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 , Oslo, Norway

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) 2

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? 3

Data – Vaccination uptake  The individual-level outcomes comprise the uptake of: o Bacillus Calmette-Guérin (BCG) o Diphtheria, pertussis and tetanus (DPT) - three doses o 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 Selection of countries was determined by the availability of at least two DHS surveys between 2001 and o Child observations were allocated to each year based on the child’s year of birth. 4

 Panel: 277,787 child observations in 20 DHS countries over the period  These data were merged to longitudinal information on paid maternity leave for each country 5 CountryDHs survey years Honduras Nepal Uganda Bangladesh Armenia Cambodia Colombia Rwanda Senegal Zimbabwe Malawi Tanzania Lesotho Ghana Kenya Madagascar Nigeria Philippines Bolivia Egypt Data - Vaccination uptake

Data – Vaccination uptake 6 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.

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 ( ).  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 Database o Council of Europe Family Policy Database o International Review of Leave Policies and Related Research 7

Data – Paid Maternity Leave (FTE weeks):

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 expenditures o per capita government health expenditure o female labor force participation 9

Summary Statistics – All variables VariableMeanStd. Dev. Outcome Variables BCG DPT DPT DPT Polio Polio Polio Exposure variable FTE/week Control variables Country-level covariates GDP/cap-log Total health expenditure/cap-log Government health expenditure/cap-log Female labor-force participation Household-level covariates Mother's education/ year Household size Urban Birth characteristics Male Female (ref.) Birth order # Birth order # Birth order # 3 and above (ref.) Mother's age at birth - 19 and below Mother's age at birth - 20 to 39 (ref.) Mother's age at birth - 40 and above Other Attendance of skilled health personnel

Summary Statistics – Vaccination Rates 11

Empirical strategy: regression with fixed effects 12

Effect of 1 additional FTE week of paid maternity leave on BCG vaccination 13 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 1Model 2Model 3Model 4Model 5Model 6Model 7 FTE (0.0006) (0.0009) (0.0009) (0.0008) (0.0008) (0.0008) (0.0008) Country-level covariates GDP/cap-log (0.0199)-0.08 (0.026) (0.0253) (0.0253) (0.0252) Total health expenditure/cap-log (0.0108) (0.0104) (0.0104)0 (0.0103) Government health expenditure/cap-log (0.008) (0.0077) (0.0077) (0.0076) Female labour-force participation (0.0005) (0.0005) (0.0004) (0.0004) Household-level covariates Mother's education (0.0003)0.014 (0.0003) (0.0003)0.011 (0.0003) Household size (0.0003) (0.0003) Urban (0.0031) (0.0031)0.001 (0.003) Birth characteristics Gender/Male (0.0014) (0.0014) Birth order Birth order # (0.002) (0.002) Birth order # (0.0017) (0.0017) Mother's age at birth 19 and below (0.0028) (0.0027) 40 and above (0.0038) (0.0038) Other Attendance of skilled health personnel (0.0025) Sample weightsYYYYYYY Clustered SEsYYYYYYY Country FEYYYYYY Time trend YYYYYY

Overall Results – Full models 14 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.

 Each additional FTE week of paid maternity leave was associated with: o 0.16 percentage point increase in the probability of BCG vaccination o 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. 15 Conclusions

 Use of mothers' recall for determination of child vaccination status when vaccination cards were not available: recall bias o 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. 16 Limitations

Thank you

Appendix Vaccination and Maternity Leave Data 18

Data – Vaccination uptake  Mothers surveyed in the DHS are asked to provide vaccination information concerning live births over the previous 59 months 19

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 20

Effect of 1 additional FTE week of paid maternity leave on DPT1 21 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 (0.0006) (0.001) (0.0011) (0.0011) (0.0011) (0.0011) Country-level covariates GDP/cap-log (0.0208) (0.0257) (0.0253) (0.0252) (0.0252) Total health expenditure/cap-log (0.0113) (0.011) (0.011) (0.0109) Government health expenditure/cap-log (0.0089) (0.0086) (0.0086) (0.0086) Female labor-force participation (0.0005) (0.0005) (0.0005) (0.0005) (0.0005) Household-level covariates Mother's education (0.0003) (0.0003) (0.0003) (0.0003) Household size (0.0004) (0.0004) Urban (0.0033) (0.0033) (0.0032) Birth characteristics Gender/Male (0.0014) (0.0014) Birth order Birth order # (0.0022) (0.0022) Birth order # (0.0019) (0.0019) Mother's age at birth 19 and below (0.0029) (0.0028) 40 and above (0.004) (0.0039) Other Attendance of skilled health personnel (0.0027)