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.

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.

Tuition-free secondary education and women's attitudes toward intimate partner violence: Evidence from Sub-Saharan Africa

Intimate partner violence against women (IPVAW) is devastatingly common around the world. It rose further during the pandemic, increasing the urgency of finding interventions to prevent IPVAW and supporting women's ability to exit violent situations. Interventions that prevent violence and eliminate views among perpetrators that violence is acceptable should be top priority. It is also critical to study women's attitudes toward IPVAW as these shape women's responses to the abuse and their exit options. Moreover, research shows that these attitudes have a direct impact on women's health outcomes. We examine the effect of tuition-free secondary education on women's attitudes toward IPVAW across 29 Sub-Saharan African countries using data from the Demographic and Health Surveys conducted between 2000 and 2019. Using the difference-in-difference-in-differences strategy, we estimate the change in women's attitudes toward IPVAW in countries that implement tuition-free secondary policy compared with countries with tuition-free primary alone and those without any tuition-free policy during the study period. We find that while tuition-free primary education policy alone did not reduce the probability of IPVAW being perceived as justified, tuition-free secondary reduced it significantly. The probability that IPVAW was perceived as justified under at least one circumstance declined by 5.3 percentage points more on average in countries that adopted tuition-free policy up to the secondary level relative to those that adopted only up to the primary level. Tuition-free secondary affects four of the five circumstances under which IPVAW was perceived as justified — if she goes out without telling the husband, argues with him, neglects children or refuses sex. We observed no declines for when she burns food, suggesting different factors affecting this outcome. Our findings underscore the importance of making a stronger commitment toward policies that make secondary education more accessible to not only benefit education outcomes but also advance population health.

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Intimate Partner Violence against women (IPVAW) is on the rise globally.

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We examine tuition-free education policy's effect on women's attitudes toward IPVAW.

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Our study exploits variation in the timing of policy rollout in Sub-Saharan Africa.

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Tuition-free primary policy alone did not affect women's attitudes toward IPVAW.

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Tuition-free secondary reduced the probability of IPVAW being perceived as justified.