PAID MATERNITY LEAVE AND CHILDHOOD VACCINATION UPTAKE:

A MULTILEVEL ANALYSIS IN 20 LOW-AND-MIDDLE-INCOME COUNTRIES

 

Mohammad Hajizadeh, Jody Heymann, Erin Strumpf, Sam Harper, Arijit Nandi

Presented by: José M. Mendoza Rodríguez

Sep. 4-6 2014, Oslo, Norway

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Background and research question

Vaccine-preventable diseases continue to be a public health problem in LMICs:o In 2013, 21.8 million children under age 1 did not receive DPT3 vaccine

worldwide (WHO 2014).o 70% of these children live in 10 countries: DR Congo, Ethiopia, India,

Indonesia, Kenya, Mexico, Nigeria, Pakistan, Viet Nam and South Africa.o About 29% of deaths in children 1-59 months of age are vaccine preventable.

Vaccination uptake is not universal even in countries where vaccinations are free - Trunz et al. (2006), Soares (2007).

Some vaccine preventable diseases are also re-emerging due to low immunization rates in middle-and-high-income countries - Glatman-Freedman & Nichols (2012).

Key factors influencing childhood vaccination include parental education, maternal age, household living conditions, financial factors, place of residence, availability of vaccines, distance to clinics, transportation, and mass media campaigns.

Studies from both low and high income countries have indicated ‘conflicting work schedules’ as a barrier to the immunization of children. – McCormick et al. (1997)

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Background and research question

Paid maternity leave -- “leave that the country guarantees employed women in connection with the birth of a child” (Heymann et al. 2011) - can provide households with the opportunity to vaccinate their children without trading off income generation. – Daku et al. (2012)

Few studies have examined the effect of maternity leave policies on vaccination:o Berge et al. (2005) found a negative impact of early return to work on

diphtheria, pertussis, and tetanus (DPT) and Polio vaccinations in the US. o Tanaka (2005) did not find an association between duration of maternal leave

and vaccination uptake in OECD countries.o An ecological study on 185 countries showed that paid maternity leave was

associated with higher childhood vaccination rates – Daku et al. (2012) Effect of national paid maternity leave policies on individual-level vaccination

outcomes has not been evaluated in low- and middle-income countries (LMICs). How do paid maternity leave policies impact the probability of vaccination uptake

in LMICs?

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Data – Vaccination uptake The individual-level outcomes comprise the uptake of:

o Bacillus Calmette-Guérin (BCG)o Diphtheria, pertussis and tetanus (DPT) - three doseso Polio – three doses

Childhood immunization data comes from the Demographic and Health Surveys (DHS), collected for all children under 5 through vaccination cards or verbal reporting of mothers.

Constructed a representative panel of child observations occurring in selected LMICs between 2001 and 2008. Selection of countries was determined by the availability of at least two DHS surveys between 2001 and 2011. o Child observations were allocated to each year based on the

child’s year of birth.

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Panel: 277,787 child observations in 20 DHS countries over the 2001-2008 period

These data were merged to longitudinal information on 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

Data - Vaccination uptake

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Data – Vaccination uptake

Daku et al. (2012)

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.

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Data – Paid Maternity Leave Our country-level exposure was the legislated length of paid maternity

leave in full time equivalent (FTE) weeks for each country-year (2001-2008). For each country and year, we recorded the legislated length of leave

available to mothers only. We calculated the length of paid maternity leave in FTE weeks by

multiplying the legislated length of leave by the wage replacement rate. Data sources

National labour legislation The Social Security Programs Throughout the World database (SSPTW) Other sources:o International Labour Organization’s Maternity Protection Databaseo Council of Europe Family Policy Database o International Review of Leave Policies and Related Research

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Data – Paid Maternity Leave (FTE weeks): 2000-2008

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

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Data – Control variables

We accounted for potential confounding by: Individual-level covariates, obtained from the DHS:

o socio-demographic characteristics of the mother and household (e.g., mother’s education and urban/rural area of residence)

o relevant birth characteristics (e.g., gender, mother’s age at birth, birth order, and number of children)

o attendance of skilled health personnel Country-level covariates, World Bank's WDI and Global Development

Finance (GDF): o per capita GDP (PPP)o per capita total health expenditureso per capita government health expenditure o female labor force participation

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Summary Statistics – All variablesVariable Mean Std. Dev.

Outcome Variables

BCG 0.89 0.31

DPT1 0.86 0.34

DPT2 0.83 0.38

DPT3 0.76 0.43

Polio1 0.91 0.29

Polio2 0.86 0.35

Polio3 0.74 0.44

Exposure variable

FTE/week 9.93 3.44

Control variables

Country-level covariates

GDP/cap-log 6.43 0.77

Total health expenditure/cap-log 4.55 0.78

Government health expenditure/cap-log 3.75 0.90

Female labor-force participation 52.81 18.59

Household-level covariates

Mother's education/ year 5.29 4.50

Household size 6.65 4.02

Urban 0.30 0.46

Birth characteristics

Male 0.51 0.50

Female (ref.) 0.49 0.50

Birth order # 1 0.26 0.44

Birth order # 2 0.22 0.41

Birth order # 3 and above (ref.) 0.52 0.50

Mother's age at birth - 19 and below 0.12 0.33

Mother's age at birth - 20 to 39 (ref.) 0.83 0.38

Mother's age at birth - 40 and above 0.05 0.22

Other

    Attendance of skilled health personnel 0.50 0.50

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Summary Statistics – Vaccination Rates

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

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Empirical strategy: regression with fixed effects Linear Probability Regression Model (LPM) of the form:

o : binary vaccination outcome (receiving BCG, DPT, Polio) o : effect of 1 additional FTE week in paid maternity leave o : set of individual, household and country-level covariates o indexes country, indexes child, and indexes year of birth

We included fixed effects for country () and year () to control for unobserved time-invariant confounders that vary across countries, and any temporal trends in vaccination shared across countries

Incorporated respondent-level sampling weights and robust standard errors to account for clustering

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Effect of 1 additional FTE week of paid maternity leave on BCG vaccination

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

      Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Model 7

FTE 0.0162 (0.0006) 0.0048 (0.0009) 0.0033 (0.0009) 0.0022 (0.0008) 0.0017 (0.0008) 0.0018 (0.0008) 0.0016 (0.0008)

Country-level covariates

GDP/cap-log -0.1255 (0.0199) -0.08 (0.026) -0.1035 (0.0253) -0.1054 (0.0253) -0.123 (0.0252)

Total health expenditure/cap-log   0.0121 (0.0108) 0.0138 (0.0104) 0.0135 (0.0104) 0 (0.0103)

Government health expenditure/cap-log   -0.0057 (0.008) -0.0005 (0.0077) -0.0003 (0.0077) 0.0065 (0.0076)

Female labour-force participation   0.0013 (0.0005) 0.0005 (0.0005) 0.0007 (0.0004) 0.0007 (0.0004) 0.0001 (0.0004)

Household-level covariates

Mother's education 0.0147 (0.0003) 0.014 (0.0003) 0.0137 (0.0003) 0.011 (0.0003)

Household size -0.0008 (0.0003) -0.0008 (0.0003) -0.0007 (0.0003)

Urban 0.0212 (0.0031) 0.0205 (0.0031) 0.001 (0.003)

Birth characteristics

Gender/Male -0.0007 (0.0014) -0.0013 (0.0014)

Birth order

Birth order # 1 0.0092 (0.002) -0.0018 (0.002)

Birth order # 2 0.0062 (0.0017) 0.0019 (0.0017)

Mother's age at birth

19 and below -0.0293 (0.0028) -0.0245 (0.0027)

40 and above 0.0007 (0.0038) -0.0009 (0.0038)

Other

  Attendance of skilled health personnel             0.0911 (0.0025)

Sample weights Y Y Y Y Y Y Y

Clustered SEs Y Y Y Y Y Y Y

Country FE Y Y Y Y Y Y

Time trend   Y Y Y Y Y Y

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Overall Results – Full models

Note: 95% confidence interval bars included. 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.

Polio3

Polio2

Polio1

DPT3

DPT2

DPT1

BCG

-0.5 0 0.5 1 1.5 2 2.5 3 3.5 4

-0.06

0.17

0.01

2.98

3.24

3.35

0.16

Effect of 1 additional FTE week of maternity leave on probability of vaccination

Percentage points

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Each additional FTE week of paid maternity leave was associated with:o 0.16 percentage point increase in the probability of BCG vaccinationo 3.35, 3.24 and 2.98 percentage points increase in the probability of DPT1/2/3 o Findings were robust to inclusion of country- and household-level covariates,

birth characteristics, and attendance of skilled health personnel. Findings suggest that there is a benefit to increasing paid maternity leave even for

vaccines scheduled soon after birth such as BCG in LMICs. No evidence of effect on the probability of receiving all three doses of the Polio

vaccine, after adjustment for potential confounders. Similar to Berge et al. (2005) and an ecological study by Daku et al. (2012), our

results indicate that paid maternity leave was positively associated with higher immunization rates for BCG and all three doses of DPT.

Policy Implication: Maternity leave policies may represent an important mechanism for removing barriers to improved vaccination coverage and child health.

Conclusions

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Use of mothers' recall for determination of child vaccination status when vaccination cards were not available: recall biaso These data may still be valid: Valadez & Weld (1992), AbdelSalam &

Sokal (2004) Our maternity leave variable is calculated based on the legislated maternity

leave and does not account for other leave (i.e., parental leave). 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).

Potential unmeasured confounding: it is possible that another policy or program that influenced vaccination coverage coincided with changes in maternity leave policy.

Limitations

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Thank you

Email: jose.mendozarodriguez@mcgill.cahttp://machequity.com

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Appendix Vaccination and Maternity Leave Data

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Data – Vaccination uptake

Mothers surveyed in the DHS are asked to provide vaccination information concerning live births over the previous 59 months

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Data – Paid Maternity Leave

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

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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)