paid maternity leave and infant health in 20 low- and middle-income countries joint work with...
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PAID MATERNITY LEAVE AND INFANT HEALTH IN 20 LOW- AND MIDDLE-INCOME COUNTRIES
Joint work with Mohammad Hajizadeh, Sam Harper, Erin Strumpf and Jody Heymann
Arijit Nandi ([email protected])
Topics for discussion
I. Background
II. Data and Empirical methods
III. ResultsIII.I. Infant and neonatal mortalityIII.II. Vaccination uptake
IV. Limitations and discussion
I. Background. Maternity leave and child health
The millennium development goals
The UN Millennium Development Goals (MDGS) represent a global commitment to achieve significant and defined progress in three health areas between 1990 and 2015:
MDG4. Reduce child mortality—Reduce under-five mortality by two-thirds
MDG5. Improve maternity health—Reduce the maternity mortality ratio by three-quarters
MDG6. Combat HIV/AIDS, malaria & other diseases—have halted and begin to reverse the spread of major diseases
The recent Countdown to 2015 report highlights global progress toward achieving MDGS 4 and 5 (child and maternity health)
The Countdown countries comprise 75 countries with >95% of global maternity and child deaths
Tracking progress in the Countdown priority countries
WHO 2012
Evaluating progress toward MDG4: child mortality
According to Countdown: Child mortality has declined
sharply However, only 23 of 74
Countdown countries with available data are on track to achieve MDG goals for reducing child mortality by 2015, whereas 13 have made little or no progress
WHO (2012)
Trends in neonatal mortality About 43% of deaths before age 5 occur in the neonatal period Neonatal mortality has declined in all world regions since 1990 Progress has been slow in areas with the highest rates
Oestergaard (2011)
Maternity and parental leave policies Paid leave for new parents, often specifically designated for new
mothers, is a standard social benefit in most of the world
Over 180 countries have enacted legislation granting paid leave from employment in connection with the birth of a child, either in the form of maternity leave or gender-neutral parental leave
Maternity leave is leave that the country guarantees employed women in connection with the birth of a child1
Heymann et al. (2011)
Availability of paid maternity leave (2014)
Source: UCLA World Policy Analysis Center
Not a DAG!
vaccination child healthpaid maternity leave
About 29% of deaths in children 1-59 months of age are vaccine preventable
uptake of pre- and post-natal health services
prenatal maternity stress
Research suggest that conflicting work schedules are a barrier to parents immunizing their children and, therefore the provision of paid leave may facilitate vaccination uptake by removing the conflict between work and child health1
Other mechanisms might include prenatal maternity stress and uptake of pre and post-natal health services, among others
12
Extant work
Research from high-income countries: Paid maternity and paternal leave policies are consistently associated
with lower infant mortality in high-income countries1-5 Early return to work decreased diphtheria, pertussis, and tetanus
(DPT) and Polio vaccinations in the US6
Tanaka (2005) showed paid parental leave did not affect vaccination uptake in OECD countries4
Research including low- and middle-income countries (LMICs): A global ecological study showed that paid maternity leave was
associated with higher childhood vaccination rates and lower infant mortality in OECD and non-OECD countries1,7
1Heymann et al. (2011); 2Winegarden et al. (1995); 3Ruhm (2000); 4Tanaka (2005); 5Rossin (2011); 6Berge et al. (2006); 7Daku et al. (2012)
Research questions
(1) What is the effect of paid maternity leave on the probability of neonatal and infant death in low- and middle-income countries
vaccination infant and neonatal mortalitypaid maternity leave
(1)
(2)
(2) What is the effect of paid maternity leave on the probability of vaccination uptake in low- and middle-income countries
II. Data and empirical strategy
Data sources Our country-level exposure was the number of full-time equivalent
(FTE) weeks of paid maternity leave provided by each country by year
Sources of information Countries’ labour legislations The Social Security Programs Throughout the World database Other sources:
International Labour Organization’s Maternity Protection Database
Council of Europe Family Policy Database International Review of Leave Policies and Related Research
Time frame: 1995-2012
Measuring paid maternity leave
Maternity leave variables Existence of maternity leave (either paid or unpaid) Length of paid maternity leave in weeks
Includes maternity leave and parental leave (leave that either parent can take) but NO child care leave
Includes pre-natal leave Includes the basic length, without extensions for multiple births,
complications, etc. Minimum/maximum wage replacement rate (WRR) Length of paid maternity leave in Full Time Equivalency (FTE) weeks
Takes into account the wage replacement wage Always coding for the minimum WRR (e.g., if it varies by occupation) Length of paid leave in weeks * wage replacement wage
Measuring paid maternity leave
Example of maternity leave coding
Rwanda Labour Code, Article 68:• Upon delivery, every employed woman has the right to suspend her
job for a period of 12 consecutive weeks, of which at least 2 weeks are taken before the presumed date of delivery and 6 weeks afterwards
• The employer cannot give the employed woman a notice of lay off during her maternity leave
• The employed woman has the right, during the period of contract suspension, at the charge of the employer, and until the instauration of a social security system that assumes the full responsibility of the matter, to 2/3 of the salary she received before suspending her job
FTE weeks of leave = 12 * 2/3 = 8Min prenatal = 2
Max prenatal = 12 – 6 = 6FTE mandatory prenatal = 2 * 2/3 = 1.3
Data sources Our country-level exposure was the number of full-time equivalent
(FTE) weeks of paid maternity leave provided by each country by year Individual-level data from the Demographic and Health Surveys (DHS)
Nationally representative surveys in 85 different countries, 2+ surveys in 57 (updated to 2012)
Largest surveys are known as Standard DHS, but other surveys also collected e.g. AIDS and malaria indicator surveys
Core DHS questionnaires cover basic demographic and health content, including: marriage, fertility, family planning, reproductive health and child health
Optional DHS modules contain special topics, including: maternity mortality, men’s survey, anthropometry, anaemia blood testing, domestic violence
~ 5000 to 30,000 households Cover women aged 15–49 years / men aged 15–59 years / children
aged 0–59 months.
The Demographic and Health Surveys (DHS)
Data sources Our country-level exposure was the number of full-time equivalent
(FTE) weeks of paid maternity leave provided by each country by year Individual-level data from the Demographic and Health Surveys (DHS) The individual-level outcomes were:
(1) the probability of neonatal (<28 day) and infant (<1 year) death among births to mothers surveyed as part of the DHS
Vital status of live births from the past 5 years
Data sources Our country-level exposure was the number of full-time equivalent
(FTE) weeks of paid maternity leave provided by each country by year Individual-level data from the Demographic and Health Surveys (DHS) The individual-level outcomes were:
(1) the probability of neonatal (<28 day) and infant (<1 year) death among births to mothers surveyed as part of the DHS
(2) vaccination uptake among children that survived
Immunizations for living children <5 years of age The DHS collect information on immunization coverage using
vaccination cards or verbal reporting by mothers Data is collected on: (i) Bacillus Calmette-Guérin (BCG); (2)
Diphtheria, pertussis and tetanus (DPT); and (3) Polio
Immunizations for living children <5 years of age The DHS collect information on immunization coverage using
vaccination cards or verbal reporting by mothers Data is collected on: (i) Bacillus Calmette-Guérin (BCG); (2)
Diphtheria, pertussis and tetanus (DPT); and (3) Polio We excluded all births that occurred less than four months prior to
the survey to allow each child a follow-up period of at least four months to receive the vaccinations recorded by the DHS.
Data sources Our country-level exposure was the number of full-time equivalent
(FTE) weeks of paid maternity leave provided by each country by year Individual-level data from the Demographic and Health Surveys (DHS) The individual-level outcomes were:
(1) the probability of neonatal (<28 day) and infant (<1 year) death among births to mothers surveyed as part of the DHS
(2) vaccination uptake among children that survived Other covariates included:
Individual-level factors, including education, employment, HH wealth, urban residence, relevant birth characteristics
Country-level characteristics, including GDP per capita, female labor force participation, health expenditures
We used birth history data from the DHS to assemble a representative panel of live births in 20 countries from 2001–2008
These data were merged with longitudinal information on the number of FTE weeks of paid maternity leave for each country
Country DHs survey years 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Honduras 2011 2005 Nepal 2011 2006 Uganda 2011 2006 Bangladesh 2011 2007 2004 Armenia 2010 2005 Cambodia 2010 2005 Colombia 2010 2005 Rwanda 2010 2005 Senegal 2010 2005 Zimbabwe 2010 2005 Malawi 2010 2004 Tanzania 2010 2004 Lesotho 2009 2004 Ghana 2008 2003 Kenya 2008 2003 Madagascar 2008 2003 Nigeria 2008 2003 Philippines 2008 2003 Bolivia 2008 2003 Egypt 2008 2005
Creating a panel of live births
Trends in paid maternity leave (FTE weeks)
Armen
ia
Bangla
desh
Bolivia
Cambodia
Colom
bia
Egypt
Ghan
a
Honduras
Kenya
Lesoth
o
Mad
agas
car
Mal
awi
Nepal
Niger
ia
Philippin
es
Rwan
da
Seneg
al
Tanza
nia
Uganda
Zimbab
we
0
5
10
15
20
25
2000 2001 2002 2003 2004 2005 2006 2007 2008
FT
E/W
ee
ks
General empirical strategy: regression with fixed effects We were concerned about unmeasured confounding of the effect of a
change in paid leave on the probability of infant death Linear probability regression model of general form:
where β1 measures the effect of an increase in maternity leave on our outcomes of interest: neonatal death, infant death, and vaccination, Yijt
Fixed effects for country (αj) and year (λt) to control for unobserved time-invariant confounders that vary across countries, and any shared temporal trends in neonatal mortality, respectively
Incorporated respondent-level sampling weights and robust standard errors to account for clustering
III.I. Results. Neonatal and infant mortality
Colom
bia
Armenia
Honduras
Egypt
Philippin
es
Nepal
Bolivia
Madagasc
ar
Ghana
AVERAGE
Zimbabwe
Senegal
Bangladesh
Tanzania
Kenya
Cambodia
Mala
wi
Uganda
Rwanda
Nigeria
Lesoth
o0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
10.00
Deaths before 28 days after birth per 100 live births Deaths between 28 days and 1 year after birth per 100 live births
Rates of infant mortality/100 births for 20 LMICs
DHS years, sample sizes, and rates of neonatal and infant mortality
Effects of an increase in paid maternity leave, measured by an additional FTE month of paid leave, on the probability of neonatal death, DHS, 2001-2008
Effects of an increase in paid maternity leave, measured by an additional month of any paid leave, on the probability of neonatal death, DHS, 2001-2008
Effects of an increase in paid maternity leave, measured by an additional FTE month of paid leave, on the probability of infant death, DHS, 2001-2008
Effects of an increase in paid maternity leave, measured by an additional month of any paid leave, on the probability of infant death, DHS, 2001-2008
Effect of a one-month increase in paid maternity leave on the probability of neonatal mortality
Additional FTE month Additional month of any leave
-0.35
-0.3
-0.25
-0.2
-0.15
-0.1
-0.05
0
-0.3 -0.3
Additional FTE month Additional month of any leave
-0.8
-0.7
-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0
-0.3
-0.7
Effect of a one-month increase in paid maternity leave on the probability of infant mortality
Average rates of neonatal and infant mortality over the study period were 3.1 and 5.5 per 100 live births, respectively
Each additional month of paid maternity leave was associated with 0.3 fewer neonatal deaths per 100 live births (95% confidence interval (95%CI)=-0.6, 0)
Similarly, an additional month of paid maternity leave was associated with between 0.3 (95%CI=-1, 0.4) and 0.7 (95%CI=-1.2, -0.1) fewer infant deaths per 1000 live births, respectively, depending on whether maternity leave was measured in full time equivalent units or irrespectively of the wage replacement rate
Estimates were robust to adjustment for individual, household, and country-level confounders and inclusion of fixed effects
Summary
III.II. Results. Vaccination uptake
Descriptive statistics for analysis of vaccine uptakeVariable Mean Std. Dev.Outcome Variables
BCG 0.89 0.31DPT1 0.86 0.34DPT2 0.83 0.38DPT3 0.76 0.43Polio1 0.91 0.29Polio2 0.86 0.35Polio3 0.74 0.44
Exposure variableFTE/week 9.93 3.44
Control variablesCountry-level covariates
GDP/cap-log 6.43 0.77Total health expenditure/cap-log 4.55 0.78Government health expenditure/cap-log 3.75 0.90Female labor-force participation 52.81 18.59
Household-level covariatesMother's education/ year 5.29 4.50Household size 6.65 4.02Urban 0.30 0.46
Birth characteristicsMale 0.51 0.50Female (ref.) 0.49 0.50Birth order # 1 0.26 0.44Birth order # 2 0.22 0.41Birth order # 3 and above (ref.) 0.52 0.50Mother's age at birth - 19 and below 0.12 0.33Mother's age at birth - 20 to 39 (ref.) 0.83 0.38Mother's age at birth - 40 and above 0.05 0.22
Other Attendance of skilled health personnel 0.50 0.50
Trends in vaccination rates over time
2001 2002 2003 2004 2005 2006 2007 20080.65
0.7
0.75
0.8
0.85
0.9
0.95
BCG DPT1 DPT2 DPT3 Pol1 Pol2 Pol3
Effect of an additional FTE week of paid maternity leave on BCG vaccination
BCG DPT 1 DPT 2 DPT 3 Polio 1 Polio 2 Polio 30.00
0.50
1.00
1.50
2.00
2.50
0.10
1.71 1.74
1.94
0.00
0.18 0.23
Effect of an additional FTE week of paid maternity leave on the probabilities of BCG, DPT, and Polio vaccinations
Extending the duration of paid maternity had a positive effect on DPT immunization rates; each additional week of paid maternity leave increased the proportion of DPT1, 2 and 3 coverage by 1.71 (95% CI = 1.46, 1.96), 1.74 (CI = 1.45, 2.04) and 1.95 (CI = 1.52, 2.39)
Estimates were robust to adjustment for birth characteristics, household-level covariates, attendance of skilled health personnel and time-varying country-level covariates
We found no evidence for an effect of maternity leave on the probability of receiving vaccinations for BCG and Polio
Summary
IV. Concluding remarks
Not a RCT—always the potential unmeasured confounding, specifically by other policies or programs that coincided with changes in maternity leave policy and also influenced infant health
Our maternity leave variable is calculated based on the legislated maternity leave and does not account for other leave (i.e., parental leave)
Subnational variation in maternity leave policies Employment history of women around time of birth not available in DHS Time-varying covariates in our analysis are subject to measurement error
because they are taken at the time of interview and assigned to all prior births (e.g., mother’s education)
Use of mothers' recall for determination of child vaccination status when vaccination cards were not available [these data may still be valid: Valadez & Weld (1992), AbdelSalam & Sokal (2004)]
Results may not be generalizable beyond the sampled countries, where labor conditions, including women’s labor force participation, may vary
Limitations
Strengths Perhaps the first multilevel study of the effect of maternity leave
policies on infant health in LMICs Cross-national design and inclusion of survey weights Control for confounding, including fixed effects for country and year Extensive robustness checks
Alternative measures of the exposure Leads and lags Control for country-specific time trends
Estimating effects of social policies is hard.
Appendix Vaccination and Maternity Leave Data
Effect of 1 additional FTE week of paid maternity leave on DPT1
Note: Bold indicates statistical significance at 5 percent or less. Standard errors in parentheses. Findings are robust to the use of Poisson regression models and an alternate measure of maternity leave based on the ILO convention
paid maternity leave: LPM results.
Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Model 7
DPT1 (First Dose)
FTE0.0214 (0.0006)
0.0318 (0.001)
0.033 (0.0011)
0.034 (0.0011)
0.0336 (0.0011)
0.0336 (0.0011)
0.0335 (0.0011)
Country-level covariates
GDP/cap-log0.1199 (0.0208)
0.054 (0.0257)
0.0315 (0.0253)
0.0297 (0.0252)
0.0141 (0.0252)
Total health expenditure/cap-log0.0801 (0.0113)
0.0815 (0.011)
0.0812 (0.011)
0.0694 (0.0109)
Government health expenditure/cap-log0.0377 (0.0089)
0.0428 (0.0086)
0.043 (0.0086)
0.0489 (0.0086)
Female labor-force participation0.006 (0.0005)
0.0053 (0.0005)
0.0055 (0.0005)
0.0054 (0.0005)
0.0049 (0.0005)
Household-level covariates
Mother's education0.0136 (0.0003)
0.0133 (0.0003)
0.013 (0.0003)
0.0105 (0.0003)
Household size-0.0009 (0.0004)
-0.0009 (0.0004)
-0.0008 (0.0004)
Urban 0.013 (0.0033)
0.0124 (0.0033)
-0.005 (0.0032)
Birth characteristics
Gender/Male-0.0006 (0.0014)
-0.0011 (0.0014)
Birth order
Birth order # 10.0096 (0.0022)
-0.0002 (0.0022)
Birth order # 20.0076 (0.0019)
0.0038 (0.0019)
Mother's age at birth
19 and below-0.0248 (0.0029)
-0.0206 (0.0028)
40 and above0.0064 (0.004)
0.005 (0.0039)
Other
Attendance of skilled health personnel
0.0807 (0.0027)