The effects of women's education on maternal health: Evidence from Peru

https://doi.org/10.1016/j.socscimed.2017.03.004Get rights and content

Highlights

  • This study investigates the causal effect of education on maternal health.

  • The study employs increased compulsory schooling in Peru as a natural experiment.

  • Improving women's education reduces the risk of select maternal complications.

  • Education has the strongest protective effect on preventable conditions like fever.

  • Women's education has corresponding effects on their fertility and healthcare use.

Abstract

This article examines the causal effect of women's education on maternal health in Peru, a country where maternal mortality has declined by more than 70% in the last two and a half decades. To isolate the effects of education, the author employs an instrumented regression discontinuity that takes advantage of an exogenous source of variation—an amendment to compulsory schooling laws in 1993. The results indicate that extending women's years of schooling reduced the probability of several maternal health complications at last pregnancy/birth, sometimes by as much as 29%. Underlying these effects, increasing women's education is found to decrease the probability of short birth intervals and unwanted pregnancies (which may result in unsafe abortions) and to increase antenatal healthcare use, potentially owing to changes in women's cognitive skills, economic resources, and autonomy. These findings underscore the influential role of education in reducing maternal morbidity and highlight the contributions of women's education to population health and health transitions.

Section snippets

Women's education and maternal health

Historically, Peru has had one of the highest rates of maternal mortality in the Western hemisphere, though these rates have fallen precipitously in recent years (World Bank, 2015). The most common causes of maternal mortality2 in Peru include complications related to unsafe abortion (which is highly restricted), hemorrhage, preeclampsia, infections, and

Compulsory schooling in Peru

Understanding whether education improves maternal health, rather than being associated with better health, requires the use of causal inference methods that isolate the effects of education from confounders such as childhood socioeconomic status. In this study, I isolate the effects of education with an instrumented regression discontinuity that takes advantage of a change in Peruvian compulsory schooling laws in the 1990s. Compulsory schooling was first implemented in Peru in 1905 (Freeburger

Sample

I use nationally representative, cross-sectional data from the continuous Demographic and Health Surveys (DHS) collected in Peru every year between 2003 and 2009.4 To isolate the effects of education reform in Peru, I compare respondents who were aged just above and just below the average age of primary school completion in 1993. As depicted in Fig. 2, respondents who were just above the

First-stage results

For CS11 exposure to be a valid instrument for women's education, it must be strongly predictive of years of schooling. Specifically, the validity of the instrument rests on CS11 exposure having a t-value greater than 3.2 or a corresponding p-value below 0.0016; and an F statistic for the excluded instrument above 10 (Stock et al., 2002). Table 2 presents the results of the first-stage model estimating the relationship between respondents' CS11 exposure and highest year of education. The

Limitations

Despite its merits, this study faces several limitations. One is that the only measure of cognitive skills in the DHS—literacy—is basic and exhibits little variation across women. Further analyses are therefore needed to verify the extent to which cognitive skills are a plausible driver of changes in women's fertility practices, healthcare use, and maternal health. Another limitation is that DHS data do not provide a full employment history. This prevents me from controlling for childhood labor

Discussion

This study expands existing scholarship by using an exogenous source of variation to demonstrate a causal link between women's schooling and maternal health. The observed protective effects of education against complications such as fevers and hemorrhaging have important implications for women's risk of disability, morbidity, and mortality over the course of their reproductive years. In the aggregate, these effects may contribute to falling maternal mortality rates and extend women's life

Acknowledgements

The author would like to thank Julia Behrman, Liz Ela, and Anne Clark for their invaluable feedback on earlier drafts of this paper. This research was made possible with the support of an NIA training grant (T32 AG000221).

References (61)

  • Sereen Thaddeus et al.

    Too far to walk: maternal mortality in context

    Soc. Sci. Med.

    (1994)
  • James Trussell et al.

    Burden of unintended pregnancy in the United States: potential savings with increased use of long-acting reversible contraception

    Contraception

    (2013)
  • Saifuddin Ahmed et al.

    Economic status, education and empowerment: implications for maternal health service utilization in developing countries

    PLoS ONE

    (2010)
  • Patricia Ames et al.

    Cambios y oportunidades: La transición de la escuela primaria a la secundaria en el Perú

  • 2009 Fatal Flaws: Barriers to Maternal Health in Peru.” London: Amnesty...
  • Gustavo Angeles et al.

    The determinants of fertility in rural Peru: program effects in the early years of the national family planning program

    J. Popul. Econ.

    (2005)
  • Joshua D. Angrist et al.

    Two-stage least squares estimation of average causal effects in models with variable treatment intensity

    J. Am. Stat. Assoc.

    (1995)
  • Sarah Baird et al.

    The short-term impacts of a schooling conditional cash transfer program on the sexual behavior of young women

    Health Econ.

    (2010)
  • Jennifer S. Barber

    Ideational influences on the transition to parenthood: attitudes toward childbearing and competing alternatives

    Soc. Psychol. Q.

    (2001)
  • Julia Andrea Behrman

    Does schooling affect Women's desired Fertility? Evidence from Malawi, Uganda, and Ethiopia

    Demography

    (2015)
  • Lucia Breierova et al.

    The Impact of Education on Fertility and Child Mortality: Do Fathers Really Matter Less than Mothers?

    (2004)
  • Guillermo Carroli et al.

    How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence

    Paediatr. Perinat. Epidemiol.

    (2001)
  • C. Andrew Combs et al.

    Factors associated with postpartum hemorrhage with vaginal birth

    Obstetrics Gynecol.

    (1991)
  • De Neve et al.

    Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment

    Lancet Glob. Health

    (2015)
  • Esther Duflo

    Schooling and labor market consequences of school construction in Indonesia: evidence from an unusual policy experiment

    Am. Econ. Rev.

    (2001)
  • Lelia Duley

    Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean

    BJOG An Int. J. Obstetrics Gynaecol.

    (1992)
  • Jane Falkingham

    Inequality and changes in women's use of maternal Health-care services in Tajikistan

    Stud. Fam. Plan.

    (2003)
  • Adela R. Freeburger et al.
  • Norma Fuller

    The social constitution of gender identity among Peruvian men

    Men Masculinities

    (2001)
  • Andrew Gelman et al.

    Data Analysis Using Regression and Multilevel/Hierarchical Models

    (2007)
  • Cited by (69)

    • Education and reproductive health: evidence from schooling expansion in Turkey

      2024, International Journal of Health Economics and Management
    View all citing articles on Scopus
    View full text