Do tuition-free lower secondary education policies matter for antenatal care among women in sub-saharan African countries?

BACKGROUND: Antenatal care (ANC) is critical to reducing maternal and infant mortality. However, sub-Saharan Africa (SSA) continues to have among the lowest levels of ANC receipt globally, with half of mothers not meeting the WHO minimum recommendation of at least four visits. Increasing ANC coverage will require not only directly reducing geographic and financial barriers to care but also addressing the social determinants of health that shape access. Among those with the greatest potential for impact is maternal education: past research has documented a relationship between higher educational attainment and antenatal healthcare access, as well as related outcomes like health literacy and autonomy in health decision-making. Yet little causal evidence exists about whether changing educational policies can improve ANC coverage. This study fills this research gap by investigating the impact of national-level policies that eliminate tuition fees for lower secondary education in SSA on the number of ANC visits. METHODS: To estimate the effect of women's exposure to tuition-free education policies at the primary and lower secondary levels on their ANC visits, a difference-in-difference methodology was employed. This analysis leverages the variation in the timing of education policies across nine SSA countries. RESULTS: Exposure to tuition-free primary and lower secondary education is associated with improvements in the number of ANC visits, increasing the share of women meeting the WHO recommendation of at least four ANC visits by 6-14%. Moreover, the impact of both education policies combined is greater than that of tuition-free primary education alone. However, the effects vary across individual treatment countries, suggesting the need for further investigation into country-specific dynamics. CONCLUSIONS: The findings of this study have significant implications for policymakers and stakeholders seeking to improve ANC coverage. Removing the tuition barrier at the secondary level has shown to be a powerful strategy for advancing health outcomes and educational attainment. As governments across Africa consider eliminating tuition fees at the secondary level, this study provides valuable evidence about the impacts on reproductive health outcomes. While investing in free education requires initial investment, the long-term benefits for both human development and economic growth far outweigh the costs.

Impact of laws prohibiting domestic violence on wasting in early childhood.

Intimate partner violence (IPV) affects an estimated 641 million women and girls globally with far-reaching consequences for the health of women and children. Yet, laws that prohibit domestic violence (DV) are not universal. Countries actively debate the effectiveness of DV laws in improving conditions given the inconclusive evidence on deterrent effects within households particularly in low- and middle-income countries that have limited infrastructure, and fewer resources to implement and enforce policy changes. This is the first study to rigorously examine the impact of DV laws on women's health decision-making and the intergenerational impact on children's wasting, a key predictor of mortality. We used the Demographic and Health Surveys (DHS) data collected between 2000-2020 across 23 African countries. Exploiting the staggered adoption of laws, we used a difference-in-differences study design to estimate the impact of DV laws in the treated countries compared to countries without such laws. We find that DV laws increased women's decision-making autonomy in healthcare by 16.7% as well as other measures of women's autonomy that matter for health such as financial autonomy by 6.3% and social mobility by 11.0%. The improvements in women's autonomy translated into reductions in the probability of wasting among children aged 0-23 months by 5.4% points, a 30.9% reduction from the mean. DV laws also reduced wasting among older children aged 24-59 months by 3.6% points, a 38.7% reduction from the mean. The laws were effective in all 6 countries analyzed individually that criminalized DV. A civil prohibition in the seventh country was not found to be effective. The effect was positive and significant for all wealth and geographical categories. Our findings demonstrate the value of enacting criminal laws that prohibit domestic violence as one important tool to reducing the profound health impacts of IPV, a critical health and human rights issue.

National Policies on Parental Leave and Breastfeeding Breaks: Racial, Ethnic, Gender, and Age Disparities in Access and Implications for Infant and Child Health.

OBJECTIVE: Parental leave and breastfeeding breaks influence the ability to initiate and continue breastfeeding. We investigated how eligibility criteria in the Family and Medical Leave Act (FMLA) and Affordable Care Act (ACA) affect access to unpaid parental leave and breastfeeding breaks and assessed affordability and alternative policy models. METHODS: We used family income data to assess the affordability of unpaid leave by race and ethnicity. We used 2017-2018 US Current Population Survey data to determine the percentage of private sector workers aged 18-44 years who met the minimum hour (1250 hours of work during a 12-month period), tenure (12 months), and firm size (≥50 employees) requirements of FMLA and ACA. We analyzed eligibility by gender, race and ethnicity, and age. We also examined parental leave and breastfeeding break policies in 193 countries. RESULTS: Most Latinx (66.9%), Black (60.2%), and White (55.3%) workers were ineligible and/or unlikely to be able to afford to take unpaid FMLA leave. Of 69 534 workers, more women (16.9%) than men (10.3%) did not meet the minimum hour requirement. Minimum tenure excluded 23.7% of all workers and 42.2% of women aged 18-24 years. Minimum firm size excluded 30.3% of all workers and 37.7% of Latinx workers. Of 27 520 women, 28.8% (including 32.9% of Latina women) were excluded from ACA breastfeeding breaks because of firm size. Nearly all other countries guaranteed mothers paid leave regardless of firm size or minimum hours and guaranteed ≥6 months of paid leave or breastfeeding breaks. CONCLUSIONS: Adopting a comprehensive, inclusive paid parental leave policy and closing gaps in breastfeeding break legislation would remove work-related barriers to breastfeeding; reduce racial, ethnic, and gender inequities; and align US national policies with global norms.

The intergenerational effect of tuition-free lower-secondary education on children's nutritional outcomes in Africa.

One in five child deaths under age 5 are a result of severe wasting. Malnutrition at early ages is linked to lifelong consequences, such as reduced cognitive skills, reduced earnings in adulthood and chronic health conditions. Countries worldwide have committed to addressing child undernutrition, and ending hunger is foundational to the Millennium Development Goals. In this paper, we study the intergenerational effect of providing free tuition in secondary school on future children's nutrition. We combined a novel longitudinal dataset that captures educational policies for 40 African countries from 1990 to 2019 with the Demographic and Health Survey (DHS). We identified three countries that introduced free secondary education several years after implementing free primary education. Exploiting this variation in timing we estimate the additional impact of providing free secondary education over free primary education. Using a difference-in-difference approach, we find that introducing free secondary education significantly reduced wasting. Cohorts exposed to free secondary had an 18% relative decrease in wasting. The impact on cohorts exposed only to free primary was smaller and not statistically significant. Expanding free secondary education has long-term, intergenerational benefits and is an effective path to reducing malnutrition. Results are robust to different specifications.

Paid Leave to Meet the Health Needs of Aging Family Members in 193 Countries.

Women and workers over 50 disproportionately provide care for aging family members worldwide, including the 101 million who are care-dependent. Paid leave for adult health needs, which temporarily replaces employment income for workers providing care, can critically support both caregivers' economic outcomes and care recipients' wellbeing. We created quantitatively comparable data on paid leave policies that can be used to meet adult family members' health needs in all United Nations member states. Globally, 112 countries fail to provide any paid leave that can be used to meet the serious health needs of an aging parent, spouse, or adult child. These gaps have profound consequences for older workers providing care as well as care access by aging, ill, and disabled adults.

US Sick Leave In Global Context: US Eligibility Rules Widen Inequalities Despite Readily Available Solutions.

Research has demonstrated that paid sick leave reduces the spread of COVID-19 and other infectious diseases and improves preventive care and access to treatment across a wide range of conditions. However, the US has no national paid sick leave policy, and even unpaid leave via the Family and Medical Leave Act (FMLA) of 1993-often viewed as a foundation for new paid leave legislation-is often inaccessible to workers. We analyzed data from a nationally representative survey to determine the extent to which specific FMLA features produce gaps and disparities in leave access. We then used comparative policy data from 193 countries to analyze whether these policy features are necessary or prevalent globally, or whether there are common alternatives. We found that the FMLA's minimum hours requirement disproportionately excludes women, whereas its tenure requirement disproportionately excludes Black, Indigenous, and multiracial workers. Latinx workers also face greater exclusion because of employer size requirements. Of the 94 percent of countries that provide permanent paid sick leave, none broadly restrict leave based on employer size, and 93 percent cover part-time workers without a minimum hours requirement. Enacting permanent paid sick leave that is accessible regardless of employer size, tenure, or hours is critical and feasible.

Immigration Detention in the United States: Identifying Alternatives That Comply With Human Rights and Advance Public Health.

Under international law, the United States is obligated to uphold noncitizens' fundamental rights, including their rights to health. However, current US immigration laws-and their enforcement-not only fail to fulfill migrants' health rights but actively undermine their realization and worsen the pandemic's spread. Specifically, the US immigration system's reliance on detention, which precludes effective social distancing, increases risks of exposure and infection for detainees, staff, and their broader communities. International agreements clearly state that the prolonged, mandatory, or automatic detention of people solely because of their migration status is a human rights violation on its own. But in the context of COVID-19, the consequences for migrants' right to health are particularly acute. Effective alternatives exist: other countries demonstrate the feasibility of adopting and implementing immigration laws that establish far less restrictive, social services-based approaches to enforcement that respect human rights. To protect public health and realize its global commitments, the United States must shift away from detaining migrants as standard practice and adopt effective, humane alternatives-both amid COVID-19 and permanently.

Paid parental leave and family wellbeing in the sustainable development era.

BACKGROUND: The Sustainable development goals (SDGs) have the potential to have a significant impact on maternal and child health through their commitments both to directly addressing health services and to improving factors that form the foundation of social determinants of health. To achieve change at scale, national laws and policies have a critical role to play in implementing the SDGs' commitments. One particular policy that could advance a range of SDGs and importantly improve maternal and infant health is paid parental leave. METHODS: This article analyzes literature on paid leave and related policies relevant to SDG 1 (poverty), SDG 3 (health), SDG 5 (gender equality), SDG 8 (decent work), and SDG 10 (inequality). In addition, this article presents global data on the prevalence of policies in all 193 UN Member States. RESULTS: A review of the literature finds that paid parental leave may support improvements across a range of SDG outcomes relevant to maternal and child health. Across national income levels, paid leave has been associated with lower infant mortality and higher rates of immunizations. In high-income countries, studies have found that paid leave increases exclusive breastfeeding and may improve women's economic outcomes. However, factors including the duration of leave, the wage replacement rate, and whether leave is made available to both parents importantly shape the impacts of paid leave policies. While most countries now offer at least some paid maternal leave, many provide less than the 6 months recommended for exclusive breastfeeding, and only around half as many provide paternal leave. CONCLUSIONS: To accelerate progress on the SDGs' commitments to maternal and child health, we should monitor countries' actions on enacting or strengthening paid leave policies. Further research is needed on the duration, wage replacement rate, and availability of leave before and after birth that would best support both child and parental health outcomes and social determinants of health more broadly. In addition, further work is needed to understand the extent to which paid leave policies extend to the informal economy, where the majority of women and men in low- and middle-income countries work.