such surgeries—females are protected by law from this—one would expect different infant mortality outcomes for males and females here, as the individual state data suggests. We would also expect infant mortality to be more nearly alike for both sexes in Finland and Austria where, except for rare ritualistic cutting, boys and girls are protected equally from unnecessary surgery in the newborn period.

Jay writes:

@G Alexander and Harry Guiremand

Do you have any evidence tying your "causes" to actual infant mortality or are we stuck at insinuations?

bogwood writes:

From the historical/pre-historical view, the "good" tribe or the "good" island did not name a newborn until there was consensus on the available supporting resources. Harsh but necessary. There can be a tragic element to each birth. It is not just the cost of the home visits, it is the two hundred thousand dollars to raise the average American child.

Abortion is free and available in Finland, almost certainly fewer unplanned "unwanted" term pregnancies.

Perinatal mortality is a tiny fraction of the 7,000 deaths per day in the USA. Opportunity costs?

Harry Guiremand writes:

@Jay The link in my earlier post is to a PDF that shows a graph of the correlation between incidence of unnecessary infant surgery and infant mortality. Raw data and their sources are included.
In case that's not working for you, here it is again:
https://pdf.yt/d/3z_9PkxogvDOkMQW

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