Women's Employment and Children's Nutritional Status: New Evidence from South and Southeast Asia

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Women's Employment and Children'sNutritional Status:

New Evidence from South and SoutheastAsia

Yana van der Meulen Rodgers

Rutgers University

January 17, 2012

Gender CoP and Health CoP

Asian Development Bank

The views expressed in this paper are the views of the author and do not necessarily reflect the views or policies of the

Asian Development Bank (ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee

the accuracy of the data included in this paper and accepts no responsibility for any consequence of their use. Thecountries listed in this paper do not imply any view on ADB's part as to sovereignty or independent status or necessarily

conform to ADB's terminology.



Motivation

• Enormous amount of attention in academic and policydialogues on improving women’s employmentopportunities

– Women’s labor force participation rates rising in manycountries around world

• Nature of women’s employment also shifted, away from ag intomanuf and services

• Women entering into non-traditional occupations

• Growing informality of work arrangements

• Availability of high quality childcare remains a top priority

• These changes also have important implications for

children’s well-being– Women’s employment contributes to household income and

socioeconomic status

– Potential trade-off between employment income andmaternal time spent with children



Motivation

• Socioeconomic status and time spent with children operatethrough intermediate variables (“proximate determinants”)that directly influence child birth outcomes and children’snutritional status– Environmental hazards (e.g. mothers with higher income more likely

to live in residences with improved facilities that protect children

from infectious agents)– Fertility patterns (e.g. higher socioeconomic status mothers more

likely to have longer birth intervals and fewer children, associatedwith more favorable nutritional status for children)

– Utilization of health services (facilitated by higher income, but lack of time could be a constraint)

– Feeding practices (also influenced by income and time)

• Primary contribution of this book is to provide newempirical evidence on the potentially competing effects of maternal employment on children’s health using householdsurvey data from 9 Asian countries



Motivation• Focus on 3 different indicators of children’s nutritional

status representing different stages of development andwell-being:

– Small birth size (correlated with low birth weight)

• Captures influences that take place before parents know the

sex of the child– Stunting (low height-for-age)

• Captures factors that operate after a child is born (e.g.environmental exposure, child’s nutritional intake, illnesses)

• Indicator of long-term nutritional status, reflecting chronicnutritional deprivation or chronic/recurrent illness

– Wasting (low weight-for-height)• Like stunting, also captures factors that operate after a child

is born

• Indicator of short-term nutritional status, including recentinadequate nutritional intake or recent illness (e.g. diarrhea)



Motivation

• New evidence for developing countries using recent (2005-2009) waves of the Demographic and Health Survey for:

– South Asia: Bangladesh, India, Maldives, Nepal, Pakistan

– SE Asia: Cambodia, Indonesia, Philippines, Timor-Leste

• Focus on a single region makes the execution of theempirical analysis more manageable

– Also ensures that sample encompasses countries with broadlycomparable geographical, historical, and cultural contexts(vs. using data that cover countries from different developingregions)

• Approach: Bivariate analysis and a set of multivariate

nested models• Also test for differences by sex of the child

– A priori, expect greater birth size for boy children (biologicalreasons), and greater likelihood of stunting and wasting for girlchildren in countries with son preference (especially India)



Conceptual Framework

• Empirical, theoretical work suggest complex set of channelsthrough which maternal employment affects child health status– Use a “proximate determinants” framework that links socioeconomic

factors to child health (Mosley and Chen 1984)

Socioeconomic

factors and care

resources:•Household incomeand wealth•Mother’s education•Mother’s health•Mother’s autonomy•Mother’s timeavailability•Alternative careproviders•Father’s education

Intermediary biological

mechanisms:•Environmental contaminants

•Fertility patterns

•Dietary intake•Medical treatment

Child health and

nutritional status



Conceptual Framework cont…• Stylized Health Production Function: show tradeoff from maternal

employment and mother’s hours spent on child care

Child

Health

Mother’s hours spent

on child care

F1

F2

F3

.

.

.

h1

h2

h3



Implementing the Framework: Data & Method

• DHS Surveys for 9 Asian countries, 2005-09– Large nationally-representative samples of women between

the ages of 15 and 49, matched with children ages 0-59months

– Part of collection of DHS datasets on population, health, HIV,and nutrition for 85+ countries (http://www.measuredhs.com/)

– Surveys conducted and coded by national governments andprivate agencies

– Use the children’s recode (merge in variables from householdmember recode)

– Limit sample to children with recorded measurements forchildren’s birth size, height, and weight, and no missingvalues for other variables. Sample size ranged from 2,347children in Maldives to 40,676 in India

– Eight countries in birth size sample (all except Bangladesh);six countries in stunting/wasting sample (all except Indonesia,

Pakistan, and the Philippines)

http://www.measuredhs.com/

http://www.measuredhs.com/




• Measurement of Small at Birth– DHS has subjective measure of birth size and objective

measure of birth weight

– Subjective: mothers asked if child was very small, smallerthan average, average, larger than average, or very large atbirth

– Small at birth = very small or smaller than average

– Subjective measure included in DHS b/c majority of babies inlow-income countries not weighed at birth

– Lack of objective birth weight measures correlated withsocioeconomic status, in project sample and in other studies

– Subjective birth size correlates fairly well with objective birthweight for most countries, in project sample and in largercomparison of 62 DHS datasets by Blanc and Wardlaw (2005)




• Measure of Stunted– Child’s height-for-age is more than 2 standard deviations below

the median of the international reference population for childrenof the same gender

– i.e. if z-score for height-for-age is below -2, child is stunted

– Intuition: short for one’s age; chronically undernourished

• Measure of Wasted– Child’s weight-for-height is more than 2 standard deviations

below the median of the international reference population forchildren of the same gender

– i.e. if z-score for weight-for-height is below -2, child is wasted

– Intuition: captures short-term inadequate nutritional intake– Note: low weight-for-age (underweight) not analyzed b/c it does

not distinguish as effectively btw long-term and short-termdeprivation as does comparison of stunting and wasting

• Reference population defined according to 2006 WHO ChildGrowth Standards, based on international sample of

breastfeeding children (replaced 1977 NCHS Reference)




• Next 3 figures illustrate prevalence of poor nutritional statusin Asian countries compared to other regions– Data points for other countries from published DHS final reports

for individual countries that used the new 2006 WHO ChildGrowth Standards

– On average, prevalence of small birth size in S/SE Asia is

comparable to SSA (about 16.5% on average), less than LatinAmerica/Caribbean, and higher than N. Africa/W. Asia/E. Europe

– On average, prevalence of stunting in S/SE Asia is substantiallyhigher than the averages for other regions

– On average, prevalence of wasting in S/SE Asia is somewhathigher than the averages for other regions

– In all regions, incidence of wasting is considerably lower thanincidence of stunting, consistent with previous studies



Prevalence of Small at Birth across DHS Sample Countries



Prevalence of Stunting across DHS Sample Countries



Prevalence of Wasting across DHS Sample Countries




• Started with bivariate analysis of maternal employment statusand children’s nutritional outcomes

• Tested nested multivariate models using probit regressions

– Baseline Model: Child outcomes regressed on mother’semployment and child characteristics (boy vs girl, age)

– SES Model: Child outcomes regressed on baseline + proxiesfor socioeconomic status

– SES & HH Model: Child outcomes regressed on baseline +socioeconomic status + household composition

– SES & Environ Model: Child outcomes regressed on baseline+ socioeconomic status + environmental factors

– Full model: Child outcomes regressed on baseline + full setof mediating factors

• Nested format allows us to test alternative mechanisms for howmother’s employment relates to nutritional status

• Used probit models (and reported marginal probabilities)



Implementing the Framework: Data & Method• Key independent variable: maternal employment

– Consistent with DHS coding, women’s employment categorized as:1. Not employed at all in past year (reference category)

2. Employed in past year but not currently

3. Currently employed

– More finely tuned measure of maternal employment. Did tryrobustness tests with binary measures (currently vs. not currentlyemployed; employed now or in past year vs. not employed at all)

– Survey does not ask if mother employed while pregnant; next bestalternative for birth size analysis is to do estimates for sub-sample of children <1 yr old

• Other independent variables

– Child’s characteristics: sex, age– SES: mother’s educ, mother’s source of news, father’s occ, father’s

educ, hh wealth, hh has electricity, rural/urban/capital

– HH composition: number of children <5, 5-12, and 13-17; number of adults; female-headed household; mother’s age at 1st birth

– HH environmental: mother smokes, house has improved toilet, water

is treated before use



Estimation Results: Small at Birth• Employment in the past year but not currently has beneficial

effect for 1 country and adverse effect in 2 countries, andcurrent maternal employment has beneficial effect in 2countries and adverse effect in 2 countries

• Estimations for sub-sample of children under the age of one(to better ensure that maternal employment covers period of

pregnancy) yields two stat. significant results:– India: current maternal employment 4% reduction in likelihood of

small birth size relative to children whose mothers did not work at all inthe past year. Implies that mothers’ earned income during pregnancyhas benefits beyond SES variables and contributes to improved prenatalhealth and healthy birth outcomes.

– Nepal: current maternal employment 11% increase in likelihood of

small birth size. Extremely high proportion of women perform physicallytaxing work in agricultural jobs with compensation that is commonly non-cash based. Results imply negative effects on prenatal health and birthoutcomes.

• In all but 2 countries, boys substantially less likely to be smallat birth than girls, even after adding all control variables



Estimation Results: Children’s Stunting

• Bivariate results point to a greater prevalence of stuntingamong children of employed mothers– In low-income countries, women of lower socioeconomic status

have little choice but to engage in market-based work in order tosupport their households

– Apparent association between greater stunting and maternalemployment could be explained by the relatively lowersocioeconomic status of employed women rather than women’stime spent away from children

• Multivariate results support this assertion: once full set of SES and household characteristics are included, maternalemployment loses its statistically significant association with

risk of stunting. See figure for case of current employment• Risk of stunting is slightly higher for boys than girls in 2 of

6 economies: Cambodia and Timor-Leste– Hence no evidence of son preference in this long term indicator

of childhood malnutrition, not even in India



Estimation Results: Children’s StuntingBivariate Relationship Between Prevalence of Stunting and Mother’s Employment Status

The notation * indicates statistically significant at the 0.10 level or better.





Estimation Results: Children’s Wasting• Multivariate results: current maternal employment leads to

roughly a 3% increase in the likelihood of child wasting inBangladesh, Maldives, and Timor-Leste, even after includingthe full set of control variables

• Wasting, an indicator of short-term nutritional deprivationthat tends to reflect recent illness or trauma from

catastrophic events, is more likely to cut across householdsof different socioeconomic status– Bangladesh: severe flooding

– Maldives: climate changes contributing to acute respiratory infections andsome vector-borne diseases

– Timor-Leste: lingering after-effects of long-term violent conflict

• Adverse effect of women’s employment in these threecountries may be capturing the opportunity cost of women’stime away from children during times of heightened need

• Two countries have a higher risk of wasting for boyscompared to girls: Timor-Leste and India



Estimation Results: Children’s Wasting

Bangladesh Cambodia India Maldives Nepal Timor-

Leste

Women's employment (reference: not employed at all in past year)

Employed in past year, not now 0.006 -0.033** 0.008 -0.003 -0.006 -0.092

(0.038) (0.015) (0.010) (0.026) (0.021) (0.067)

Currently employed 0.033** -0.002 0.003 0.028* -0.011 0.030***

(0.016) (0.015) (0.006) (0.016) (0.016) (0.011)

Child's characteristics

Boy 0.016 0.006 0.017*** -0.005 0.005 0.037***

(0.012) (0.010) (0.005) (0.013) (0.010) (0.010)

Marginal Probabilities and Standard Errors from Full Model



Other Estimation Results

• Overall, once SES is controlled, household composition andenvironmental factors play relatively small roles in explainingthe association between mother’s employment and childnutritional outcomes

– None of the other variables related to hh composition andenvironmental factors appear to mediate the association betweenmaternal employment and children’s nutritional outcomes as muchas socioeconomic status

• The most important SES indicators for all 3 measures of children’s nutrition are maternal education, mother’sinformal access to information (especially reading

newspapers), father’s education, and household wealth– Providing mothers with nutrition knowledge outside of classroom

can contribute to child health even in areas where women have lowlevels of formal schooling

– Consistent with other studies in the literature



Take Home Points• No evidence of son preference in the indicators of long-term

and short-term nutritional deprivation

– Consistent with earlier conclusion of a discrepancy betweenevidence of son preference and lack of bias against girls inanalyses of child nutrition surveys. Possible explanations:

• Potential lack of country-wide discrimination against girls

• Data covers surviving daughters; translation of son preferenceinto selective abortions not captured by data

• Girls may cope with food deprivation differently than boys

• Favoring boys with long breastfeeding duration, at the expense of solid foods, may potentially hurt them

• Son preference may be translated into health care seekingbehavior that favors boys, rather than feeding practices

• Mothers may favor young boys by carrying them around in thekitchen longer, with longer exposure to cooking fuel toxins



Take Home Points

• Policy implications: continued policy reforms that supportworking families and promote child health

• Of particular importance are innovations in programs andenforcement of existing policies that:

– Boost the remunerative value and security of women’s jobs

– Strengthen enforcement of national labor regulations– Greater support for productive employment opportunities for women

• Microfinance, rural banking reforms, training programs, provisionof business-development services

– Improve the compatibility of women’s market work with child care

• Maternity and parental leave benefits, public support of child care– Interventions to improve children’s health and reduce health

inequities within and across Asia-Pacific countries

• Institutional, supply-side, and demand-side interventions



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Women's Employment and Children's Nutritional Status: New Evidence from South and Southeast Asia