1. 11 Recessions and Babies’ Health Ainhoa Aparicio & Libertad González (Collegio Carlo Alberto and UPF-Barcelona GSE) June 2013

2. 22 Motivation: Health at birth Health at birth (in particular, low birth weight) has been shown to have important effects on long-term outcomes. –Cognitive development, education, income, adult health. A significant fraction of babies are born with LBW, even in rich countries. –6.5% of singleton births in the US in 2006, 6% in Spain in 2011. There is a large degree of inequality in health at birth. –In the US (2006), 8% of white babies are LBW, vs. 15% of blacks –In Spain (2010), 4.7% of babies with high-educated parents, vs. 7.3% of those with low education.

3. 33 Motivation: Recessions Recessions increase income inequality. –Heathcote, Violante & Perri (2010) for the US, Hospido & Bonhomme (2012) for Spain. Do they also increase inequality in health at birth? If so, important long-term consequences of recessions for the next generation. –“An individual born in a recession lives a few years less than an individual born in a boom” (Van den Berg et al., AER 2006)

4. 44 Why would recessions affect health at birth? Via effects on household income. (-) –Unemployment and wages could affect household consumption, and thus maternal nutrition and health-related habits. Other channels. –Time use of mothers, working conditions, mental health (stress, depression), etc. (?) –Effects on quality of medical care. (?) –Air quality (pollution). (+)

5. 55 What we do Study the effect of the cycle on birth outcomes in Spain. –Exploiting regional variation. –Main effect as well as channels.

6. 66 Previous work Dehejia & Lleras-Muney (QJE, 2004). –Unemployment rate and babies’ health in the US by state, 1975-1999 (25 years). –They find that babies conceived during recessions are healthier! –Channels are unclear. Child mortality in developing countries: –Miller & Urdinola (JPE, 2010) find procyclicality for Colombia; –Bhalotra (JDE, 2010), countercyclicality for India.

7. 77 What’s new We “replicate” the US analysis with 30 years of data for Spain (1981-2010). We confirm their finding that health at birth improves during recessions. We extend the analysis of the sources of this effect. –Composition/selection effects (mother fixed-effects). –Health behaviors (with National Health Survey data for 1987-2009).

8. 8 Why Spain? Middle-high income country. High-quality data on newborns’ health (from birth certificates) since 1975. Large fluctuations in the unemployment rate across regions and over time.

9. 9 Unemployment rate, 1980-2012 9

10. 10 Unemployment rate by province, 2012 10

11. 11 Birth rate, 1980-2011 11 (Annual number of births per 1,000 population.)

12. 12 Infant health, 1980-2010 12

13. 13 Empirical strategy Main dependent variable (y): infant health (by province i and year of conception t). Main explanatory variable (u): unemployment rate (by province and year of conception). N = 50 provinces*30 years= 1500 Province and year fixed effects, (province-specific trends). Standard errors clustered by province (to allow for serial correlation).

14. 14 Descriptive statistics

15. 15 Descriptive statistics

16. 16 Descriptive statistics

17. 17 Results Babies’ health outcomes Fertility Composition (family characteristics) Behaviors (of mothers) (Environment)

18. 18 Babies’ Health (i): Birth Weight [Controls include fraction of mothers in different age ranges, fraction mother married, fraction with no info on father, and fraction high skill occupation (mother, father and both).]

19. 19 Babies’ Health (i): Birth Weight [Controls include fraction of mothers in different age ranges, fraction mother married, fraction with no info on father, and fraction high skill occupation (mother, father and both).]

20. 20 Babies’ Health (i): Birth Weight [Controls include fraction of mothers in different age ranges, fraction mother married, fraction with no info on father, and fraction high skill occupation (mother, father and both).]

21. 21 Babies’ Health (i): Birth Weight [Controls include fraction of mothers in different age ranges, fraction mother married, fraction with no info on father, and fraction high skill occupation (mother, father and both).]

22. 22 Babies’ Health (ii): Mortality [Controls include fraction of mothers in different age ranges, fraction mother married, fraction with no info on father, and fraction high skill occupation (mother, father and both).]

23. 23 Income effects? Results for India (Bhalotra 2012) suggest that the effect might reverse sign in poor regions. –Income effects dominate. We allow for heterogeneous effects by level of per capita GDP by province in 1980. –We would expect the opposite sign for poor provinces.

24. 24 Health results by income The health effects are driven by richer regions.

25. 25 So Far Babies are born healthier during recessions. –At least in richer regions. But perhaps fewer children are born in a recession, and perhaps they are “selected” positively. –Number of live births and number of abortions analysis.

26. 26 Fertility results (live births)

27. 27 Fertility results (live births)

28. 28 Fertility results (live births) Higher unemployment (less employment), fewer births!

29. 29 Abortions Higher unemployment (lower employment), fewer abortions! Fewer conceptions during recessions.

30. 30 Fertility results by income The fertility effects are also driven by richer regions.

31. 31 Composition Are children born during recessions coming from “better” families? –Mothers aged 25-35 –Married mothers –High-skill parents (positively correlated with infant health)

32. 32 Composition results

33. 33 Composition results If anything, composition effects go in the opposite direction!

34. 34 Family fixed-effects We can link siblings in the birth certificate data. –Using information on date of birth of mother, father, and previous children. –For families with multiple children only (obviously). This allows for the inclusion of parents fixed- effects. –Thus controlling for “selection” or “composition” effects.

35. 35 Results with family fixed effects

36. 36 Behaviors or environment Mothers’ health behavior could improve during recessions. –Drinking, smoking, exercise, diet, stress. Health care quality could be higher. –Less congestion? Air quality could be better. –Less pollution? Anything else??

37. 37 Mothers’ Health Behavior Spanish Health Survey, 1987-2011. Very detailed data on health-related behaviors. –Weight, BMI, diet, exercise, smoking, drinking, sleep, mental health, doctor visits, etc. Sample of women in relevant age range. –17 to 43 (more than 99% of mothers). 37

38. 38 Preliminary Health Results Sample: Women ages 17 to 43. Data aggregated by province and year (1987, 1993, 1995, 1997, 2001, 2003, 2006 and 2011). N = 50*8 = 400

39. 39 Preliminary Health Results Sample: Women ages 17 to 43. Data aggregated by province and year (1987, 1993, 1995, 1997, 2001, 2003, 2006 and 2011). N = 50*8 = 400

40. 40 Results Babies’ health outcomes Fertility Composition (family characteristics) Behaviors (of mothers) Environment –Quality of medical assistance. –Air quality

41. 41 Medical Care Quality Congestion effects? 41

42. 42 Medical Care Quality Congestion effects? High unemployment is significantly associated with less waiting time during last doctor visit (Health Survey data). 42

43. 43 Medical Care Quality Congestion effects? High unemployment is associated with less waiting time during last doctor visit (Health Survey data). When unemployment is high, fewer births without medical assistance (birth certificate data). 43

44. 44 Medical assistance at birth Hospital birth: Birth taking place in a health center (average 94%). Assisted birth: Birth attended by a health professional (average 99.7%).

45. 45 Air quality Less pollution during recessions? –Chay & Greenstone (QJE 2003)

46. 46 Preliminary conclusions Using birth certificate data from Spain for 1980- 2010, we find that babies conceived during high unemployment are healthier (at birth). This cannot be attributed to “better” parents being more likely to conceive during recessions. It must be behaviours! (or environment) We’re looking into it. –More results to come. 46

47. 47 Thanks for your attention! 47