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Hi Dean!

Of the two components of KMC, breastfeeding assistance seems to me much more bottlenecked by nurses than skin to skin contact. That is, while breastfeeding assistance might need a nurse to provide bespoke information to each mother in the moment, skin-to-skin contact seems less individually specific and an easier piece of advice to share impersonally and by non-experts.

Two questions about this:

Is the distinction I drew above directionally correct, or does skin to skin contact require as much in person expert attention as breastfeeding assistance?
If the distinction is directionally correct, might it be possible to scale the provision of the skin to skin contact advice for much cheaper than it would take to hire a lot more nurses (some kind of information provision/belief change intervention in econ jargon)?
1. This could look like some kind of door-to-door campaign by community health workers, or a video version of text-message reminders for vaccines (though an internet requirement might screen out some of the households we care most about).
2. Are the two parts of KMC strong complements in a way that would make the provision of just one of them much less effective?

deanspears

May 7 2024

I think the right econ-jargon way to think about this is that they are “complements in production”: The activities that promote skin-to-skin contact make it very natural to also promote breastfeeding. Indeed, that’s one part of why skin-to-skin contact is helpful! It would be odd to have a skin-to-skin promotion program that doesn’t also promote breastfeeding, I mean. Maybe implicit in your question is the guess that the nurses more or less tell the moms about skin-to-skin contact and then they go along their way and do it. But in fact, the skin-to-skin part is pretty labor intensive too, because it requires keeping the moms present in the hospital and engaged in the effort, instead of giving up and going home. Yes, there’s some troubleshooting (the angle, the KMC wrap, …). But more than that, there’s a lot of cheerleading (“How’s it going?” “You’re doing great!” “Keep it up!”), which is often a big part of good nursing care, and especially here. Part of what the program is doing—by helping the moms have what they need in terms of food, bathroom opportunities, and encouragement—is helping the moms feel good about the long slog of getting these babies up to a safer weight and ready to eat and grow. I ran this question by a colleague who wrote back: “I think [mere] information campaigns that show parents doing KMC for LBW babies in healthcare settings and at home would be a good idea, and I think that having non-nursing staff (say ward ayas) teaching parents KMC in a hospital setting would be better than not doing so, but I don't think we should expect large effects. “It takes time for the mothers to learn positioning and wrapping (KMC can be unsafe without these inputs), and the constant checking and temperature measurement and encouragement matter to getting mothers to do enough hours. “I would say, if you have the option of using trained nursing staff, you should. If you don't, then by all means give people the [mere] information that prolonged skin to skin con

Karan MakkarMay 9 20241

Thanks a lot for the detailed response Dean! The details on the motivational help that nurses provide make it clear that there's much less of an arbitrage opportunity/free lunch than I'd hoped (as is often the case with mere info).

Thanks again for all the great work (including on OD, I learned a lot from where India goes)!

See in context

Ask me questions here about my 80,000 hours podcast on preventing neonatal deaths with Kangaroo Mother Care

by deanspears

May 2 20241 min read 8

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Opportunities to take actionEffective givingGlobal health & developmentAsk Me AnythingMaternal and newborn health

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I was interviewed in yesterday’s 80,000 hours podcast: Dean Spears on why babies are born small in Uttar Pradesh, and how to save their lives. As I say in the podcast, there’s good evidence that this is a cost-effective way to save lives. Many peer-reviewed articles show that Kangaroo Mother Care is effective. The 80k link has many further links to the articles and data behind the podcast. You can see GiveWell’s write up of their support for our project at this link.

This partnership with a large government medical college is able to reach many babies. And with more funding, we could achieve more. Anyone can support this project by donating, at riceinstitute.org, to a 501(c)3 public charity.

If you have any questions, please feel free to ask below!

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MHR🔸May 3 202421

Thanks so much for going on the podcast and for the incredible work that you and everyone involved in r.i.c.e. are doing! It's amazing that you've been able to save so many lives so cost-effectively. I did have a few questions I was curious about though:

In discussing your room for more funding, you mentioned likely cost-effectiveness improvements from economies of scale as the program grows. That makes complete sense to me on the current margin, but I'm curious if you have thoughts about how the cost-effectiveness might change if the program were to scale up say an order of magnitude. It seems like both r.i.c.e.'s staff and the medical college staff are exceptionally engaged and motivated. Do you sense of how important that's been to the program's success, and of whether that would be hard to maintain and replicate if the program expanded substantially more broadly? I know that for example in early childhood education interventions, there's quite a bit of evidence of negative scale-up effects where programs that look really great in pilots have ended up looking a lot less good when implemented at large scale. (This isn't at all intended to be a negative on r.i.c.e.'s current or near-term work, I'm just curious how optimistic or non-optimistic to be about the larger potential of kangaroo mother care programs)
In talking about why this program wasn't done before r.i.c.e.'s intervention and why it isn't done in more places, you said "There are just a few paediatricians who work there, and they had just a few nurses working with them. And that’s just not going to be enough for this many babies. The government of Uttar Pradesh recognises this; the Department of Medical Education is working hard to open more new medical colleges and new nursing colleges." Given that context, do you worry that part of what r.i.c.e is doing in the short-run is reallocating medical care from being provided to other people to being provided to the babies in the program? I of course don't think this is an argument for r.i.c.e. being ineffective - I think there are strong reasons to think that the care you're providing is doing more good than the counterfactual use of the nurses' time, and that in the long-run the supply of nurses is relatively elastic. But I'm curious if this might be a reason to think the program is less cost-effective than it initially appears.
GiveWell's moral weights take a time-relative interest account-like approach to the value of a human life, in which saving the life of a newborn infant is weighted as moderately less valuable than saving the life of an older child. This leads to GiveWell estimating r.i.c.e.'s cost-effectiveness as about 30% lower than it would have been if they had weighted preventing infant deaths as equally valuable as preventing the deaths of older children. Do you personally have any thoughts about the right approach to making these kinds of difficult tradeoffs when evaluating different charities? And how important a consideration do you think this moral weight question is for donors who are considering donating to r.i.c.e. vs. GiveWell's current top charities.

deanspearsMay 4 20249

Thanks so much for asking!

My sense is that expanding the program at this site (or keeping it alive and well for more years at this site) has increasing returns, because we spread the administrative costs over more babies. In fact, knowing we have the funding runway to keep the program healthy lets us hire higher-quality staff with multi-year commitments. But expanding to another district would have huge fixed costs, even if the marginal cost is identical once it is up and running. We would still have a lot of our learning-by-doing, and we would have the paperwork, software, and protocols that we have developed, but we would fundamentally need some new relationships and a new entrepreneurial leader to captain that ship. We don’t currently have that person, but there is no in-principle reason that they could not be found and hired someday. More broadly, running this program has caused us to realize that cost-effectiveness in EA, philanthropy, and development economics has not paid enough attention to what microeconomic theory knows about fixed, variable, marginal, and average costs all being different. It's on the to-do list to write about that someday.
There are three margins of behavior: The families, the government-salary doctors, and the nurses who are privately hired by the program. The families would counterfactually be bringing most babies home to poor odds. We believe the doctors are working harder and doing more, because the returns to their efforts are improved by the collaboration with the nurses and families. So what about the nurses? Government nurse jobs, for now, remain very hard to get (it's a bad equilibrium where there both are not enough nurses and not enough public facilities to hire them). So these nurses would likely work somewhere in the private sector. Who knows the tiny general equilibrium effect on statewide nurse wages (!) but the quality of healthcare and neonatal survival for babies born in private facilities is worse, on average, than public facilities in this context, so on the margin shifting activity from private to public facilities would be likely to save lives.
If I understand the question, my own view is the opposite: all else equal, saving a neonate is 60 person-months better than saving a five year old. But I personally suspect this isn't a huge practical deal: The uncertainties and variance in cost-effectiveness are plausibly much larger than one-part-in-three.

MHR🔸May 4 20242

Thanks so much for your response, that all makes sense!

You're understanding question 3 correctly - GiveWell's moral weights look like the following, which is fairly different from valuing every year of life equally.

Karan MakkarMay 6 20247

Hi Dean!

Two questions about this:

Is the distinction I drew above directionally correct, or does skin to skin contact require as much in person expert attention as breastfeeding assistance?
If the distinction is directionally correct, might it be possible to scale the provision of the skin to skin contact advice for much cheaper than it would take to hire a lot more nurses (some kind of information provision/belief change intervention in econ jargon)?
1. This could look like some kind of door-to-door campaign by community health workers, or a video version of text-message reminders for vaccines (though an internet requirement might screen out some of the households we care most about).
2. Are the two parts of KMC strong complements in a way that would make the provision of just one of them much less effective?

deanspearsMay 7 20244

Maybe implicit in your question is the guess that the nurses more or less tell the moms about skin-to-skin contact and then they go along their way and do it. But in fact, the skin-to-skin part is pretty labor intensive too, because it requires keeping the moms present in the hospital and engaged in the effort, instead of giving up and going home. Yes, there’s some troubleshooting (the angle, the KMC wrap, …). But more than that, there’s a lot of cheerleading (“How’s it going?” “You’re doing great!” “Keep it up!”), which is often a big part of good nursing care, and especially here. Part of what the program is doing—by helping the moms have what they need in terms of food, bathroom opportunities, and encouragement—is helping the moms feel good about the long slog of getting these babies up to a safer weight and ready to eat and grow.

I ran this question by a colleague who wrote back: “I think [mere] information campaigns that show parents doing KMC for LBW babies in healthcare settings and at home would be a good idea, and I think that having non-nursing staff (say ward ayas) teaching parents KMC in a hospital setting would be better than not doing so, but I don't think we should expect large effects.

“It takes time for the mothers to learn positioning and wrapping (KMC can be unsafe without these inputs), and the constant checking and temperature measurement and encouragement matter to getting mothers to do enough hours.

“I would say, if you have the option of using trained nursing staff, you should. If you don't, then by all means give people the [mere] information that prolonged skin to skin contact is beneficial for their LBW newborn. But it is not a close second best.”

Karan MakkarMay 9 20241

Toby Tremlett🔹May 7 20243

Hi Dean, thanks for doing this! I really enjoyed the episode. I've got a couple questions:
1. Do you know why private hospitals in Uttar Pradesh had higher mortality rates for premature babies than public hospitals? Seemed super surprising.
2. Is kangaroo mother care the best practice for underweight/premature babies overall, or just the most cost-effective improvement compared to current standards of care in Uttar Pradesh? I.e. do, or should, hospitals in wealthy countries also use this method?

deanspearsMay 7 20241

Thanks for asking! Both of these turn out to be questions at the research frontier.

On 1:

The public-hospital survival advantage in Uttar Pradesh (and a few similar states in north India) is surprising! There’s a literature in development economics that public and private service delivery fails in different ways, because of different incentives. Private providers are paid more when they appear to be doing more, so they often provide unnecessary, or even harmful “treatments.” These interventions tend to do more harm than good for most births. Patients unfortunately don't know this; healthcare is a setting where information asymmetry is severe.

This is an active research area for our team: We’re working on an NIH grant application, and Nathan Franz (a PhD student at UT) is doing great dissertation research on this topic. As a rough answer, private providers have an economic incentive to do things to the baby that they can charge for, so they separate the mom and baby and, say, wash the baby, which might delay breastfeeding or make it cold. Public providers more or less leave the mom and baby alone, which tends to be the best plan for most newborns. I should also note that the data supporting the public-facility survival advantage is about the average baby, not about the low birthweight and premature babies that r.i.c.e.’s program targets (even the big Demographic and Health Survey doesn’t have enough of those babies to have enough statistical power to draw conclusions about that group).

There’s more detail and not every case is the average case, but there’s an interesting implication for our project: If, as the years go on and word gets out, improving care in public facilities attracts more births to happen in public rather than private facilities, that could be a positive externality even for babies who are not small or premature enough to be eligible for this program.

On 2:

Different babies need different things, so there is no one right answer. Hospitals in rich countries are able to provide many more interventions that improve survival chances for the smallest and most preterm babies than hospitals in poor settings, such as Uttar Pradesh. For example, breathing support (ventilators and CPAP) and continuous vital sign monitoring are available in almost all rich country settings. Sometimes these interventions are compatible with KMC and other times they are not. Where they are, doctors and nurses in rich countries are increasingly combining them with KMC. The iKMC trial I talked about occurred in more of a middle-income setting where KMC was combined with continuous vital signs monitoring, but none of the babies were on ventilators, for example. That study found improved outcomes relative to keeping the baby in a radiant warmer with vital sign monitoring.

In settings where staff and machines are scarce, KMC is the standard of care. Given the staff shortages, the cost of machines, and the difficulties of training staff to use those machines, I would argue that it would do more good to expand Kangaroo Care to more babies in poor country settings rather than be able to serve a much smaller number of babies with rich-country style care.