Early Life Public Health Intervention and Adolescent Cognition: Evidence from the Safe Motherhood Program in Indonesia Ava Gail Cas Duke University March 17, 2012

*This work is supported by Hewlett/International Institute of Education Dissertation Fellowship Program, the Population Reference Bureau Fellows Program and partly by World Bank (Indonesia) Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Motivation Growing interest in early life health interventions Increasing awareness of the importance of early life in predicting later success in adulthood But, rigorous evaluation of early life public health interventions is still rare Some important questions remain unresolved: Do the effects of early life interventions persist later in life? When is it most effective to intervene?

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Literature: For long-run impact, when is it best to intervene? Fetal period (Almond, 2006; Almond et. al., 2009; Berhman and Rosenzweig, 2004) Early childhood years: 0 to 2 or 0 to 3 (Alderman, 2006; Maccini and Yang, 2009; Maluccio et. al., 2009)

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Two Main Goals in this Study Empirically examine the impact of the Safe Motherhood Program in Indonesia for outcomes later in life: adolescent cognition and schooling Examine the relative importance of each period of development for later outcomes

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Findings from Biology/Development Psychology

Critical or sensitive periods in the developmental process The first two years of life (Grantham-McGregor and Ani, 1999; Politt et. al., 1993)

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Findings from Biology/Development Psychology Critical or sensitive periods in the developmental process The first two years of life (Grantham-McGregor and Ani, 1999; Politt et. al., 1993)

The fetal period (Barker et. al., 1989; Liu et. al., 2000; Meaney, 2001; Rodier, 2004)

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Findings from Biology/Development Psychology Critical or sensitive periods in the developmental process The first two years of life (Grantham-McGregor and Ani, 1999; Politt et. al., 1993)

The fetal period (Barker et. al., 1989; Liu et. al., 2000; Meaney, 2001; Rodier, 2004)

Maternal health and nutritional status prior to ovulation and conception (Aagaard-Tillery et. al., 2008; Kanakkaparambil, 2009; Wang et. al., 2009; Winder et. al., 2011)

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Importance of maternal health and nutriton prior to conception nutrition or diet (Aagaard-Tillery et. al., 2008; Watkins and Fleming, 2009) vitamin intake (Kanakkaparambil, 2009) glucose levels (Wang et. al., 2009)

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Findings from Biology/Development Psychology Critical or sensitive periods in the developmental process The first two years of life (Grantham-McGregor and Ani, 1999; Politt et. al., 1993)

The fetal period (Barker et. al., 1989; Liu et. al., 2000; Meaney, 2001; Rodier, 2004)

Maternal health and nutritional status prior to ovulation and conception (Aagaard-Tillery et. al., 2008; Kanakkaparambil, 2009; Wang et. al., 2009; Winder et. al., 2011)

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

The Program

First Safe Motherhood Program in Indonesia:Allocation of Village Midwives In 1987: U.N. issued a call to action to make maternal health an urgent priority 1990 to 1996: Over 54,000 trained midwives were deployed in nonmetropolitan villages

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Figure: Expansion of the Program over the period 1990 to 1996 % of IFLS Communities

50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 1990

1991

1992

1993

1994

1995

1996

Year

- Allocated in communities with poorer infrastructure, poor health outcomes, more remote Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Role of the Village Midwives Provide antenatal care, safe delivery services and postnatal care Serve as health resource providing general health care Educate families on nutrition and other health promoting behaviors Health Services for children: curative care and medicines such as antibiotics and cough syrup Immunization and vitamins/mineral supplements

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Earlier Safe Motherhood Studies in Indonesia Show Program Impacts (Frankenberg et. al., 2009; Frankenberg and Thomas, 2001; Frankenberg, Suriastini and Thomas, 2005) Improved antenatal care, Iron tablets intake during pregnancy and utilitzation of medically oriented delivery Improved nutritional status (body mass index) of women of reproductive age Improved the nutritional status (height-for-age) of children aged 1-4

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Data

The Indonesian Family Life Survey (IFLS): 1993, 1997, 2000, 2007 Longitudinal survey that collects information at individual, household and community level Sample will focus on 10,245 children in 1993 IFLS and 1997 IFLS who were born in 1983 to 1996 in the baseline IFLS communities

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Identifying presence of village midwives In all IFLS waves: the village head and the head of the Village Womens Group were asked about the presence of village midwife 1997, 2000 and 2007 IFLS waves includes information on timing and length of stay of the first village midwife arrival in the community

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Empirical Strategy Intensity of Exposure Specification

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Intensity ofX Exposure Specification Yijt = c1 +

βk EXPijtk + θXijt + µZjt + δt + γj + ijt

k

EXPijtk is a set of indicator variables that reflect the timing of the arrival of the midwife relative to the child’s birthdate. The indicator is set to 0 if the community did not receive a midwife Timing of midwife arrival relative to child’s birth: 6 years before child birth up to 13 years after child birth Hypothesis: βk should be 0 for k ≥ 4 and decreasing with later exposure for k <4

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Timing of Midwife Arrival Relative to Child’s Birth 

‐3 to ‐6

3 to 6 years before birth

‐2

2 years before birth

‐1

1 year before birth (prenatal period)

0

At year of birth

1

1 year after birth 1 year after birth

2

2 years after birth

3

3 years after birth

4

4 years after birth

5

5 years after birth

6 : : : 13

6 years after birth y : :  : 13 years after birth

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Variation in exposures

Child is exposed to the program starting at age 1 Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Variation in exposures

Child is exposed to the program 1 year before birth (fetal period) Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Variation in exposures

Child is exposed to the program starting at age 1 Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Intensity ofX Exposure Specification Yijt = c +

βk EXPijtk + θXijt + µZjt + δt + γj + ijt

k

Control Variables: δt year of birth fixed effect γj community of birth fixed effect Xijt vector of individual and parental characteristics - gender, age at measurement, mothers height, mothers and fathers education Zjt vector of time varying community characteristics - time-varying changes in local amenities, availability of child development services and availability of schools at the time of measurement ijt error term

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Timing of Midwife Arrival Relative to Child’s Birth  Hypothesis yp ‐3 to ‐6

3 to 6 years before birth

‐2

2 years before birth

‐1

1 year before birth (prenatal period)

0

At year of birth

1

1 year after birth 1 year after birth

2

2 years after birth

3

3 years after birth

4

4 years after birth

5

5 years after birth

6 : : : 13

6 years after birth y : :  : 13 years after birth

Ava Gail Cas

Decreasing Effect size with  later exposure

No effect

Early Life Public Health Intervention and Adolescent Cognition: E

Comparing Cohorts of Same Age: Lexis Diagram

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Outcomes Cognitive Test Score - comprised of 80% Raven’s CPM Test Questions and 20% Mathematics Test Questions Measures of education: Whether entered school by age 6 (LPM) Whether attending school at the time of measurement (LPM) Educational Attainment (in years)

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Figure: Raven’s CPM Sample Exercise

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Outcomes Cognitive Test Score - comprised of 80% Raven’s CPM Test Questions and 20% Mathematics Test Questions Measures of education: Whether entered school by age 6 (LPM) Whether attending school at the time of measurement (LPM) Educational Attainment (in years)

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Cognitive Outcomes

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Figure: Coefficients of the Intensity of Exposure to Safe Motherhood Program in the Cognition Equation (Cohorts 1983 to 1996) % Point Increase in Test Score 16 14 12 10 8 6 4 2 0 ‐2 ‐3 to  ‐2 ‐6 ‐4 ‐6

‐1

0

1

2

3

4

5

6

7

8

9

10 11

Timing of Midwife’s Arrival Relative to Birth (Year of Midwife’s Arrival  ‐ Year of Birth)  

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Table: Impact By Intensity of Exposure:Cognitive Test Score (% Correct) Timing/Age of Exposure to Midwife 3 to 6 years before birth (-3 to -6) 2 years before birth (-2) 1 year before birth (-1) At year of birth (0) 1 year after birth (1) 2 years after birth (2) 3 years after birth (3)

Coefficient 7.27*** 6.56*** 4.54*** 4.39*** 2.88** 3.06** 0.67

Standard Error 2.00 1.69 1.53 1.40 1.32 1.32 1.30

*** - significant at 1%; ** - significant at 5% Controls: Birth year and community of birth fixed effects, mother’s and father’s education, mother’s height, age at the time of measurement, sex; indicator of changes in the local amenities and the timing and availability of child development services over time

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Table: Impact By Intensity of Exposure:Cognitive Test Score (% Correct) Timing/Age of Exposure to Midwife

Coefficient

3 to 6 years before birth (-3 to -6) 2 years before birth (-2) 1 year before birth (-1) At year of birth (0) 1 year after birth (1) 2 years after birth (2) 3 years after birth (3)

7.27*** 6.56*** 4.54*** 4.39*** 2.88** 3.06** 0.67

Standardized Test Scores (S.D.) 0.33 0.30 0.21 0.20 0.13 0.14 0.03

*** - significant at 1%; ** - significant at 5% Controls: Birth year and community of birth fixed effects, mother’s and father’s education, mother’s height, age at the time of measurement, sex; indicator of changes in the local amenities and the timing and availability of child development services over time

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Figure: Coefficients of the Intensity of Exposure to Safe Motherhood Program in the Cognition Equation (Cohorts 1983 to 1996) % Point Increase in Test Score 8 Main result

7

N = 8295

6 5 4 3 2 1 0 ‐3 to ‐6 ‐3 to ‐6

‐2

‐1

0

1

2

3

Age of Exposure (Year of Midwife’s Arrival  ‐ Year of Birth)  

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Figure: Coefficients of the Intensity of Exposure to Safe Motherhood Program in the Cognition Equation: Robustness Checks

Add Province X Birth Year FE % Point Increase in Test Score 8 Main result Main result

7

PROV x BYR FE

6

N = 8295

5 4 3 2 1 0 ‐3 to ‐6

‐2

‐1

0

1

2

3

Age of Exposure (Year of Midwife’s Arrival  ‐ Year of Birth)  

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Figure: Coefficients of the Intensity of Exposure to Safe Motherhood Program in the Cognition Equation: Robustness Checks

+ Restrict to Non-Movers Before Age 5 % Point Increase in Test Score 8 Main result 7 6

Prov x Byr FE

5

+ Non‐movers N = 8073

4 3 2 1 0 ‐3 to ‐6

‐2

‐1

0 1 Age of Exposure

2

3

(Year of Midwife’s Arrival  ‐ Year of Birth)  

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Figure: Coefficients of the Intensity of Exposure to Safe Motherhood Program in the Cognition Equation: Robustness Checks

+ Use Community of Mothers 3 Years Before the Child’s Birth % Point Increase in Test Score 9

Main result

8 Prov x Byr FE

7 6

+ Comm mother

5

N = 7981

4 3 2 1 0 ‐3 to ‐6

‐2

‐1

0 1 Age of Exposure

2

3

(Year of Midwife’s Arrival  ‐ Year of Birth)  

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Figure: Coefficients of the Intensity of Exposure to Safe Motherhood Program in the Cognition Equation: Robustness Checks

+ Restrict to communities that Ever Received Midwife (as of 2007) % Point Increase in Test Score 9 8

Main result Main result

7

Prov x Byr FE

6

+ Ever midwife N = 6991

5 4 3 2 1 0 ‐3 to ‐6

‐2

‐1

0 1 Age of Exposure

2

3

(Year of Midwife’s Arrival  ‐ Year of Birth)  

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Figure: Coefficients of the Intensity of Exposure to Safe Motherhood Program in the Cognition Equation: Falsification Test

Running the Same Specification using Cohorts All Born Prior to Start of the Program % Point Increase in Test Score 8 Cohorts born Cohorts born  1983 to 1996

7 6

Cohorts born Cohorts born  1976‐1989

5 4 3 2 1 0 ‐1 ‐2

‐3 to ‐6

‐2

‐1

0

1

2

3

Age of Exposure (Year of Midwife’s Arrival  ‐ Year of Birth)  

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Examining By Subcomponents of Cognitive Test Table: By Intensity of Exposure: Math and Raven’s CPM Test Score (% Correct)

Timing/Age of Exposure to Midwife 3 to 6 years before birth (-3 to -6) 2 years before birth (-2) 1 year before birth (-1) At year of birth (0) 1 year after birth (1) 2 years after birth (2) 3 years after birth (3)

Mathematics Coeff. SE 6.67** 2.68 7.43*** 2.27 6.40*** 2.05 5.13*** 1.88 4.01** 1.76 1.88 1.76 0.88 1.74

Raven’s Coeff. SE 7.26*** 2.26 6.07*** 1.91 3.97** 1.59 3.71** 1.99 2.36 1.49 3.78** 1.49 0.56 1.47

*** - significant at 1%; ** - significant at 5%

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Schooling Outcomes Table: By Intensity of Exposure: Schooling Outcomes

Timing/Age of Exposure to Midwife 3 to 6 years before birth (-3 to -6) 2 years before birth (-2) 1 year before birth (-1) At year of birth (0) 1 year after birth (1) 2 years after birth (2) 3 years after birth (3)

School level Attained (in years) (years) Coeff. SE 0.52*** 0.16 0.48*** 0.13 0.48*** 0.12 0.23** 0.11 0.29*** 0.10 0.11 0.10 -0.04 0.10

*** - significant at 1%; ** - significant at 5%

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Conclusion Confirms the importance of environmental influences during the fetal period and the first two years of life for later human capital Suggests that the health of the mother even prior to conception is important for child’s long term development

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Policy Implications For long term gains, interventions during the prenatal period and the first two years of life of the child are important Behavior modications in parents may need to start even before they start trying to conceive

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E

Thank You!

Ava Gail Cas

Early Life Public Health Intervention and Adolescent Cognition: E