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Early Life Health Interventions and Academic Achievement

Development Challenge

The 2005 World Health Report documents that persistent gaps in infant healthcare both between and within countries lead to largely avoidable deaths of over 4 million babies before they reach the age of 28 days. In fact, infant deaths due to healthcare gaps are considerably more common than infant deaths caused by malaria and AIDS combined.[1] While programs to improve childhood health often focus on reducing infant mortality, research suggests that early life health interventions may also affect long-run academic achievement. This feature of early childhood healthcare programs indicates that broader infant and child healthcare provision could be effective in both preventing avoidable deaths and improving long-term educational outcomes of children.

Context

In Chile, approximately 75% of the population uses the public insurance system for healthcare.[2] The national health system has 26 regions and each region has at least one hospital with a Neonatal Intensive Care Unit (NICU), which provides specialized care to Very Low Birth Weight (VLBW) infants. All of these NICUs have the same standards of care and equipment.[3] In the 1990s, Chile introduced standardized neonatal healthcare procedures that emphasized treatment for infants with birth weights below 1500 grams and/or gestational age of less than 32 weeks. Specialized treatments provided to infants below these cutoffs include examination by a neonatologist, a five-day check-up, various X-rays, nutritional supplements, screening to help avoid blindness, screening and treatment for hearing loss, and other forms of specialized care. In 1998, Chile expanded the program to include a national policy for universal surfactant therapy to be administered to VLBW babies. This treatment addresses respiratory problems common to infants with low birth weight.

In Norway, medical practices are similar to those of Chile in that infants below 1500 grams are given extra care, including surfactant therapy (introduced in 1989). This study focuses on the impact of these standardized infant healthcare procedures on mortality and academic achievement.

Evaluation Strategy

For the purposes of this evaluation, the researchers focused on the birth weight cutoff of Chile and Norway’s neonatal healthcare provisions, where infants with a birth weight below 1500 grams were eligible for additional healthcare while those with a birth weight just above the cutoff were not eligible. In Chile, the study compares mortality rates and academic achievement between those infants just below and above the VLBW cutoff of 1500 grams, including approximately 7,230 births between 1400 and 1600 grams and above 32 weeks of gestation. The study also pays specific attention to the introduction of the Chilean national surfactant policy. Mortality rate data was compiled by matching birth records between 1992-2007 to death certificates for the same years. Academic achievement data was drawn from two sources: (1) birth records between 1992-2002 matched to school outcomes for the period 2002-2009, and (2) fourth grade test scores from Chile’s national test – the SIMCE.

For Norway, researchers observed 2,477 births between 1300 and 1700 grams. About 1,498 of those births were infants above 32 weeks of gestation. The research team matched those birth files to standardized test score data among 10th graders from the Norwegian Registry Data, an administrative dataset that covers the entire population of Norwegians aged 16-74 in the 1986-2008 period. Researchers used a regression discontinuity design to avoid confounding factors such as unobservable family characteristics in order to infer that the impacts on mortality rates and academic achievement were caused by early childhood health interventions

Results and Policy Implications

Impact on Mortality: The study finds compelling evidence that increased medical care provided to newborns with low birth weights has a significant impact on mortality rates. In Chile, infants born just below the 1500-gram cutoff (those who received treatment) were 4.5% less likely to die within a year compared to infants above the cutoff (who did not receive the treatment).  In addition, those who received the treatment were 1.9% less likely to die within the first 24 hours. In Norway, children below 1500 grams (who received the treatment) were 3.1% less likely to die within a year if they were born at or greater than 32 weeks in gestational age.

Impact on Academic Achievement: In Chile, children born just below the 1500 gram cutoff had math and language grades that were higher on average than kids born above the cutoff, despite the otherwise positive relationship between birth weight and academic achievement. Additionally, test scores for children who received increased medical care were higher for both math and language than those who did not. In Norway, children born just below the 1500 gram cutoff had 10th grade standardized test scores higher than the average. These findings suggest that early healthcare interventions have spillover effects on educational achievement.

Impact of Surfactant Program on Mortality and Academic Achievement: Results show that children with low birth weights born after the therapy was introduced in both countries had increased test scores. In Chile, the program also resulted in additional decreases in infant mortality and 24-hour mortality.

Overall, the study finds an important role for early childhood healthcare in determining later life outcomes. By examining the impact on both mortality and academic achievement, the authors highlight multiple benefits for providing infant and child healthcare. The evidence may also help to explain the link between health and income in adulthood by showing that better health in childhood improves cognitive development and thus enhances an individual’s potential to succeed later in life.

Timeline

1992-2008

[1] World Health Organization (WHO). The World Health Report 2005: Make Every Mother and Child Count. Available at http://www.who.int/whr/2005/whr2005_en.pdf.

[2] Palomino, M. M. Morgues, and F. Martinez (2005): “Management of infants with chronic lung disease of prematurity in Chile,” Early Human Development.

[3] Gonzalez, R., M. Merialdi, O. Lincetto, J. Lauer, C. Becerra, R. Castro, P. Garcia, O. Saugstad, and J. Villar (2006): “Reduction in neonatal mortality in Chile between 1990 and 2000,” Pediatrics.

Photo via Flickr: Julio Pantoja / World Bank