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.

Race, ethnicity, and discrimination at work: a new analysis of legal protections and gaps in all 193 UN countries

Purpose

While only one aspect of fulfilling equal rights, effectively addressing workplace discrimination is integral to creating economies, and countries, that allow for everyone's full and equal participation.

Design/methodology/approach

Labor, anti-discrimination, and other relevant pieces of legislation were identified through the International Labor Organization's NATLEX database, supplemented with legislation identified through country websites. For each country, two researchers independently coded legislation and answered questions about key policy features. Systematic quality checks and outlier verifications were conducted.

Findings

More than 1 in 5 countries do not explicitly prohibit racial discrimination in employment. 54 countries fail to prohibit unequal pay based on race. 107 countries prohibit racial and/or ethnic discrimination but do not explicitly require employers to take preventive measures against discrimination. The gaps are even larger with respect to multiple and intersectional discrimination. 112 countries fail to prohibit discrimination based on both migration status and race and/or ethnicity; 103 fail to do so for foreign national origin and race and/or ethnicity.

Practical implications

Both recent and decades-old international treaties and agreements require every country globally to uphold equal rights regardless of race. However, specific national legislation that operationalizes these commitments and prohibits discrimination in the workplace is essential to their impact. This research highlights progress and gaps that must be addressed.

Originality/value

This is the first study to measure legal protections against employment discrimination based on race and ethnicity in all 193 UN countries. This study also examines protection in all countries from discrimination on the basis of characteristics that have been used in a number of settings as a proxy for racial/ethnic discrimination and exclusion, including SES, migration status, and religion.

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 spread of COVID-19 and other infectious diseases and improves preventive care and access to treatment across a wide range of conditions. However, the U.S. has no national paid sick leave policy, and even unpaid FMLA leave-often viewed as a foundation for new paid leave legislation-is often inaccessible. We analyzed a nationally representative survey to determine the extent to which specific FMLA features produce gaps and disparities in leave access. We then use 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, while its tenure requirement disproportionately excludes Black, Indigenous, and multiracial workers. Latinx workers face greater exclusion due to employer size. Of the 94% of countries that provide permanent paid sick leave, none broadly restrict leave based on employer size and 93% cover part-time workers without a minimum hour requirement. Enacting permanent paid sick leave accessible regardless of employer size, tenure, or hours is critical and feasible. [Editor's Note: This Fast Track Ahead Of Print article is the accepted version of the peer-reviewed manuscript. The final edited version will appear in an upcoming issue of Health Affairs.].

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.

An automated computer system to support ultra high throughput SNP genotyping

Celera Genomics has constructed an automated computer system to support ultra high-throughput SNP genotyping that satisfies the increasing demand that disease association studies are placing on current genotyping facilities. This system consists of the seamless integration of target SNP selection, automated oligo design, in silico assay quality validation, laboratory management of samples, reagents and plates, automated allele calling, optional manual review of autocalls, regular status reports, and linkage disequilibrium analysis. Celera has proven the system by generating over 2.5 million genotypes from more than 10,000 SNPs, and is approaching the target capacity of over 10,000 genotypes per machine per hour using limited human intervention with state of the art laboratory hardware.

The sequence of the human genome

A 2.91-billion base pair (bp) consensus sequence of the euchromatic portion of the human genome was generated by the whole-genome shotgun sequencing method. The 14.8-billion bp DNA sequence was generated over 9 months from 27,271,853 high-quality sequence reads (5.11-fold coverage of the genome) from both ends of plasmid clones made from the DNA of five individuals. Two assembly strategies-a whole-genome assembly and a regional chromosome assembly-were used, each combining sequence data from Celera and the publicly funded genome effort. The public data were shredded into 550-bp segments to create a 2.9-fold coverage of those genome regions that had been sequenced, without including biases inherent in the cloning and assembly procedure used by the publicly funded group. This brought the effective coverage in the assemblies to eightfold, reducing the number and size of gaps in the final assembly over what would be obtained with 5.11-fold coverage. The two assembly strategies yielded very similar results that largely agree with independent mapping data. The assemblies effectively cover the euchromatic regions of the human chromosomes. More than 90% of the genome is in scaffold assemblies of 100,000 bp or more, and 25% of the genome is in scaffolds of 10 million bp or larger. Analysis of the genome sequence revealed 26,588 protein-encoding transcripts for which there was strong corroborating evidence and an additional approximately 12,000 computationally derived genes with mouse matches or other weak supporting evidence. Although gene-dense clusters are obvious, almost half the genes are dispersed in low G+C sequence separated by large tracts of apparently noncoding sequence. Only 1.1% of the genome is spanned by exons, whereas 24% is in introns, with 75% of the genome being intergenic DNA. Duplications of segmental blocks, ranging in size up to chromosomal lengths, are abundant throughout the genome and reveal a complex evolutionary history. Comparative genomic analysis indicates vertebrate expansions of genes associated with neuronal function, with tissue-specific developmental regulation, and with the hemostasis and immune systems. DNA sequence comparisons between the consensus sequence and publicly funded genome data provided locations of 2.1 million single-nucleotide polymorphisms (SNPs). A random pair of human haploid genomes differed at a rate of 1 bp per 1250 on average, but there was marked heterogeneity in the level of polymorphism across the genome. Less than 1% of all SNPs resulted in variation in proteins, but the task of determining which SNPs have functional consequences remains an open challenge.

Charting in record time

Nurses working in intrapartum settings have many responsibilities to ensure a safe and satisfying birth experience for the families in their care. Paperwork, while essential, often takes time away from providing supportive care for laboring women and their families. In striking a balance between responsibilities and obligations, nurses must play an active role in designing a charting system that allows essential and important data to be recorded in the least amount of time.

Evaluation of a fetal monitoring education program

OBJECTIVE

To evaluate the effectiveness of a fetal monitoring education program in increasing nurses' knowledge and clinical skills.

DESIGN

Multicenter randomized control trial.

SETTING

Twelve hospitals in eastern Ontario, Canada.

PARTICIPANTS

One hundred nine volunteer registered nurses randomly assigned, within each hospital, to an experimental (n = 47) or control (n = 62) group. Ninety-six nurses (40 in the experimental group and 56 in the control group) completed the 6-month follow-up (88% retention).

INTERVENTIONS

The experimental group participated in a 1-day fetal monitoring workshop and a review session 6 months later.

MAIN OUTCOME MEASURES

Performance on a 45-item knowledge test and a 25-item skills checklist. The passing score was at least 75% correct on each test.

RESULTS

The percentage of nurses in the experimental group passing both the knowledge and the clinical skills tests after the workshop was significantly higher (p < 0.01) than that of the nurses in the control group: 68.1% versus 6.5%, respectively. A large difference between the groups remained at the 6-month follow-up (experimental, 45%; control, 6.5%). The performance of the nurses in the experimental group improved to an 85% pass rate after they attended the 6-month review session.

CONCLUSION

This comprehensive, research-based program is effective in increasing fetal monitoring knowledge and clinical skills.

Post-war fertility and female labour force participation rates

"This paper provides an explanation for the change in fertility and female labour supply over the post-war period [in England and Wales]. A model of fertility and labour force participation is outlined and estimated over the period 1953-82 for six age groups of women. The most significant factors to influence fertility and participation are found to be male and female earnings and education. Interest rates, number of children and the state of the labour market are also important."