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It's a Long Walk: Lasting Effects of Maternity Ward Openings on Labor Market Performance
Abstract
Being born in a hospital versus having a traditional birth attendant at home represents the most common early life policy change worldwide. By applying a difference-in-differences approach to register-based individual-level data on the total population, this paper explores the long-term economic effects of the opening of new maternity wards as an early life quasi-experiment. It first finds that the reform substantially increased the share of hospital births and reduced early neonatal mortality. It then shows sizable long-term effects on labour income, unemployment, health-related disability and schooling. Small-scale local maternity wards yield a larger social rate of return than large-scale hospitals.
... Based on causal designs, economists have recently studied the establishment of epidemical and modern hospitals (Hollingsworth et al. 2024;Lazuka 2023), the impacts of licensed midwifery (Kotsadam, Lind, and Modalsli 2022;Anderson et al. 2020;Lazuka 2018), of tuberculosis dispensaries (Egedesø, Hansen, and Jensen 2020;Clay et al. 2020;Anderson et al. 2019), and of mid-twentieth-century antibiotics and vaccinations (Atwood 2022;Bütikofer and Salvanes 2020;Lazuka 2020). The focus on historical interventions has helped us better understand their effects on individuals. ...
Can the effects of childhood vaccination extend across three generations? Using Swedish data spanning 250 years, we estimate the impact of smallpox vaccination on longevity, disability, and occupational achievements. Employing mother fixed-effects, difference-in-differences, and shift-share instrumental-variables designs, we find that vaccination improves health and economic outcomes for at least two subsequent generations. Causal mediation analysis reveals that these benefits arise from improved health behaviors and epigenetic factors. Even in milder disease environments as seen today, vaccination delivers lasting advantages, demonstrating its long-term benefits beyond epidemic contexts. These findings highlight the benefits of early-life health interventions lasting for subsequent generations.
... Third, we examine the effects of a secondary education reform that has received less attention compared to the broader literature on long-term impacts of primary education reforms (Dominguez and Ruffini (2023); Heinesen and Stenholt Lange (2022);Fischer et al. (2022);Mazumder et al. (2021);Fischer et al. (2020); Hyman (2017); Jackson et al. (2016)). Finally, we show that investments in skills in school ages yield long-term benefits similar to preschool investments, often considered especially effective (Lazuka (2023); Wüst (2022); Almond et al. (2018)). We also propose that our study will encourage the use of DiD estimators robust to heterogeneous treatments within a multiple-treatment framework to estimate interaction effects. ...
This paper investigates the dynamic complementarity between school health and education reforms implemented in Denmark between 1940 and 1965: the introduction of school doctors and the expansion of secondary education. Using a staggered difference-in-differences approach for multiple treatments, we study the reform effects on individuals' outcomes in the ages 55-64. We find that each reform leads to significant improvements in health and education outcomes, including reduced mortality, fewer hospitalizations, and higher educational attainment. The singular impact of each reform is doubled when both reforms are implemented together, resulting in a 9 percent increase in earnings. These findings underscore high societal returns to complementary school investments in the long term.
... 2022 study, which examined the introduction of maternity wards in Sweden, found that the wards substantially reduced home deliveries and early neonatal mortality, as well as positive long-term effects on labor income, unemployment, health-related disability and schooling for individuals born in maternity wards [43] . These findings held true for both nulliparous (RR 1.04, 95% CI 0.62-1.73) ...
Background: A home birth is a birth that takes place in a residence rather than in a hospital or a birthing center.
Exposure to infectious diseases in early life has been linked to increased mortality risk in later life in high-disease settings, such as eighteenth- and nineteenth-century Europe. Less is known about the long-term effects of early-life disease exposure in milder disease environments. This study estimates heterogeneous effects from disease exposure in infancy on later-life mortality in twentieth-century Sweden, by socioeconomic status at birth and sex. Using historical population data for southern Sweden, we study 11,515 individuals who were born in 1905–1929 from age 1 until age 85. We measure exposure to disease using the local post–early neonatal mortality rate in the first 12 months after birth and apply flexible parametric survival models. For females, we find a negative effect on life expectancy (scarring) at ages 1–85 following high disease exposure in infancy, particularly for those born to unskilled workers. For males, we find no negative effect on later-life survival, likely because stronger mortality selection in infancy outweighs scarring. Thus, even as the incidence of infectious diseases declined at the start of the twentieth century, early-life disease exposure generated long-lasting negative but heterogeneous population health effects.
This paper estimates the causal effect of a historical midwifery policy experiment on maternal mortality, infant mortality, and stillbirth during the period of 1830–1894 in Sweden. Exploiting sharp changes or “discontinuities” across time and place in the availability of trained and licensed midwives as an exogenous source of variation, we find that a doubling of trained midwives led to a 20%–40% reduction in maternal mortality and a 20% increase in the uptake of midwife-assisted homebirths. The results thus suggest that a 1% increase in the share of midwife-assisted homebirths decreased maternal mortality by as much as 2%, which is a remarkable finding given that midwife training was only 6–12 months at that time. The results of this study contribute to the current debate about the most effective strategy to reduce the unacceptably high rate of maternal mortality in many developing countries, especially in low-resource settings.
This paper quantifies and aggregates the multiple lifetime benefits of an influential high-quality early childhood program with outcomes measured through midlife. Guided by economic theory, we supplement experimental data with non-experimental data to forecast the life-cycle benefits and costs of the program. Our point estimate of the internal rate of return is 13.7% with an associated benefit/cost ratio of 7.3. We account for model estimation and forecasting error and present estimates from extensive sensitivity analyses. This paper is a template for synthesizing experimental and non-experimental data using economic theory to estimate the long-run life-cycle benefits of social programs.
We investigate the effects of perinatal medical treatments on low-income newborns who are classified as low-risk. A policy rule in The Netherlands states that low-risk deliveries before week 37 should be supervised by physicians and later deliveries only by midwives with no physician present. This creates large discontinuities in the probability of receiving medical interventions only physicians are allowed to perform. Using a regression discontinuity design, we find that babies born slightly before the week-37 cutoff are significantly less likely to die than babies born slightly later. Our data suggest that physician supervision of birth reduces the likelihood of adverse events such as fetal distress or emergency C-section. Our results indicate that low-income women benefit from receiving a higher level of medical care even if no explicit risk factors have been recognized, pointing to challenges in identifying all high-risk pregnancies. “Back-of-the-envelope” calculations suggest this additional care is highly cost-effective.
Do early-life effects of investments in public health persist to the oldest-old ages? This article answers this question by using the primary care reform in rural Sweden that between 1890 and 1917 led to the establishment of local health districts, together with openings of hospitals and recruitments of medical personnel, as a natural experiment in early-life environmental conditions. The initiatives undertaken within these districts targeted control of infectious diseases, including various isolation and disinfection measures. This study applies a difference-in-differences method combined with propensity score matching to register-based individual-level data for Sweden from 1968 to 2012 and to multisource, purposely collected data on the reform implementation. Providing pioneering evidence for such a distal relationship (ages 78–95), this study finds that treatment through primary care in the year of birth leads to a significant reduction in all-cause mortality (4 % to 6%) and mortality from cardiovascular diseases (5 % to 6 %) and to an increase in average incomes (2 % to 3 %). The effects are universal and somewhat stronger among individuals from poor socioeconomic backgrounds and at higher baseline levels of disease burden.
Electronic supplementary material
The online version of this article (10.1007/s13524-018-0758-4) contains supplementary material, which is available to authorized users.
Growing evidence from a number of countries in Asia and Africa documents a large shift towards facility deliveries in the past decade. These increases have not led to the improvements in health outcomes that were predicted by health policy researchers in the past. In light of this unexpected evidence, we have assessed data from multiple sources, including nationally representative data from 43 countries in Asia and Africa, to understand the size and range of changing delivery location in Asia and Africa. We have reviewed the policies, programs and financing experiences in multiple countries to understand the drivers of changing practices, and the consequences for maternal and neonatal health and the health systems serving women and newborns. And finally, we have considered what implications changes in delivery location will have for maternal and neonatal care strategies as we move forward into the next stage of global action. As a result of our analysis we make four major policy recommendations. (1) An expansion of investment in mid-level facilities for delivery services and a shift away from low-volume rural delivery facilities. (2) Assured access for rural women through funding for transport infrastructure, travel vouchers, targeted subsidies for services and residence support before and after delivery. (3) Increased specialization of maternity facilities and dedicated maternity wards within larger institutions. And (4) a renewed focus on quality improvements at all levels of delivery facilities, in both private and public settings.
Skilled birth attendant (SBA) utilization is low in remote and rural areas of Nepal. We designed and implemented an evaluation to assess the effectiveness of a five-component intervention that addressed previously identified barriers to SBA services in mid- and far-western Nepal. We randomly and equally allocated 36 village development committees with low SBA utilization among 1-year intervention and control groups. The eligible participants for the survey were women that had delivered a baby within the past 12 months preceding the survey. Implementation was administered by trained health volunteers, youth groups, mothers' groups and health facility management committee members. Post-intervention, we used difference-in-differences and mixed-effects regression models to assess and analyse any increase in the utilization of skilled birth care and antenatal care (ANC) services. All analyses were done by intention to treat. Our trial registration number was ISRCTN78892490 (http://www.isrctn.com/ISRCTN78892490). Interviewees included 1746 and 2098 eligible women in the intervention and control groups, respectively. The 1-year intervention was effective in increasing the use of skilled birth care services (OR = 1.57; CI 1.19-2.08); however, the intervention had no effect on the utilization of ANC services. Expanding the intervention with modifications, e.g. mobilizing more active and stable community groups, ensuring adequate human resources and improving quality of services as well as longer or repeated interventions will help achieve greater effect in increasing the utilization of SBA.
Background
Primary health care (PHC) encompasses an array of health and social services that focus on preventative, diagnostic, and basic care measures to maintain wellbeing and address illnesses. In Canada, PHC involves the provision of first-contact health care services by providers such as family physicians and general practitioners – collectively referred as PHC physicians here. Ensuring access is a key requirement of effective PHC delivery. This is because having access to PHC has been shown to positively impact a number of health outcomes.
Methods
We build on recent innovations in measuring potential spatial access to PHC physicians using geographic information systems (GIS) by running and then interpreting the findings of a modified gravity model. Elsewhere we have introduced the protocol for this model. In this article we run it for five selected Canadian provinces and territories. Our objectives are to present the results of the modified gravity model in order to: (1) understand how potential spatial access to PHC physicians can be interpreted in these Canadian jurisdictions, and (2) provide guidance regarding how findings of the modified gravity model should be interpreted in other analyses.
Results
Regarding the first objective, two distinct spatial patterns emerge regarding potential spatial access to PHC physicians in the five selected Canadian provinces: (1) a clear north–south pattern, where southern areas have greater potential spatial access than northern areas; and (2) while gradients of potential spatial access exist in and around urban areas, access outside of densely-to-moderately populated areas is fairly binary. Regarding the second objective, we identify three principles that others can use to interpret the findings of the modified gravity model when used in other research contexts.
Conclusions
Future applications of the modified gravity model are needed in order to refine the recommendations we provide on interpreting its results. It is important that studies are undertaken that can help administrators, policy-makers, researchers, and others with characterizing the state of access to PHC, including potential spatial access. We encourage further research to be done using GIS in order to offer new, spatial perspectives on issues of access to health services given the increased recognition that the place-based nature of health services can benefit from the use of the capabilities of GIS to enhance the role that visualization plays in decision-making.
The first half of the twentieth century saw rapid improvements in the health and height of British children. Average height and health can be related to infant mortality through a positive selection effect and a negative scarring effect. Examining town-level panel data on the heights of school children I find no evidence for the selection effect but some support for the scarring effect. The results suggest that the improvement in the disease environment, as reflected by the decline in infant mortality, increased average height by about half a centimeter per decade in the first half of the twentieth century.
Taller populations are typically richer populations, and taller individuals live longer and earn more. In consequence, adult height has recently become a focus in understanding the relationship between health and wealth. We investigate the childhood determinants of population adult height, focusing on the respective roles of income and of disease. Across a range of European countries and the United States, we find a strong inverse relationship between postneonatal (ages 1 month to 1 year) mortality, interpreted as a measure of the disease and nutritional burden in childhood, and the mean height of those children as adults. Consistent with these findings, we develop a model of selection and stunting in which the early-life burden of undernutrition and disease not only is responsible for mortality in childhood but also leaves a residue of long-term health risks for survivors, risks that express themselves in adult height and in late-life disease. The model predicts that at sufficiently high mortality levels, selection can dominate scarring, leaving a taller population of survivors. We find evidence of this effect in the poorest and highest-mortality countries of the world, supplementing recent findings on the effects of the Great Chinese Famine.
In the 1990s, the Indonesian government placed over 50,000 midwives in communities throughout the country. We examine how this expansion in health services affected children's height-for-age. To address the problem that midwives were not randomly allocated to communities, the estimation exploits the biology of childhood growth, the timing of the introduction of midwives to communities, and rich longitudinal data. The evidence indicates that the nutritional status of children fully exposed to a midwife during early childhood is significantly better than that of their peers of the same age and cohort in communities without a midwife. The former are also better off than children assessed at the same age from the same communities but who were born before the midwife arrived. Within communities, the improvement in nutritional status across cohorts is greater where midwives were introduced than where they were not. This result is robust to the inclusion of community fixed effects.
We propose a new regression method to estimate the impact of explanatory variables on quantiles of the unconditional (marginal) distribution of an outcome variable. The proposed method consists of running a regression of the (recentered) influence function (RIF) of the unconditional quantile on the explanatory variables. The influence function is a widely used tool in robust estimation that can easily be computed for each quantile of interest. We show how standard partial effects, as well as policy effects, can be estimated using our regression approach. We propose three different regression estimators based on a standard OLS regression (RIF-OLS), a logit regression (RIF-Logit), and a nonparametric logit regression (RIF-OLS). We also discuss how our approach can be generalized to other distributional statistics besides quantiles.
We develop a framework for difference-in-differences designs with staggered treatment adoption and heterogeneous causal effects. We show that conventional regression-based estimators fail to provide unbiased estimates of relevant estimands absent strong restrictions on treatment-effect homogeneity. We then derive the efficient estimator addressing this challenge, which takes an intuitive “imputation” form when treatment-effect heterogeneity is unrestricted. We characterize the asymptotic behavior of the estimator, propose tools for inference, and develop tests for identifying assumptions. Our method applies with time-varying controls, in triple-difference designs, and with certain non-binary treatments. We show the practical relevance of our results in a simulation study and an application. Studying the consumption response to tax rebates in the United States, we find that the notional marginal propensity to consume is between 8 and 11 percent in the first quarter — about half as large as benchmark estimates used to calibrate macroeconomic models — and predominantly occurs in the first month after the rebate.
We identify earnings impacts of exposure to an infant health intervention in Sweden, using individual-linked administrative data to trace potential mechanisms. Leveraging quasi-random variation in eligibility, we estimate that exposure was associated with higher test scores in primary school for boys and girls. However, only girls were more likely to score in the top quintile. Subsequent gains, in secondary schooling, employment, and earnings, are restricted to girls. We show that the differential gains for women accrued from both skills and opportunities.
The canonical difference-in-differences (DD) estimator contains two time periods, ”pre” and ”post”, and two groups, ”treatment” and ”control”. Most DD applications, however, exploit variation across groups of units that receive treatment at different times. This paper shows that the two-way fixed effects estimator equals a weighted average of all possible two-group/two-period DD estimators in the data. A causal interpretation of two-way fixed effects DD estimates requires both a parallel trends assumption and treatment effects that are constant over time. I show how to decompose the difference between two specifications, and provide a new analysis of models that include time-varying controls.
We use administrative data from the IRS to examine long-term impacts of childhood Medicaid eligibility expansions on outcomes in adulthood at each age from 19-28. Greater Medicaid eligibility increases college enrollment and decreases fertility, especially through age 21. Starting at age 23, females have higher contemporaneous wage income, although male increases are imprecise. Together, both genders have lower mortality. These adults collect less from the earned income tax credit and pay more in taxes. Cumulatively from ages 19-28, at a 3% discount rate, the federal government recoups 58 cents of each dollar of its "investment" in childhood Medicaid.
Linear regressions with period and group fixed effects are widely used to estimate treatment effects. We show that they estimate weighted sums of the average treatment effects (ATE ) in each group and period, with weights that may be negative. Due to the negative weights, the linear regression coefficient may for instance be negative while all the ATEs are positive. We propose another estimator that solves this issue. In the two applications we revisit, it is significantly different from the linear regression estimator. (JEL C21, C23, D72, J31, J51, L82)
We study the impact of preschool targeted at children from low-income families over the life cycle and across generations, and examine its interaction with an infant health intervention. Using Danish administrative data with variation in the timing of program implementation over the period 1933–1960, we find lasting benefits of access to preschool on adult educational attainment, earnings, and survival beyond age 65. We also show that children of women exposed to pre-school obtain more education by age 25. However, exposure to a nurse home visiting program in infancy reduces the added value of preschool, implying that the programs serve as partial substitutes. (JEL I12, I18, I21, I26, J13, J24, J31)
Objective:
To investigate whether inverse probability of participation weighting (IPPW) using register data on sociodemographic and disease history variables can improve external validity in a cohort study with selective participation.
Study design and setting:
We fitted various IPPW models by logistic regression using register data for the participants (n = 1,111) and nonparticipants (n = 1,132) of a Swedish cohort study. For each of six diagnostic groups, we then estimated (1) weighted disease prevalence proportions and (2) weighted cross-sectional associations (odds ratios) between sociodemographic variables and disease prevalence. Using register data on the remaining individuals of the entire study population of men and women aged 50-64 years (n = 22,259), we addressed how the choice of variables used for IPPW influenced estimation errors.
Results:
Disease prevalence proportions were generally underestimated in the absence of IPPW but became markedly closer to population values after IPPW using sociodemographic variables. We found limited evidence of selective participation bias in association estimates, but IPPW improved external validity when bias was present.
Conclusions:
IPPW using sociodemographic register data can improve the external validity of disease prevalence estimates in cohort studies with selective participation. The performance of IPPW for association estimates merits further investigations in longitudinal settings and larger cohorts.
That prenatal events can have life-long consequences is now well established. Nevertheless, research on the fetal origins hypothesis is flourishing and has expanded to include the early childhood (postnatal) environment. Why does this literature have a "second act?" We summarize the major themes and contributions driving the empirical literature since our 2011 reviews, and try to interpret the literature in light of an overarching conceptual framework about how human capital is produced early in life. One major finding is that relatively mild shocks in early life can have substantial negative impacts, but that the effects are often heterogeneous reflecting differences in child endowments, budget constraints, and production technologies. Moreover, shocks, investments, and interventions can interact in complex ways that are only beginning to be understood. Many advances in our knowledge are due to increasing accessibility of comprehensive administrative data that allow events in early life to be linked to long-term outcomes. Yet, we still know relatively little about the interval between, and thus about whether it would be feasible to identify and intervene with affected individuals at some point between early life and adulthood. We do know enough, however, to be able to identify some interventions that hold promise for improving child outcomes in early life and throughout the life course.
This paper studies the long-term and life cycle consequences of increasing access to mother and child health care centers in the first year of life. Access to these centers increased completed years of schooling by 0.15 years and earnings by 2%. These effects were stronger for children from a low socioeconomic background and contribute to a 10% reduction in the intergenerational persistence in educational attainment. Better nutrition within the first year of life is a likely mechanism. In particular, we find positive effects on adult height, fewer health risks at age 40, and decreased infant mortality from diarrhea. © 2019 by the President and Fellows of Harvard College and the Massachusetts Institute of Technology.
This paper studies the effects of improvements in infant health produced by the introduction of sulphapyridine in the late-1930s as treatment against pneumonia on outcomes in adulthood. Based on longitudinal individual data for the whole population of Sweden 1968–2012 and archival data on the availability of sulphapyridine and applying a difference-in-differences approach, it finds that mitigation of pneumonia infection in infancy increased labor income in late adulthood by 2.8–5.1 percent. The beneficial effects are strong for health, measured by length of stay in hospital, and weaker for years of schooling. These effects are similar between men and women.
Hospitals in the United States increasingly belong to multihospital systems that operate in numerous geographic markets. A large literature in management and economics suggests that competition between firms may be softened as a result of multimarket contact- i.e., firms competing with one another in multiple markets simultaneously. Exploiting plausibly exogenous variation in multimarket contact generated by out-of-market consolidation, I find that increases in multimarket contact over the 2000-2010 period led to higher hospital prices. These results suggest that continued hospital consolidation may produce higher prices even if that consolidation only minimally affects within-market concentration.
This paper studies how in utero exposure to maternal stress from family ruptures affects later mental health. We find that prenatal exposure to the death of a maternal relative increases take-up of ADHD medications during childhood and anti-anxiety and depression medications in adulthood. Further, family ruptures during pregnancy depress birth outcomes and raise the risk of perinatal complications necessitating hospitalization. Our results suggest large welfare gains from preventing fetal stress from family ruptures and possibly from economically induced stressors such as unemployment. They further suggest that greater stress exposure among the poor may partially explain the intergenerational persistence of poverty.
This paper explores the long-term effects of being born with the assistance of a qualified midwife on health and skills, using longitudinal register-based data for individuals born in rural Swedish parishes between 1881 and 1930 and followed from birth until age 80. In the setting of home deliveries, midwives strictly followed hygiene instructions and monitored the health of the mothers and newborns for 3 weeks after birth, and the study observes these individual-level treatments. The results from empirical strategies controlling for observables, using instrumental variables and mother fixed effects are consistent. This paper first finds that treatment by qualified midwives at birth reduced neonatal mortality. It further concludes that individuals treated by qualified midwives at birth had substantially lower mortality from cardiovascular diseases and diabetes at ages 40–80 and that males had lower morbidity and better skills at ages 19–21 than those treated by traditional birth attendants.
Exploiting the Danish roll-out of same-day discharge policies after uncomplicated births, we find that treated newborns have a higher probability of hospital readmission in the first month after birth. While these short-run effects may indicate substitution of hospital stays with readmissions, we also find that—in the longer run—a same-day discharge decreases children's ninth grade GPA. This effect is driven by children and mothers, who prior to the policy change would have been least likely to experience a same-day discharge. Using administrative and survey data to assess potential mechanisms, we show that a same-day discharge impacts those parents’ health investments and their children's medium-run health. Our findings point to important negative effects of policies that expand same-day discharge policies to broad populations of mothers and children.
This paper investigates the potential of an infant intervention to improve life expectancy, contributing to emerging interest in the early life origins of chronic disease. We track individuals from birth to death, and are able to identify age and cause of death. The intervention was pioneered in Sweden in 1931–1933, and appears to have been pivotal in the emergence of universal infant care programmes in the Scandinavian countries during the creation of the Welfare State. It provided information and support to mothers, with an emphasis on nutrition and sanitation, while monitoring infant care through home visits and clinics. We estimate that the average duration of programme exposure in infancy led to a 1.56% point decline in the risk of infant death (24% of baseline risk) and a 2.56% point decline in the risk of dying by age 75 (7.0% of baseline risk), and these impacts are much larger for children born out of wedlock. Intervention-led declines in the risk of dying after the age of 50 are dominated by reductions in cancer and cardiovascular mortality. We find no evidence of selective utilisation, and the estimates are similar when we exploit within-mother variation in outcomes. (JEL: I15; I18; H41)
This article examines the long-term impacts on health and healthy behaviour of two of the oldest and most widely cited US early childhood interventions evaluated by the method of randomisation with long-term follow-up: the Perry Preschool Project (PPP) and the Carolina Abecedarian Project (ABC). There are pronounced gender effects strongly favouring boys, although there are also effects for girls. Dynamic mediation analyses show a significant role played by improved childhood traits, above and beyond the effects of experimentally enhanced adult socioeconomic status. These results show the potential of early life interventions for promoting health.
The field of life course epidemiology has expanded rapidly since this book was first published. The purpose of this field is to study how biological and social factors during gestation, childhood, adolescence, and earlier adult life independently, cumulatively, and interactively influence later life health and disease. Contributors to this edition capture the excitement of the developing field and assess the latest evidence regarding sources of risk to health across the life course and across generations. The chapters on life course influences on cardiovascular disease, diabetes, blood pressure, respiratory disease, and cancer have been updated and extended. New chapters on life course influences on obesity, biological ageing, and neuropsychiatric disorders have been added. Life course explanations for disease trends and for socioeconomic differentials in disease risk are given more attention in this edition, reflecting recent developments in the field. The section on policy implications has been expanded, assessing the role of interventions to improve childhood social circumstances, as well as interventions to improve early growth. Emerging new research themes and the theoretical and methodological challenges facing life course epidemiology are highlighted.
Mounting evidence across different disciplines suggests that early-life conditions can have consequences on individual outcomes throughout the life cycle. Relative to other developed countries, the United States fares poorly on standard indicators of early-life health, and this disadvantage may have profound consequences not only for population well-being, but also for economic growth and competitiveness in a global economy. In this paper, we first discuss the research on the strength of the link between early-life health and adult outcomes, and then provide an evidence-based review of the effectiveness of existing U.S. policies targeting the early-life environment. We conclude that there is a robust and economically meaningful relationship between early-life conditions and well-being throughout the life cycle, as measured by adult health, educational attainment, labor market attachment, and other indicators of socioeconomic status. However, there is some variation in the degree to which current policies in the United States are effective in improving early-life conditions. Among existing programs, some of the most effective are the Special Supplemental Program for Women, Infants, and Children (WIC), home visiting with nurse practitioners, and high-quality, center-based early-childhood care and education. In contrast, the evidence on other policies such as prenatal care and family leave is more mixed and limited.
We leverage the introduction of antibiotics in 1937 to demonstrate the long-run impacts of pneumonia in infancy on human capital and socioeconomic status among American adults. These impacts are larger for whites, despite the fact that blacks experienced larger post-1937 declines in pneumonia mortality rates. We argue that pre-Civil Rights barriers inhibited blacks from consolidating the socioeconomic returns to improved health endowments by depressing returns to human capital accumulation and limiting complementary investments. Consistent with this, we demonstrate gradients in impacts for blacks (but not whites) by indicators of institutional segregation. Our results highlight the importance of responsive investments in translating early-life health into later life socioeconomic status and persistent impacts of racial segregation.
This paper studies the effect of improved neonatal health care on mortality and long run academic achievement in school. We use the idea that medical treatments often follow rules of thumb for assigning care to patients, such as the classification of Very Low Birth Weight (VLBW), which assigns infants special care at a specific birth weight cutoff. Using detailed administrative data on schooling and birth records from Chile and Norway, we establish that children who receive extra medical care at birth have lower mortality rates and higher test scores and grades in school. These gains are in the order of 0.15-0.22 standard deviations.
Many developed countries have recently experienced sharp increases in home birth rates. This paper investigates the impact of home births on the health of low-risk newborns using data from the Netherlands, the only developed country where home births are widespread. To account for endogeneity in location of birth, we exploit the exogenous variation in distance from a mother’s residence to the closest hospital. We find that giving birth in a hospital leads to substantial reductions in newborn mortality. We provide suggestive evidence that proximity to medical technologies may be an important channel contributing to these health gains.
This chapter seeks to set out what Economists have learned about the effects of early childhood influences on later life outcomes, and about ameliorating the effects of negative influences. We begin with a brief overview of the theory which illustrates that evidence of a causal relationship between a shock in early childhood and a future outcome says little about whether the relationship in question biological or immutable. We then survey recent work which shows that events before five years old can have large long term impacts on adult outcomes. Child and family characteristics measured at school entry do as much to explain future outcomes as factors that labor economists have more traditionally focused on, such as years of education. Yet while children can be permanently damaged at this age, an important message is that the damage can often be remediated. We provide a brief overview of evidence regarding the effectiveness of different types of policies to provide remediation. We conclude with a list of some of (the many) outstanding questions for future research. Hard-copy subscribers may access the tables for this paper here.
How do adverse childhood experiences get 'under the skin' and influence health outcomes through the life-course? Research reviewed here suggests that adverse childhood experiences are associated with changes in biological systems responsible for maintaining physiological stability through environmental changes, or allostasis. Children exposed to maltreatment showed smaller volume of the prefrontal cortex, greater activation of the HPA axis, and elevation in inflammation levels compared to non-maltreated children. Adults with a history of childhood maltreatment showed smaller volume of the prefrontal cortex and hippocampus, greater activation of the HPA axis, and elevation in inflammation levels compared to non-maltreated individuals. Despite the clear limitations in making longitudinal claims from cross-sectional studies, work so far suggests that adverse childhood experiences are associated with enduring changes in the nervous, endocrine, and immune systems. These changes are already observable in childhood years and remain apparent in adult life. Adverse childhood experiences induce significant biological changes in children (biological embedding), modifying the maturation and the operating balance of allostatic systems. Their chronic activation can lead to progressive wear and tear, or allostatic load and overload, and, thus, can exert long-term effects on biological aging and health.
A key policy question is whether the benefits of additional medical expenditures exceed their costs. We propose a new approach for estimating marginal returns to medical spending based on variation in medical inputs generated by diagnostic thresholds. Specifically, we combine regression discontinuity estimates that compare health outcomes and medical treatment provision for newborns on either side of the very low birth weight threshold at 1500 grams. First, using data on the census of US births in available years from 1983-2002, we find that newborns with birth weights just below 1500 grams have lower one-year mortality rates than do newborns with birth weights just above this cutoff, even though mortality risk tends to decrease with birth weight. One-year mortality falls by approximately one percentage point as birth weight crosses 1500 grams from above, which is large relative to mean infant mortality of 5.5% just above 1500 grams. Second, using hospital discharge records for births in five states in available years from 1991-2006, we find that newborns with birth weights just below 1500 grams have discontinuously higher charges and frequencies of specific medical inputs. Hospital costs increase by approximately 40,000 just above 1500 grams. Under an assumption that observed medical spending fully captures the impact of the "very low birth weight" designation on mortality, our estimates suggest that the cost of saving a statistical life of a newborn with birth weight near 1500 grams is on the order of $550,000 in 2006 dollars.
We study the consequences of hospital competition for Medicare beneficiaries' heart attack care from 1985 to 1994. We examine
how relatively exogenous determinants of hospital choice such as travel distances influence the competitiveness of hospital
markets, and how hospital competition interacts with the influence of managed-care organizations to affect the key determinants
of social welfare—expenditures on treatment and patient health outcomes. In the 1980s the welfare effects of competition were
ambiguous; but in the 1990s competition unambiguously improves social welfare. Increasing HMO enrollment over the sample period
partially explains the dramatic change in the impact of hospital competition.
Patients who receive more hospital treatment tend to have worse underlying health, confounding estimates of the returns to such care. This paper compares the costs and benefits of extending the length of hospital stay following delivery using a discontinuity in stay length for infants born close to midnight. Third-party reimbursement rules in California entitle newborns to a minimum number of hospital "days," counted as the number of midnights in care. A newborn delivered at 12:05 a.m. will have an extra night of reimbursable care compared to an infant born minutes earlier. We use a dataset of all California births from 1991-2002, including nearly 100,000 births within 20 minutes of midnight, and find that children born just prior to midnight have significantly shorter lengths of stay than those born just after midnight, despite similar observable characteristics. Furthermore, a law change in 1997 entitled newborns to a minimum of 2 days in care. The midnight discontinuity can therefore be used to consider two distinct treatments: increasing stay length from one to two nights (prior to the law change) and from two to three nights (following the law change). On both margins, we find no effect of stay length on readmissions or mortality for either the infant or the mother, and the estimates are precise. The results suggest that for uncomplicated births, longer hospitals stays incur substantial costs without apparent health benefits.
This paper estimates and documents changes in the rate of return to education in Sweden between 1968 and 1991. Both the "quantity" (i.e.) years of schooling completed) and "quality" (i.e. education level obtained) dimensions of education are considered. These returns are calculated by estimating human capital wage equations. The data used are from the 1968, 1981 and 1991 Swedish Level of Living Surveys. There are three main conclusions. The first is that the rate of return to education declined considerably between 1968 and 1981. However, since 1981 there has been little change. The second is that the magnitude of the decline was not the same for all levels of education, with the decline being particularly pronounced for university education. The third is that the decline was not equally shared between men and women, with the decline being larger for women.
This paper discusses the bias that results from using nonrandomly selected samples to estimate behavioral relationships as an ordinary specification error or "omitted variables" bias. A simple consistent two stage estimator is considered that enables analysts to utilize simple regression methods to estimate behavioral functions by least squares methods. The asymptotic distribution of the estimator is derived.
A Researcher's Guide to the Swedish Compulsory School Reform', Swedish Institute for Social Research SOFIs Meddelande/Working papers
- H Holmlund
Holmlund, H. (2008) 'A Researcher's Guide to the Swedish Compulsory School Reform',
Swedish Institute for Social Research SOFIs Meddelande/Working papers.
- Riksarkivet
Riksarkivet (1931-1946) Statistik Centralbyrån Födda, Vigda, Döda 1860-1947 [Statistics
Sweden Birth, Marriages, Deaths 1860-1947] (Archive).
Sveriges Församlingar genom Tiderna
- Skatteförvaltningen
Skatteförvaltningen (1989) Sveriges Församlingar genom Tiderna [Swedish Parishes through
the Times], Stockholm, Graphic Systems.
Investigation Concerning Maternity Payments from 26
September 1929 [Investigation Concerning Maternity Payments from 26 September 1929]:
Statens Offentliga Utredningar 1929: 28 [The Government's Official Investigation],
Stockholm, Kungl. Boktryckeriet. P.A. Norstedt & Söner.
- Socialstyrelsen
Socialstyrelsen (1915-1950) Sveriges Officiella Statistik. Allmän Hälso-och Sjukvård
[Swedish Official Statistics. Health and Healthcare], Stockholm, Kungl. Boktryckeriet. P.A.
Norstedt & Söner.
En Upplivningsapparat för Nyfödda Barn
- Wachenfeldt
Public Health Programmes, Healthcare and Child Health
- Knutsson