Poverty Reduction: Does Reproductive Health Matter? Tom Merrick & Margaret Greene Woodrow Wilson Center January 2006

Outline of presentation Why we did the study How we did it The main findings (and issues) Recommendations for strengthening the evidence base

Why study RH/poverty links: Financing of the "Cairo" agenda has fallen far short of changing needs. Changed funding modes: poverty- reduction credits, with MDG focus, guided by evidence about social sector investments and poverty reduction. How strong is the evidence that poor RH outcomes undermine poverty reduction?

Macro evidence that fertility decline helps economies grow Rapid fertility declines in East Asia created a demographic bonus—a temporary bulge in working ages that enabled greater investment. Cashing in on bonus required "good" economic policies: open economies, job creation, investments in health and education, gender equity. Is there a parallel household-level story?

Bonus countries

Public-Sector Management Matters Benefits from a ‘demographic bonus’ depend on good public-sector management. 1.Fiscal discipline 2.Open and competitive markets 3.Public investment in education and health care

But… Will the economic policies that worked for East Asia help Africa, South Asia? Why didn't they work for Latin America? Will the bonus really help reduce poverty—(yes, a bigger pie; but how about distribution, gender equity)? Motivated us to question whether household-level evidence is strong enough to convince bonus skeptics that spending on the post-Cairo reproductive health agenda will help reduce poverty?

Poor women get less care Poorest 20% Richest 20% Source: World Bank/DHS 1999 Summary of data for 10 countries % of population reached by services But does this, in turn, make them poorer?

Do poor RH outcomes keep households poor? Poverty analyses by others suggests: Not much direct impact of RH outcomes (early childbearing, unintended pregnancy, maternal mortality) on poverty in households. Linkages are indirect—via health, education, consumption—see chart 

Adapted from work by Ruger, Jamison and Bloom 2001 Consider early childbearing and poverty:

Measuring the link between reproductive health and poverty Many dimensions of reproductive health: fertility and family planning, maternal health, STDs, HIV/AIDS, violence and harmful practices Many dimensions of poverty: income, wealth/assets, expenditures, consumption, Sen's "capacities": health and education

We limited review to three sets of RH outcomes 1. Early childbearing 2. Maternal mortality and morbidity 3. Unintended, mistimed pregnancy & large family size

Adverse effects of poor RH on poverty: preview Health: strong evidence on obstetric complications, unsafe abortion, low birth weight, lasting health problems affecting productivity, well-being. Schooling: evidence is good, includes debate on intergenerational transmission of poverty via early childbearing and school drop out. Well-being (consumption, productivity): evidence harder to find, impact affected by welfare and educational policies, labor market conditions.

1. Impact of early childbearing on poverty in developing countries Health: fairly strong evidence on adverse health effects of very early pregnancy, including life-long morbidities. Education: some evidence on dropping out, but reasons other than pregnancy (poor performance, cost) often a more important factor. Well-being (earnings/consumption): more evidence for Latin America (marriage age is later, but early childbearing more disruptive) than in Africa and Asia (early marriage and childbearing linked).

2. Impact of maternal morbidities on poverty Health: some evidence about impacts on health of children; very limited evidence about longer-term pregnancy-related morbidities. Education: limited evidence (except for HIV/AIDS) of adverse impact on education of children, but mediated by fosterage, contextual factors. Well-being: little or no evidence on impacts of mortality & morbidity on well- being of households.

3. Impact of unintended, mistimed pregnancy, high fertility on poverty Health: short birth intervals affect child survival, but number of births affects maternal mortality more; unsafe abortion a health risk associated with unwanted pregnancy. Education: in some contexts, large family size reduces investment in children’s education, especially for girls. Well-being: some evidence that large family size creates competition in household spending on children, possibly with adverse effects on girls.

Common threads: Context matters (fosterage, labor market conditions, stage of demographic transition). Causality is very difficult to demonstrate (many feedbacks). Scarcity of information on maternal deaths in survey data.

Context Child rearing customs: fosterage mitigates impact of early childbearing, maternal mortality in Africa Labor market conditions in Latin America affects link between women’s work and fertility Effects are more pronounced when conditions are changing (an echo of the macro story)

The causality problem Reproductive Health Outcome Poverty Indicator Possible third causal variable

Need more research on: Impact by age of mother and wealth status. The experiences of young mothers over the medium and long term. Household-level effects of maternal death and disability (building on HIV/AIDS work). Are potential benefits of scale economies in large families outweighed by unequal distribution of benefits within household? Effects of close spacing on educational prospects of children.

For a stronger evidence base: Apply analytical techniques that can overcome the problems of mutual causality ("natural experiments"). Make more use of longitudinal data that enable tracking of effects over time (our work with Progresa/Oportunidades data). Get more mileage out of existing data sources (DHS, LSMS). Address knowledge gaps: for example, effects of morbidity associated with poorly managed obstetric complications.

Country-level work is needed: Research on P/RH consequences suggests that impacts affected by context: stage of demographic and epidemiological transition, political, economic and social contexts, including gender, so we need country studies It's not necessary to have "gold standard' causal research to make the case in each country. It is important to link country evidence to relevant international evidence.

Our bottom line Financing for the "Cairo" agenda is falling far short of changing needs. Resources can be mobilized through the new poverty-reduction, MDG- focused mechanisms that donors and governments are embracing. To tap into these resources, RH advocates must demonstrate that poor RH outcomes undermine poverty reduction at the country level.