1. 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 (arijit.nandi@mcgill.ca)arijit.nandi@mcgill.ca

2. Topics for discussion I. Background II. Data and Empirical methods III. Results III.I. Infant and neonatal mortality III.II. Vaccination uptake IV. Limitations and discussion

3. I. Background. Maternity leave and child health

4. 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

5.  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

6. 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)

7. 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)

9. 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 child 1 Heymann et al. (2011)

10. Availability of paid maternity leave (2014) Source: UCLA World Policy Analysis Center

11. Not a DAG! vaccinationchild 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 health 1 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 countries 1-5  Early return to work decreased diphtheria, pertussis, and tetanus (DPT) and Polio vaccinations in the US 6  Tanaka (2005) showed paid parental leave did not affect vaccination uptake in OECD countries 4 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 countries 1,7 1 Heymann et al. (2011); 2Winegarden et al. (1995); 3 Ruhm (2000); 4 Tanaka (2005); 5 Rossin (2011); 6 Berge et al. (2006); 7 Daku et al. (2012) 12

14. 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 vaccinationinfant 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

15. II. Data and empirical strategy

16. 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

17. 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

18. 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

19. 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 = 8 Min prenatal = 2 Max prenatal = 12 – 6 = 6 FTE mandatory prenatal = 2 * 2/3 = 1.3

20. 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)

22.  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)

24. 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

25. Vital status of live births from the past 5 years

26. 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

27. 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

28. 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.

29. 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

30.  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 CountryDHs survey years1999200020012002200320042005200620072008200920102011 Honduras 20112005 Nepal 20112006 Uganda 20112006 Bangladesh 201120072004 Armenia 20102005 Cambodia 20102005 Colombia 20102005 Rwanda 20102005 Senegal 20102005 Zimbabwe 20102005 Malawi 20102004 Tanzania20102004 Lesotho 20092004 Ghana 20082003 Kenya 20082003 Madagascar 20082003 Nigeria 20082003 Philippines 20082003 Bolivia 20082003 Egypt 20082005 Creating a panel of live births

31. Trends in paid maternity leave (FTE weeks)

32. 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 β 1 measures the effect of an increase in maternity leave on our outcomes of interest: neonatal death, infant death, and vaccination, Y ijt  Fixed effects for country (α j ) and year (λ t ) 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

33. III.I. Results. Neonatal and infant mortality

34. Rates of infant mortality/100 births for 20 LMICs

35. DHS years, sample sizes, and rates of neonatal and infant mortality

36. 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

37. 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

38. 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

39. 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

40. Effect of a one-month increase in paid maternity leave on the probability of neonatal mortality

41. Effect of a one-month increase in paid maternity leave on the probability of infant mortality

42.  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

43. III.II. Results. Vaccination uptake

44. Descriptive statistics for analysis of vaccine uptake VariableMeanStd. Dev. Outcome Variables BCG0.890.31 DPT10.860.34 DPT20.830.38 DPT30.760.43 Polio10.910.29 Polio20.860.35 Polio30.740.44 Exposure variable FTE/week9.933.44 Control variables Country-level covariates GDP/cap-log6.430.77 Total health expenditure/cap-log4.550.78 Government health expenditure/cap-log3.750.90 Female labor-force participation52.8118.59 Household-level covariates Mother's education/ year5.294.50 Household size6.654.02 Urban0.300.46 Birth characteristics Male0.510.50 Female (ref.)0.490.50 Birth order # 10.260.44 Birth order # 20.220.41 Birth order # 3 and above (ref.)0.520.50 Mother's age at birth - 19 and below0.120.33 Mother's age at birth - 20 to 39 (ref.)0.830.38 Mother's age at birth - 40 and above0.050.22 Other Attendance of skilled health personnel0.50

45. Trends in vaccination rates over time

46. Effect of an additional FTE week of paid maternity leave on BCG vaccination

47. Effect of an additional FTE week of paid maternity leave on the probabilities of BCG, DPT, and Polio vaccinations

48.  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

49. IV. Concluding remarks

50.  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

51. 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

52. Estimating effects of social policies is hard.

53. http://machequity.com Thank you.

54. Appendix Vaccination and Maternity Leave Data

55. 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 1Model 2Model 3Model 4Model 5Model 6Model 7 DPT1 (First Dose) FTE 0.0214 (0.0006) 0.0318 (0.001) 0.033 (0.0011) 0.034 (0.0011) 0.0336 (0.0011) 0.0335 (0.0011) Country-level covariates GDP/cap-log 0.1199 (0.0208) 0.054 (0.0257) 0.0315 (0.0253) 0.0297 (0.0252) 0.0141 (0.0252) Total health expenditure/cap-log 0.0801 (0.0113) 0.0815 (0.011) 0.0812 (0.011) 0.0694 (0.0109) Government health expenditure/cap-log 0.0377 (0.0089) 0.0428 (0.0086) 0.043 (0.0086) 0.0489 (0.0086) Female labor-force participation 0.006 (0.0005) 0.0053 (0.0005) 0.0055 (0.0005) 0.0054 (0.0005) 0.0049 (0.0005) Household-level covariates Mother's education 0.0136 (0.0003) 0.0133 (0.0003) 0.013 (0.0003) 0.0105 (0.0003) Household size -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 # 1 0.0096 (0.0022) -0.0002 (0.0022) Birth order # 2 0.0076 (0.0019) 0.0038 (0.0019) Mother's age at birth 19 and below -0.0248 (0.0029) -0.0206 (0.0028) 40 and above 0.0064 (0.004) 0.005 (0.0039) Other Attendance of skilled health personnel 0.0807 (0.0027)