Mothers' Social Status and Children's Health: Evidence From Joint Households in Rural India.

The premise that a woman's social status has intergenerational effects on her children's health has featured prominently in population science research and in development policy. This study focuses on an important case in which social hierarchy has such an effect. In joint patrilocal households in rural India, women married to the younger brother are assigned lower social rank than women married to the older brother in the same household. Almost 8% of rural Indian children under 5 years old-more than 6 million children-live in such households. We show that children of lower-ranking mothers are less likely to survive and have worse health outcomes, reflected in higher neonatal mortality and shorter height, compared with children of higher-ranking mothers in the same household. That the variation in mothers' social status that we study is not subject to reporting bias is an advantage relative to studies using self-reported measures. We present evidence that one mechanism for this effect is maternal nutrition: although they are not shorter, lower-ranking mothers weigh less than higher-ranking mothers. These results suggest that programs that merely make transfers to households without attention to intrahousehold distribution may not improve child outcomes.

Endogenous inclusion in the Demographic and Health Survey anthropometric sample: Implications for studying height within households.

Development economists study both anthropometry and intra-household allocation. In these literatures, the Demographic and Household Surveys (DHS) are essential. The DHS censors its anthropometric sample by age: only children under five are measured. We document several econometric consequences, especially for estimating birth-order effects. Child birth order and mothers' fertility are highly correlated in the age-censored anthropometric subsample. Moreover, family structures and age patterns that permit within-family comparisons of siblings' anthropometry are unrepresentative. So strategies that could separate birth order and fertility in other data cannot here. We show that stratification by mother's fertility is important. We illustrate this by comparing India and sub-Saharan Africa (SSA). Children in India born to higher-fertility mothers are shorter, on average, than children of lower-fertility mothers. Yet, later-born children in India are taller, adjusted for age, than earlier-born children of the same sibsize. In SSA, neither of these associations is large.

Local Social Inequality, Economic Inequality, and Disparities in Child Height in India.

This study investigates disparities in child height-an important marker of population-level health-among population groups in rural India. India is an informative context in which to study processes of health disparities because of wide heterogeneity in the degree of local segregation or integration among caste groups. Building on a literature that identifies discrimination by quantifying whether differences in socioeconomic status (SES) can account for differences in health, we decompose height differences between rural children from higher castes and rural children from three disadvantaged groups. We find that socioeconomic differences can explain the height gap for children from Scheduled Tribes (STs), who tend to live in geographically isolated places. However, SES does not fully explain height gaps for children from the Scheduled Castes (SC) and Other Backward Classes (OBCs). Among SC and OBC children, local processes of discrimination also matter: the fraction of households in a child's locality that outrank her household in the caste hierarchy predicts her height. SC and OBC children who are surrounded by other lower-caste households are no shorter than higher-caste children of the same SES. Our results contrast with studies from other populations where segregation or apartheid are negatively associated with health.

The association between neonatal death and facility birth in regions of India.

BACKGROUND: Reducing neonatal mortality in India is critical to achieving the 2030 Sustainable Development Goal of a global neonatal mortality rate (NNM) of no more than 12 per 1,000. Policy efforts to reduce India's NNM, including a large-scale conditional cash transfer program, have focused on promoting birth in health facilities, rather than at home. Between 2005 and 2015, the percentage of facility births doubled, from 40% to 80%. OBJECTIVE: We assess evidence for the hypothesis that facility births reduce NNM by using new data from the National Family Health Survey, 2015-2016. METHODS: We analyze the association between neonatal death and facility birth at the region level, using ordinary least squares (OLS) linear probability models with fixed effects for the primary sampling unit, as well as child, mother, and household-level controls. RESULTS: For babies born outside of Uttar Pradesh and Bihar, facility birth is robustly associated with neonatal survival. The controlled association between facility birth and neonatal survival is 7 per 1,000 in the east region (West Bengal, Assam, Jharkhand, Odisha) and 13 per 1,000 in the central region (Madhya Pradesh and Chhattisgarh). In Uttar Pradesh and Bihar, however, being born in a health facility appears to confer no neonatal survival advantage. CONTRIBUTION: Documenting the lack of an association between facility birth and neonatal death in Uttar Pradesh and Bihar is important because these states collectively contribute 43% of India's NNM. These findings suggest the need for future research to investigate whether and how the quality of maternal and newborn care in health facilities differs across regions.

Prepregnancy body mass and weight gain during pregnancy in India and sub-Saharan Africa.

Despite being wealthier, Indian children are significantly shorter and smaller than African children. These differences begin very early in life, suggesting that they may in part reflect differences in maternal health. By applying reweighting estimation strategies to the Demographic and Health Surveys, this paper reports, to my knowledge, the first representative estimates of prepregnancy body mass index and weight gain during pregnancy for India and sub-Saharan Africa. I find that 42.2% of prepregnant women in India are underweight compared with 16.5% of prepregnant women in sub-Saharan Africa. Levels of prepregnancy underweight for India are almost seven percentage points higher than the average fraction underweight among women 15-49 y old. This difference in part reflects a previously unquantified relationship among age, fertility, and underweight; childbearing is concentrated in the narrow age range in which Indian women are most likely to be underweight. Further, because weight gain during pregnancy is low, averaging about 7 kg for a full-term pregnancy in both regions, the average woman in India ends pregnancy weighing less than the average woman in sub-Saharan Africa begins pregnancy. Poor maternal health among Indian women is of global significance because India is home to one fifth of the world's births.

Place and Child Health: The Interaction of Population Density and Sanitation in Developing Countries.

A long literature in demography has debated the importance of place for health, especially children's health. In this study, we assess whether the importance of dense settlement for infant mortality and child height is moderated by exposure to local sanitation behavior. Is open defecation (i.e., without a toilet or latrine) worse for infant mortality and child height where population density is greater? Is poor sanitation is an important mechanism by which population density influences child health outcomes? We present two complementary analyses using newly assembled data sets, which represent two points in a trade-off between external and internal validity. First, we concentrate on external validity by studying infant mortality and child height in a large, international child-level data set of 172 Demographic and Health Surveys, matched to census population density data for 1,800 subnational regions. Second, we concentrate on internal validity by studying child height in Bangladeshi districts, using a new data set constructed with GIS techniques that allows us to control for fixed effects at a high level of geographic resolution. We find a statistically robust and quantitatively comparable interaction between sanitation and population density with both approaches: open defecation externalities are more important for child health outcomes where people live more closely together.

The association between cesarean birth and breastfeeding initiation in Odisha, India: A mother fixed effects analysis.

Cesarean births are becoming more common in India, with health implications for both mothers and infants. Between 2005 and 2015, the proportion of cesarean births to total births in India roughly doubled, from 9% to 17%. We analyze Annual Health Survey data from the state of Odisha in eastern India. These population-level, longitudinal data on births between 2007 and 2011 allows us to estimate the association between cesarean birth and breastfeeding outcomes using mother fixed effects. Mother fixed effects allow comparisons of siblings born to the same mother who experienced different types of births (vaginal and cesarean). This empirical strategy controls for many potential observable and unobservable confounders in the relationship. Ordinary Least Squares linear probability models without mother fixed effects find that babies born by cesarean in Odisha are about 14 percentage points (p<0.001) more likely to experience delayed initiation of breastfeeding (that is, not being breastfed in the first 24 hours) compared with babies born vaginally. After introducing mother fixed effects, we find that babies born by cesarean are 11 percentage points more likely to (p<0.001) experience delayed initiation of breastfeeding. Because breastfeeding success is important for protecting against infectious disease in this context, future research should investigate whether cesarean birth impacts other aspects of breastfeeding as well.

Children's welfare and short term migration from rural India.

Few papers in the literature provide quantitative analysis of the difficult circumstances faced by children of short-term labour migrants. This paper uses new survey data from rural northwest India to study both children who migrate and those left behind. It finds that, unlike in other contexts, children who migrate rarely work when they accompany adult migrants. Additionally, this paper reports a robust, previously unquantified negative relationship between children's migration and educational outcomes and investments. It calls for further research about externalities of migration for children and suggests that expansion of a large public employment program might help these children.

NEONATAL DEATH IN INDIA: BIRTH ORDER IN A CONTEXT OF MATERNAL UNDERNUTRITION.

We document a novel fact about neonatal death, or death in the first month of life. Globally, neonatal mortality is disproportionately concentrated in India. We identify a large effect of birth order on neonatal mortality that is unique to India: later-born siblings have a steep survival advantage relative to the birth-order gradient in other developing countries. We show that India's high prevalence of maternal undernutrition and its correlation with age and childbearing can explain this pattern. We find that Indian mothers exit the underweight body mass range at an internationally comparatively high rate as they progress through childbearing careers.

When women eat last: Discrimination at home and women's mental health.

The 2011 India Human Development Survey found that in about a quarter of Indian households, women are expected to have their meals after men have finished eating. This study investigates whether this form of gender discrimination is associated with worse mental health outcomes for women. Our primary data source is a new, state-representative mobile phone survey of women ages 18-65 in Bihar, Jharkhand, and Maharashtra in 2018. We measure mental health using questions from the World Health Organization's Self-Reporting Questionnaire. We find that, for women in these states, eating last is correlated with worse mental health, even after accounting for differences in socioeconomic status. We discuss two possible mechanisms for this relationship: eating last may be associated with worse mental health because it is associated with worse physical health, or eating last may be associated with poor mental health because it is associated with less autonomy, or both.

Measurement of population mental health: evidence from a mobile phone survey in India.

In high-income countries, population health surveys often measure mental health. This is less common in low- and middle-income countries (LMICs), including in India, where mental health is under-researched relative to its disease burden. The objective of this study is to assess the performance of two questionnaires for measuring population mental health in a mobile phone survey. We adapt the Kessler-6 screening questionnaire and the World Health Organization's Self-Reporting Questionnaire (SRQ) for a mobile phone survey in the Indian states of Bihar, Jharkhand and Maharashtra. The questionnaires differ in the symptoms they measure and in the number of response options offered. Questionnaires are randomly assigned to respondents. We consider a questionnaire to perform well if it identifies geographic and demographic disparities in mental health that are consistent with the literature and does not suffer from selective non-response. Both questionnaires measured less mental distress in Maharashtra than in Bihar and Jharkhand, which is consistent with Maharashtra's higher human development indicators. The adapted SRQ, but not the adapted Kessler-6, identified women as having worse mental health than men in all three states. Conclusions about population mental health based on the adapted Kessler-6 are likely to be influenced by low response rates (about 82% across the three samples). Respondents were different from non-respondents: non-respondents were less educated and more likely to be female. The SRQ's higher response rate (about 94% across the three states) may reflect the fact that it was developed for use in LMICs and that it focuses on physical, rather than emotional, symptoms, which may be less stigmatized.

Caste, Religion, and Mental Health in India.

The relationship between mental health and social disadvantage in low- and middle-income countries is poorly understood. Our study contributes the first population-level analysis of mental health disparities in India, where the two marginalized groups that we study constitute a population larger than that of the USA. Applying two complementary empirical strategies to data on 10,125 adults interviewed by the World Health Organisation's Survey of Global Ageing and Adult Health (WHO-SAGE), we document and standardize gaps in self-reported mental health between the dominant social group (higher caste Hindus) and two marginalized social groups (Scheduled Castes and Muslims). We find that differences in socioeconomic status cannot fully explain the large disparities in mental health that we document, especially for Muslims. Our results highlight the need for research to understand the causes and consequences of mental health disparities in India, and for policies to move beyond redistribution and address discrimination against Scheduled Castes and Muslims.

Assessing high-profile public messaging for sanitation behaviour change: evidence from a mobile phone survey in India.

The UN Sustainable Development Goals call for the elimination of open defecation by 2030. Assessing global progress will require learning from India's sanitation efforts because of its ambitious program of high-profile behavior change messaging to tackle open defecation, and because open defecation is widespread in India. In 2014, the Prime Minister announced a policy called the Swachh Bharat Mission (SBM), which aimed to eliminate open defecation by 2019. However, the 2015-16 National Family Health Survey -4 found that about 55% of rural and 11% of urban Indian households lack a toilet or latrine. To assess the extent of public awareness of the SBM, we use a mobile phone survey to ask about people's knowledge of the existence and purpose of the SBM. We report representative estimates of awareness of the SBM among adults in Delhi (2016), Uttar Pradesh (2016), Mumbai (2016-17), Rajasthan (2016-17), Bihar (2018), Jharkhand (2018), and Maharashtra (2018). While much of the SBM's activities took place in its last two years, we find that, at the time of the survey, no more than one-third of adults in any state are aware that the SBM intends to promote toilet and latrine use. Awareness was particularly low in Uttar Pradesh, where one in eight people who defecates in the open worldwide lives. While the SBM was very active in constructing latrines, the lack of awareness we find suggests that the SBM was less successful in raising the awareness required for large-scale behavior change in promoting latrine use.

Persisting Prejudice: Measuring Attitudes and Outcomes by Caste and Gender in India.

Nearly seventy years after India adopted one of the most progressive constitutions in the world ensuring equality for all its citizens irrespective of caste, class, race, and gender, the mind-set of its vast majority Indian remains steeped in gender and caste bias. Results from a new telephonic survey confirm persistence of conservative gender and caste attitudes in Indian society. High proportions of men and women across all social groups disapprove of women working outside their homes, consider it 'acceptable for husbands to beat their wives', and would object to relatives marrying a Dalit person. Analyzing data from the National Family Health Survey and the India Human Development Survey, it has been found that outcomes associated with these attitudes are even more conservative: a smaller fraction of women work than those who feel it is okay to step out of the house for work; a larger fraction of women experience violence in marriage than men who consider marital violence acceptable, and an even smaller fraction of people have inter-caste marriages than people who say they would not oppose such an alliance. An overwhelming majority is opposed to an inter-caste marriage with a Dalit in the family. With a few exceptions, the attitudes and outcomes we studied vary, surprisingly, little by respondent gender, caste, and religion. Dr.Ambedkar's legacy is indeed unfinished-people from all backgrounds must continue to work for the equality and dignity of women and Dalits.

Persistence of Solid Fuel Use in Rural North India.

Survey evidence from rural North India showing persistent solid fuel use despite increases in liquefied petroleum gas ownership is presented. Although three-quarters of survey households in these states had LPG, almost all also had a stove that uses solid fuels. Among those owning both, almost three-quarters used solid fuels the day before the survey. Household economic status, relative costs of cooking fuels, gender inequality, and beliefs about solid fuels were important contributors to high solid fuel use. To realise the full health benefits of the LPG expansion, attention must now be turned towards encouraging exclusive LPG use.

Revisiting Open Defecation: Evidence from a Panel Survey in Rural North India, 2014-18.

Since October 2014, the Government of India has worked towards the goal of eliminating open defecation by 2019 through the Swachh Bharat Mission. Since October 2014, the Government of India (GOI) has worked towards the goal of eliminating open defecation by 2019 through the Swachh Bharat Mission (SBM). In 2014, several of the co-authors reported on a survey of rural sanitation behaviour in North India (Coffey et al 2014) conducted by the Research Institute for Compassionate Economics (r.i.c.e.). Different statistical methods produce slightly different numbers, but results from a wide range of approaches used concur that approximately 40% to 50% of rural people in these states defecated in the open in late 2018. The 2014 survey used a multistage sampling strategy to select households: first, districts were purposively selected to match the state-level trend in rural open defecation between the 2001 and 2011 Censuses; second, villages were randomly drawn using proportional-to-size sampling from a frame taken from the Government of India's District Level Health Survey; third, households were selected using an in-field randomisation technique similar to that used for Pratham's Annual Status of Education Report (ASER) survey.

Assessing public awareness and use of medical abortion via mobile phone survey in India.

OBJECTIVE: We assess the feasibility of measuring awareness and use of medical abortion via a mobile phone survey on social attitudes in India. STUDY DESIGN: In 2018, we conducted a mobile phone survey with 3455 married men and women in Bihar and Maharashtra, two of India's most populous states. As part of a broader survey on social inequality, welfare programs, and health, we asked respondents about their awareness of medical abortion and whether they (or their wife) had ever had a medical abortion. RESULTS: Among men and women in Bihar and Maharashtra, one fifth to one third of respondents said that they had heard of medical abortion. In Bihar, men were more likely than women to report having heard of pills that can be used to end a pregnancy. Awareness of medical abortion was positively associated with education and with women's status within the household. Consistent with results from representative face-to-face surveys, reported use of abortion medications was low. CONCLUSION: Our findings demonstrate that respondents are willing to answer abortion-related questions via mobile phone survey and reveal differences in reported awareness of medical abortion according to region, sex, education, and household status. IMPLICATIONS: Inclusion of abortion-related questions in a large-scale, social attitudes phone survey is a feasible option for assessing public awareness of medical abortion in India.

The Consequences of Social Inequality for the Health and Development of India's Children: The Case of Caste, Sanitation, and Child Height.

The links among social inequality, economic inequality, and health have long been of interest to social scientists, but causal links are difficult to investigate empirically. In particular, studies examining the impact of social status on one's own health may overlook important effects of inequality on the health of populations as a whole occurring due to negative externalities of social forces. A recent literature on caste, sanitation, and child net nutrition provides an example of one social context where social inequality makes an entire population less healthy. This paper presents new observational analysis of the India Human Development Survey that provides descriptive evidence of this mechanism. We show that, on average, children in rural India are shorter if they live in villages where more people report practicing untouchability-meaning that they enforce caste hierarchies in their interactions with people from the lowest castes. This association is explained by the association between casteism and the prevalence of rural open defecation.

Measuring open defecation in India using survey questions: evidence from a randomised survey experiment.

OBJECTIVES: To investigate differences in reported open defecation between a question about latrine use or open defecation for every household member and a household-level question. SETTING: Rural India is home to most of the world's open defecation. India's Demographic and Health Survey (DHS) 2015-2016 estimates that 54% of households in rural India defecate in the open. This measure is based on a question asking about the behaviour of all household members in one question. Yet, studies in rural India find substantial open defecation among individuals living in households with latrines, suggesting that household-level questions underestimate true open defecation. PARTICIPANTS: In 2018, we randomly assigned latrine-owning households in rural parts of four Indian states to receive one of two survey modules measuring sanitation behaviour. 1215 households were asked about latrine use or open defecation individually for every household member. 1216 households were asked the household-level question used in India's DHS: what type of facility do members of the household usually use? RESULTS: We compare reported open defecation between households asked the individual-level questions and those asked the household-level question. Using two methods for comparing open defecation by question type, the individual-level question found 20-21 (95% CI 16 to 25 for both estimates) percentage points more open defecation than the household-level question, among all households, and 28-29 (95% CI 22 to 35 for both estimates) percentage points more open defecation among households that received assistance to construct their latrines. CONCLUSIONS: We provide the first evidence that individual-level questions find more open defecation than household-level questions. Because reducing open defecation in India is essential to meeting the Sustainable Development Goals, and exposure to open defecation has consequences for child mortality and development, it is essential to accurately monitor its progress. TRIAL REGISTRATION NUMBER: Registry for International Development Impact Evaluations (5b55458ca54d1).

Child Height in India: Facts and Interpretations from the NFHS-4, 2015-16.

An analysis of child height-for-age using the newly released data from the National Family Health Survey-4 indicates that the average child height increased by about four-tenths of a height-for-age standard deviation between 2005 and 2015. Although important, this increase is small relative to India's overall height deficit, and relative to economic progress; children in India remain among the shortest in the world. It is unsurprising that the increase in height-for-age has been modest because none of the principal factors responsible for India's poor child height outcomes have substantially improved over the last decade. Familiar patterns of regional, sex, and caste disadvantage are reflected in child height in 2015.