WOMEN'S HEALTH SERIES VOLUME 3
Maternal Education and Child Health in the Western Pacific Region
World Health Organization Regional Office for the Western Pacific Manila 1995
Copyright © World Health Organization 1995 This document is issued by the World Health Organization - Regional Office for the Western Pacific (WHOIWPRO) for general distribution. All rights are reserved. Subject to due acknowledgement to WHOIWPRO, this document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, provided that such is not done for or in conjunction with commercial purposes and provided that, if it is intended to translate or reproduce the entire work, or substantial portions thereof, prior application is made to the Materoal and Child Health Unit, WHOIWPRO, Manila, Philippines.
The views expressed in this document are those of the principal contributors and do not necessarily reflect the policies of the World Health Organization.
Map of the WHO Western Pacific Region
NORTHERN '. MARIANA ISLANDS
GUAM. FEDERATED STATES OF M.lCRON~1A
MARSHALL
'. ISLANDS ~.KIRI6ATI
I.I.
TOKELAU '.. • AMERICAN SAMOA
SAMOA .FIJI~· VANUAllJ NIVE
'-
TONGA
FRENCH
NEW CALEDONIA
COOK' ISLANDS
POLYNESIA
~
j, NEW ZEALAND
Contents Foreword Acknowledgements 1. 2. Introduction The links between maternal education and child health 2.1 2.2 2.3 2.4 Infant and child mortality Nutritional status Other child health measures How does maternal education affect child health? 3 ix xi
3 5 6 8 15 15 16 16
3.
Other benefits of educating women 3.1 3.2 3.3 3.4 Reduced fertili1y Health investment Improved status of women Economic returns
17 19 19 20 20 23 25 25 25
4.
The situation in the Western Pacific Region 4.1 4.2 4.3 4.4 Educational status of women and health measures Primary and secondary enrolment rates Secondary and tertiary education Illiteracy rates
5.
Constraints to women's education 5.1 5.2 5.3 5.4 5.5 5.6 Macroeconomic constraints Household economic constraints Constraints dictated by culture and tradition Low status of women Dealing with the constraints Educating adult women
26 26 27 27
6.
Conclusions and recommendations Issue No.1 Issue No.2
29 29
-
Lack of information The perceived value of female education Policies and programmes concerning education of girls Adult literacy Enhancing women's economic returns
30 30 32 32
Issue NO.3 Issue No.4 Issue No.5 Annexes Annex 1
-
Female gross enrolment ratiO at the primary and secondary level (1979-1982), infant mortality rate and life expectancy at birth (1989-1991) in selected countries in the Western Pacific Female illiteracy rate (1979-1982), infant mortality rate and life expectancy at birth (1989-1991) In selected countries in the Western Pacific Literacy programmes: summary of essential needs
33
Annex 2
35
Annex 3 Bibliography
37 39
List of Figures and Tables Figure 1 Table 1 Routes through which maternal education affects child health Median relative risk associated with maternal schooling: Summary measure from 39 countries Gross effect of maternal education with different measures of child health: Relative Risk Sex-specific Infant mortality rate and child mortality rate by maternal education (per 1000 livebirthsj Comparison of child health outcomes with different levels of maternal education 13
4
Table 2
5
Table 3
6 7
Table 4
..
-
.Y!.
Table 5
Table 6
Correlation coefficients between infant mortali1y rate, life expectancy at birth and female education: selected countries in the Westem Pacific Regression coefficients between Infant mortality rate, life expectancy at birth and female education: selected countries in the Western Pacific Comparison of male and female gross enrolment ratio at the primary and secondary level: selected countries in the Westem Pacific Illiteracy rate In selected countries in the Westem Pacific
20
21
Table 7
22 23
Table 8
Foreword The importance of women's education in promoting and maintaini.~g famil~ health, nutrition and well-being has been recognized for many years. In addition, studies have shown that a country with more educated women is not only healthier, but also wealthier. A woman has the right to education. However, recognition of this right is not automatically translated into action, and many societies still prefer to educate their sons. The consistent link between education and lasting improvements in other aspects of women's lives has been documented in many studies throughout the world. Education has been regarded as an equalizer in the lives of women. Access to education generally opens myriad opportunities for women. It not only improves a woman's ability to take care of herself, but also allows her greater chances of paid employment, thereby increasing her earning capacity. An educated woman has greater self-determination. She exercises control over decisions that affect her entire life, such as age of marriage, fertility, family size and child-spacing. Her stronger status extends beyond lhe confines of her home. Education gives her lhe confidence to participate actively in community affairs and assert her legal and political rights.
Although the past few decades have witnessed considerable strides in increasing the proportion of educated children in the population, the gender gap in education is still an embarrassing reality. Men still have higher literacy rates than women, and at school boys still outnumber girls in many parts of the world. Some countries of the Western Pacific Region have among the highest literacy rates in the world, and others have rates among the lowest. The discrepancy between female and male school enrolment rates also varies widely throughout the Region.
This monograph examines the links between maternal education and child health, discusses aspects of women's health that are affected by education, and profiles literacy and enrolment in the Western Pacific Region. The conclusions and recommendations stress the need for more research, because of the scarcity of the kind of data that will direct policies and programmes to address the situation of women's education. Such research could include studies on the interrelationships between women's education, and development of indicators that cover the whole of the female life cycle.
$tMf~ S.T. Han, MD, Ph.D. Regional Director
Acknowledgements We would like to thank the principal contributors to this monograph, namely, Professor Milagros P. Querubin, College of Home Economics, University of the Philippines, and MariquitaJ. Mantala, MD., MP.H, Director, Tuberculosis Control Service, Department of Health. The following are also gratefully acknowledged: Dr Marilen Danguilan; Dr Cecilia A Florencio, Dean, College of Home Economics, University of the Philippines; Dr Margarita de la Paz, Chairman, Department of Food Science and Nutrition, College of Home Economics, University of the Philippines; Ms Connie Basilio, WHO-WPRO Librarian; Mr Nilo Sandoval, ADB Librarian; and Ms Marites Vitug, Philippine Center for Investigative Journalism
1.
Introduction
Maternal education strongly enhances the chance of child survival as measured by nutritional status, infant mortality and child mortaIity. A child whose mother has not gone to school is 2.5 times more likely to die than a child whose mother has had seven or more years of schooling. This trend is found in all major regions of the developing world. Child and infant mortality decrease with greater number of years schooling for the mother, and even a short experience offormal schooling is associated with a reduced risk of death. The level of the mother's education has a stronger effect on child health than that of the father's education. Uneducated women in many developing countries accept traditional explanations for illness and use traditional cures which may do more harm than good. Education for many women increases exposure to modem health facilities and preventive and curative health care, which leads to a chain of behaviour beneficial to their own and their children's health.
Educated women have a range of other advantages over their uneducated counterparts. Improved health, reduced fertility, better economic conditions, social gains and improved status are all linked to education. This report examines the relationship between child health and female education, looks at other aspects of women's health that are affected by education, and profiles the current status of female education in the Western Pacific Region. The study concludes that educating women is a significant step in safeguarding the health of children and improving a country's economy because educated women have healthier children, are more productive and earn more, man:y later and choose to have fewer children, have greater control in family decisions, are more confident and independent, have a higher status in society and participate more in community affairs.
_1_
2. The links between maternal education and child health Children of educated women have a wide range of advantages over children ofless-educated or WledUcated women. Infant and child morbidity and mortality, nutritional status, use ofhea1th facilities and domestic health care are all related to the mother's education. similar in urban and rural areas. Paternal literacy was also associated with health status, but the effect was only about half as strong as that of the mother's education. A study in Malaysia (Davanzo, 1983) also showed that the education of parents, especially of the mother, was correlated with infant mortality. A linear relationship between maternal education and childhood mortality was also established using data from 33 countries and a 15-country United Nations study. Each one-year increment in maternal education corresponded on average to a seven to nine per cent decline in childhood mortality (Cochrane, 1980, as cited in Cleland, 1988). Using data from the World Fertility Survey in ten developing countries, mortality for children whose mothers have primary schooling was found to be 20 to 50 per cent lower than those with uneducated mothers (Caldwell and McDonald, 1982). For those whose mothers had secondary or tertiary education, mortality was 30 to 60 per cent and 60 to 90 per cent lower,
2.1
Infant and child mortality
One of the earliest investigations into the relationship between maternal education and child health was done by Cochrane (1982). Studies from 16 cOWltries in Latin America, Middle Africa and Asia, covering the period 1970 to 1979 were reviewed. Most of the studies found that maternal education, expressed as either number of years of schooling or literacy level, was inversely related to infant and child mortality. A bivariate analysis fOWld that, on average, one additional year of schooling was associated with a reduction in mortality by about nine deaths per thousand. The effect of number of years schooling seemed
Maternal Education and Child Health In the Western Pacific Region
respectively. Other studies that included data from a greater number of countries supported these findings (Hobcraft, 1985; Cleland, 1988). The median relative risk associated with maternal schooling is sho\W in Table 1.
women with secondary education experienced the lowest probability of neonatal mortality. Although the gross effect of education was small and not statistically different from the null value of 1.00 which means no association, a
Table 1.
Median relative risk associated with maternal schooling: Summary measure from 39 countries
Maternal education No education < 4 years schooling 4-6 years schooling > 7 years schooling
Median Relative Risk
2.5 1.8 1.6
1.5
Source: Hobcraft, J.N., J.W. McDonald and O. Rutstein. Demographic Detenninants of Early Child Mortality. Population Studies, 39 (1985), pp. 363-385.
The education-mortality association is stronger in childhood than in tnfancy. Maternal schooling o~ four to six years was found to be associated with a fall in infant mortality of about 20 per cent, but mortality falls by from 30 to 58 per cent in early childhood, and by from 43 to 72 per cent in later childhood (Cleland, 1988). A recent study (Bicego, 1993) found that the mortality risk from age 1 to 23 months was more than twice as sensitive to the maternal education effect as that in the first month of life, the neonatal period (see Table 2). Children of women lacking any education fared worst. Children of
higher mortality risk was still associated with little or no education. Similar trends were observed in many household surveys, and Simmons (1982) also observed that households where the mother had some education tended to have lower female than male mQrtality rates (see Table 3). Another study (Victoria et al, 1992) examined maternal education in relation to a wide array of child health outcomes. In the crude analyses, all child health indicators - birthweight, perinatal and infant mortality, hospital admissions in the first 20 months of life and nutritional status - were associated with maternal schooling. There was a
The links between maternal education and child health
steady reduction in infant mortality rates from 95 per 1000 among mothers without schooling to 17 per 1000 among those with more than nine years of schooling, or a 5.6-fold differential (Table 4). The association with perinatal mortality, however, was not clear since children whose mothers had no schooling presented similar levels (around 35 to 40 per thousand) as those who had on average less than eight years of schooling. For those with more than nine years of schooling, there was a 50 per cent decrease in perinatal mortality, to 19 per 1000. Clear trends of decreasing mortality with higher education were seen for all causes of deaths. These trends were particularly strong for infectious diseases. Among mothers who had no
formal schooling, over 50 per cent of the deaths of infants were due to infectious diseases, compared with under 10 per cent for mothers with nine or more years of schooling. The mortality rate due to infectious diseases among the former was three times higher than the overall mortality rate of the latter.
2.2
Nutritional status
A well-nourished child has better chances of surviving than a malnourished child. Mothers of malnourished children were found to have had significantly less schooling
Table 2. Gross effect of maternal education with different measures of child health: Relative Risk
Measures of child health
Relative Risk No education VS.
Primary VB
Secondary education Neonatal mortality (0-28 days) Post-neonatal mortality (1-23 months) Stunting (3-23 months) 1.65 2.48 2.32
Secondary education 1.30 1.77 1.74
SOlU'Ce: Bicego, G. and J.T. Boenna. Maternal Education and Child Survival: A Comparative Study of Survey Data from 17 Countries. Social Science and Medicine. 36(9), 1993.
Maternal Education and Child Health In the Western Pacific Region
than mothers of well-nourished children (Cochrane, 1982). Mothers of malnourished children averaged 2.7 years of school compared with mothers of well-nourished children, who averaged 3.6 years of school. When rates of literacy were compared, four studies found a significantly larger proportion of illiterates among mothers of malnourished children than mothers of well-nourished children. A weighted average from these four studies shows 61 per cent of mothers of malnourished Table 3.
2.3
Other child health measures
Life expectancy. Using the 1980 World Development Indicators compiled by the World Bank, a very high correlation was found between life expectancy at birth in 1978 and adult literacy rate and proportion of school enrolment in 1960 (Hanada, 1982).
Sex-specific infant mortality rate and child mortality rate by maternal education (per 1000 live births)
Maternal Education
Infant Mortality Rate per 1000 live births Male Female
Child Mortality Rate per 1000 live births Male Female
No schooling With schooling
20.13 14.19
23.04 10.16
25.79 15.54
29.80 13.28
SOUICe: Simmons, G. and S. Bemstain. The Educational Status of Parents and Infant and Child Mortality in Rural North India. Health Policy and Education, 2 (1982), 349-367.
children to be illiterate, compared with 49 per cent of mothers of wellnourished children. A clear direct association has also been observed for the three indices of nutritional status: length-for-age, weight-for-age and weight-for-height (Victoria et al, 1992) (see Table 4). Children of mothers with more than nine years of schooling had better nutritional status than the children of mothers without schooling.
Birth weight. The proportion of lowbirth-weight infants (under 2500g) was found to be inversely associated with maternal education, ranging from 14 per cent among mothers with no schooling to 7 per cent for those with more than nine years of schooling (Victoria, 1992).
The links between maternal education and child health
Table
4.
Comparison of child health outcomes with different levels of maternal education Years of schooling
Child health outcome Proportion low birthweight infants Infant mortality rate per 1000 livebirths Perinatal mortality rate per 1000 live births
0
14
5-8
9+
P-value (0 vs. 9 + years)
14
10
10
7
<.001
95
51
37
17
<.001
36
39
35
19
.007
Cause-specific infant mortality rate (per 1000) Infectious diseases 49 Other causes 46
19 32
10 27
1 18
Nutritional status (z-scores) Length-for-age -1.30 Weight-for-age Weight-for-height -0.77 -0.02
-1.06 -0.60 -0.02
-0.70 -0.29 0.17
-0.15 0.22 0.43
<.001 <.001 <.001
Source: Victoria, Cesar et al. Matemal Education in Relation to Early and Late Child Health Outcomes: Findings from a Brazilian Cohort Study. Social Science and Medicine, 34(8), 1992.
Mammal Education and Child Health in the Western Pacific Region
2.4
How does maternal education influence child health?
The studies above demonstrate a clear relationship between maternal education and child health. However, the exact mechanism by which education influences child health is unclear. The complex interrelationship between maternal education, socio-economic slatus, health service provision and child health must be examined to clarify policy directions. Caldwell (1982) underscored that the influence of education should not be considered in isolation. It was suggested that the inverse
status through statistical control of other variables. Caldwell (1979) found that, across various socioeconomic characteristics, maternal education was the single most significant determinant of child mortality. Maternal education even lessened the impact on child mortality of the presence or absence of medical facilities in the area of residence. The same conclusion was derived in a cross-country comparison using World Fertility Survey data (Caldwell, 1982). Education was not a proxy for standard ofliving. In fact, it emerged as the strongest influence on child mortality, even after controlling other variables that maybe correlated with education. Bicego (1993) noted that a large part of the maternal education-child mortality link could be attributed to education's association with household economics. Similar fmdings were cited by Cleland (1988). In a 15-country comparative analysis, the effect of maternal education and a net of diverse economic controls were re-examined. Overall, the authors concluded that the economic advantages associated with education (income, water and latrine facilities, clothing, housing quality, etc.) may account for one half of the overall education-child mortality link. The broad conclusion was that approximately half of the gross effect of a mother's education could be attributed to economic advantage.
relationship between maternal education and child health was a function of a higher standard of living. Another possibility was that education masked the effect of other variables that are highly correlated with child health, such as access to preventive and curative health care (e.g. immunization), family planning services and potable water supply. If these other variables proved to be more significant, then investing in maternal education may not be the best way to improve child health. Socioeconomic status. Several investigators addressed the question of maternal education and socioeconomic
The links between lllllternal education and child health
Nutritional status of children. The importance of maternal education as a determinant of nutritional status was found to be contingent on the family's socioeconomic status (Ruel, 1992). Although maternal education was positively associated with weight-forage for both wealthier and poorer households, the size of the effect was much larger for the latter group. A stronger association between maternal education and child nutritional status was observed in households with incomes above a certain minimum threshold. Below this threshold, maternal education had little effect and this could be partly explained by the overwhelming constraint of resources. Improved domestic health care. More educated mothers had better knowledge of disease prevention and cure, hygiene and the nutritional requirements of children. Women with education were more knowledgeable about the causes of childhood illnesses like diarrhoea and measles, and were more ready to accept non-traditional heal1h remedies like oral rehydration and measles vaccinations (Goodbum et al, 1990). Education was found to be associated with greater awareness of 1he importance of nutrition (Chaudhury, 1986), and there was a higher effect for maternal education than paternal education. Education may represent greater efficiency in household production for better child health - better educated parents should be able to provide more nutritious diets at any
income level. More educated mothers were found to feed their children more frequently, with fresher food and in cleaner, more protected places (Guldan, 1993). A longitudinal study in the Philippines also showed that as maternal education increased, the children's caloric intake also increased. An improvement in excreta disposal practices, increased use of quality drinking water and decreased food contamination risk were also observed (Cebu Study Team, 1991). Access to health services. Physical access was proposed as an important co-factor in determining·use of health services. The question of whether the observed effect of education on child survival is modified depending on the level of access to modem health services was investigated. However, few studies have looked into whether greater physical access to health services widens or narrows the difference between children of moreeducated and less-educated mothers in the use of child health-related services. Caldwell (1979) demonstrated the possible link between maternal education and access to health services vis-a-vis child health. The educational differentials in childhood mortality were larger in a village with a hospital than a village without such a facility. In a subsequent analysis, a huge interaction was found: the presence of health services improved child survival by 20 per cent; maternal education in the
Maternal Education and Child Health In the Western Pacific Region
absence of services was associated with a 33 per cent improvement, but the joint effect of services and maternal education resulted in an 87 per cent improvement. Rosenzweig (1982) estimated the interactive effects of community's health inputs (availability of medical services, family planning activities, transportation infrastructure, etc.) and maternal education on fertility and child survival. The education of mothers was found to be strongly inversely correlated with child mortality ratio and fertility. The reason for this correlation is partially clarified by the interactions observed between the mother's schooling and the community's health inputs. In urban areas, the availability of medical services, family planning activities and transportation infrastructure in addition to mother's education are associated with child mortality ratios and fertility. The least-educated mo1hers are the most strongly affected, in terms of their reduced fertility and increased child survival rates, by the local urban health programmes. No effect of programme interventions and medical facilities are found in rural populations, though bo1h child mortality ratios and fertility are lower for more-educated rural women. Cleland (1988) cautioned 1hat 1he ability of superior service provision to erode the advantage conferred by education should not be exaggerated. Although several studies have shown that: a) services can diminish the advantage of
children with educated mothers; b) the educational differences seem to be smaller in the presence of good health programmes; and c) the educational differentials in mortality tend to decrease as per capita health expenditure rises, the fact remains that large differences in relative risks of infant death across social classes and educational categories still persist in developed countries. Even after adjustment for economic factors, one to three years of schooling is associated with a fall of 20 per cent in childhood risks of death. Further large decreases are recorded with successive increments in educational attainment. Most cross-sectional studies in developing countries demonstrate that the sharpness of educational inequalities in childhood mortality remains unaffected by controls for access to modem health services. Furthermore, the similarity of maternal education effects in both urban and rural sectors suggest that educated mothers maintain their advantage, regardless of access to health services. This was found in the United Nations comparative study (1985) and in the detailed analysis of 1he Colombian data (Rosenzweig, 1982). The strong relationship between maternal education and child health is consistently observed, even in countries with contrasting levels of health services. It persists both in countries with accessible and effective health services, and those with a weak primary health care system (Cleland, 1988). The health
The links between maternal education and child health
gains derived from access to health services are enhanced by maternal education.
Use of health services. Bettereducated mothers were found to make better use of existing health services than less-educated mothers, both for preventative and curative purposes (Bicego, 1993). Each additional year in maternal education implied a four per cent increase in the use of preventive health services (Cebu Study Team, 1991). In the Philippines, the percentage of fully-immunized children was found to increase as maternal education increased (Herrin et al, 1993). Non-use of antenatal care was found enormously sensitive to maternal education even after controlling for economic status of the household. Absence of antenatal care was 55 to 1300 per cent higher among uneducated women than women with secondary education (Bicego, 1993). In addition to the increased propensity of educated mothers to seek medical attention for themselves and their children, it is likely that they do so with greater regularity, extract a higher quality care and adhere to advice with greater persistence (Cleland, 1988). Education makes women more responsive to novel ideas and services, identify more with the outside world, and more confident at handling officials (Caldwell, 1979). Education also allows women to break from traditional isolation
and be a part of a new culture where health and illness are viewed from a less traditional and fatalistic perspective (Caldwell, 1982; Cleland, 1988). The major impact of schooling relates to a new family system whereby mothers can make immediate decisions about child care (Caldwell, 1979; Caldwell, 1982). It is a system in which children, and women, are awarded higher priorities in terms of care and consumption than in the traditional system. It is hypothesized that education brings changes in the traditional balance of familial relationships with profound effects on child health. However, research in this field is scarce.
factors. Various behavioural mechanisms have been proposed to explain the association between maternal education and child health outcomes. These mechanisms relate to the possibility that, compared to the uneducated, educated mothers may be: less fatalistic about disease and death; better informed about disease prevention and management; more likely to use available health services; more innovative in the use of remedies; more likely to adopt health-related innovative behaviours; place greater value on the welfare and health of children; and exercise greater decision-making power in the family on health-related and other matters.
Behavioural
Maternal Education and Child Health In the Western Pacific RegIon
All these behavioural pathways enhance the health of children through: greater protection against infection primarily by means of improved hygiene; reduced susceptibility to infection, primarily through immunization and better nutrition; enhanced recovery from infection, brought about by more effective domestic and external health care; and greater attention to the health needs of children. What kind of behaviours serve to mediate the education advantage in child health and survival? Cleland (1988) explored this problem and proposed several possible mechanisms through whim education may affect child health. The health pathways relate to the cognitive, social and attitudinal consequences of education. These consequences underlie changes in maternal behaviour leading to improved health and lower mortality. The cognitive consequences relate to knowledge of disease causation, prevention and cure, and the nutritional
requirements of infants and children. Educated mothers may have a better knowledge of health requirements than uneducated mothers. Schooling may help a mother to understand health matters better to enhance a woman's ability to provide for the well-being of her children. The social consequences of education imply that education provides women with a wider social network and new role models, leading to greater willingness to try new ideas and make use of health services. The attitudinal consequences touch on women's improved status. Caldwell (1979) advances the view that an educated mother is more capable of relating to the modem world. She has higher self-esteem, giving her confidence in dealing with doctors and nurses. She is more likely to know where the right facilities are. Education also results in a shift in the balance of power in the home.
The links between maternal education and child health
Figure 1.
Routes through which maternal education affects child health Improved domestic health care • increased knowledge on health and nutrition
Matlmal education
--
...
Women EmpoWllrment • greater control in family decisions
--
...
Child health
More utiliZition of health servicII • ImmunlZltion • antlnatel care • preventive and curative services
1
3. Other benefits of educating women
The comparative advantage of educated women over their non-educated counterparts is not limited to having healthier children. Female education also results in other social gains, such as improved women's health and reduced fertility. A wealth of information has also shown that educating women not only brings social gains, but also has tremendous economic advantages as well.
Econometric studies also demonstrated that an extra year of schooling reduces female fertility by approximately ten per cent. Thus, if 1000 women have one extra year of education, 660 births are averted. Another study showed that female secondary education, family planning and health programmes all affect fertility, but the effect of female secondary education appeared to be very strong. Using cross-country regressions based on data from 72 developing countries, family planning reduced fertility when combined with female education. A simulated regression suggested that a doubling of female secondary enrolments (from the mean of 19 per cent to 38 per cent) in 1975 would have reduced the total fertility rate in 1985 from 5.3 to 3.9, whereas a doubling of family planning services (from 25 per cent to 50 per cent) in 1982 would only have reduced the total fertility rate from 5.5 to 5.0. Simulations were also done to compare the differences in terms of numbers of
3.1
Reduced fertility
Educated women tend to marry later and choose to have fewer children. Data from the World Fertility Survey found that women with over seven years of schooling married around four years later than uneducated women. Schooling was also associated with fertility decisions, accounting for 40 to 60 per cent of the fertility decline in one study.
Maternal Education and Child Health In the Western pacmc Region
births averted. Doubling female secondary enrolment would have lowered the number of births by 29 per cent, whereas doubling family planning services without an increase in female secondary education would have reduced the number of births by 3.5 per cent (Subbarao, 1992).
3.2
Health investment
example, it has been estimated that a health care intervention costs on average US$800 per life saved. Thus, the cost of achieving the same reduction in mortality that would accrue from investing $30 000 in educating another 1000 women is $48 000. Similar trends were observed with computations for other health indicators such as averting maternal deaths and births. Summers concluded that the social benefits of increased education were sufficient to cover its cost.
Summers (1992) made a simple economic computation to demonstrate the cost of educating women versus other health interventions. Using data from Pakistan, it was estimated that educating an extra 1000 women for an additional year would have cost US$30 000 in 1990. It has been suggested that each year of schooling reduces under-five mortality by up to 10 per cent. Thus, with an average woman in Pakistan having 6.6 children, it follows that providing 1000 women with an extra year of schooling would prevent roughly 60 infant deaths. Summers' computations imply that higher costs will be incurred to achieve similar results through investments in health care such as immunization or antenatal supplementary feeding. For
3'.3
Improved status of women
The most tangible benefit that could be gained in educating women is their liberation from exploitation and oppression. Educating women helps to improve their status in their homes and in society. Educated women assume greater control in family decisions, receive better treatment at clinics and hospitals and participate more in community affairs. Education helps women regain their self-worth and become respected members of their family, community and country.
Other benefits of educating women
3.4
Economic returns
Educated women are more productive and earn more. Wages of women rise by 10 to 20 per cent for each additional year of schooling. For example, in Morocco, an additional year of education is associated with a 15.8 per cent increase in women's earnings. In Thailand, an additional year of sclJ.ooling is associated with a 26 per cent increase in women's hourly wages. Data from 70 developing countries showed that increasing girls schooling would increase women's participation in the labour force.
4. The situation in the Western Pacific Region
4.1
Educational status of women and health measures
mortality rate (lMR) and life expectancy at birth (LEB). The results showed that there is a very high correlation between the various education and health measures (Table 5). For IMR, there is an inverse relationship to female gross enrolment rate. As the percentage of women with primary and secondary education increases, IMR decreases. Similarly, as the female illiteracy rate increases, IMR increases. For LEB, a positive relationship exists. With more women having primary and secondary education, the number of years a child is expected to live also increases. Conversely, as female illiteracy increases, LEB decreases. Results of regression analysis showed that for every percentage increase in the female gross enrolment ratio at the primary and secondary level, IMR decreases by 0.63 and 0.92 respectively, holding the effect of other factors constant. In the same manner, for every percentage increase in the proportion of illiterate women, there is a 0.64 increase in IMR. Similarly for LEB, every percentage increase in the
Most of the studies cited in this report come from research done in countries outside the Region. However, since most of the studies were done in developing countries, one can assume that the positive effect of maternal education on child health also holds true in developing countries in the Region. To test the above assumption, correlation and regression analyses were done to explore the effects of female education on various health measures in some countries of the Region (Annexes 1 and 2). Education data covered the period 1979-1982 and health data covered the period 19891991. Educational measures included female gross enrolment ratio (primary and secondary) and female illiteracy rate. Health measures included infant
Maternal Education and Child Health In the western Pacific Region
Table 5. Correlation coefficients between Infant mortality rate, life expectancy at birth and female education: selected countries in the Western Pacific Health Indicators! Female education2 Primary
IMR -0.40 -0.78* 0.42
LEB 0.59 0.85* -0.91 **
Secondary illiteracy rate
.p < .01 ••p < .001 1
Data cover 1989-1991 statistics (see
Annex 1)
2
Data cover the period 1979-1982 (see Annex 2)
proportion of females with primary and secondary education, LEB increases by 0.30 and 0.32 years, respectively, while a percentage increase in female illiteracy rate decreases LEB by 0.23 years (Table 6),
At the secondary level, females do not lag behind males, in fact, for most WPRO countries except for China, Lao PDR, Papua New Guinea and Viet Nam, gross enrolment ratios for females exceed those of males.
4.2
Prh:nary an~ .... secondary enrolment ,,!f :: rates'"O '.C " \\
4.3
-;;.;
Secondary and tertiary education
Gender discrepancy in education in the Region is not evident based on the UNESCO data for 1991 (Table 7). Universal primary education has been achieved in most countries except for Papua New Guinea, Lao PDR and Viet Nam.
This indicator measures the educational attainment of women and men, as it relates to opportunities to advance in the labour force and improve women's work and status. As education levels move up, more girls drop out of school. Reasons are often limited financial resources and
Educational status of women In the Westam Pacific Region
Table 6. Regression coefficients between infant mortality rate, life expectancy at birth and female education: selected countries in the Western Pacific
Health Indlcators l Female education' Infant Mortality Rate Constant Primary
Life Expectancy
Coefficient
Constant
Coefficient
95.12 81.08 13.90
-0.63 -0.92** 0.64*
37.83 50.66 73.78
0.30* 0.32** -0.23*
Secondary IIIHeracy rate
*p < .05
."'p < .001 1 2
Data cover 1989-1991 statistics (see Annex I) Data cover the period 1979-1982 (see Annex 2)
preference for educating boys, parental fears and attitudes about the position of women in society, negative prevailing attitudes about female education in rural areas, and the need tor girls to assist their mothers with household chores (Litaic, 1993; Ledgerwood, 1992; World Bank 1992) The overall trend in the Region indicates that more males complete secondary education than females. In China, females lag behind males by almost half (18 per cent offerna1es have secondary education, as opposed to 33 per cent of males). In the NIEs and Southeast Asian countries, including the Philippines where education is
encouraged for both sexes, there are huge drop-out rates among females. Data for this indicator are not readily available for most Pacific island countries. Among the NIEs, the Republic of Korea has the highest number of women in the age group 20 years and above who have completed secondary education (25.8 per cent). At the tertiary level in the NIEs, less than half as many women as men aged 25 years and over have completed their college education. In China, 1.3 per cent of men acquired a college education, as oppposed to 0.5 per cent of women.
Maternal Education and Child Health in the Western Pacific Region
Table 7. Comparison of male and female gross enrolment ratio at the primary and secondary level: selected countries in the Western Pacific Country 1991 Gross Enrolment Ratio (%) Primary* Male Australia China FII Hong Kong Japan
Secondary Male 81
Female 106
Female
106
84
142 129 106
126 129
50 54
37 57
lOS 101 94
71 94 31
76 96 22
102 118
Lao PDR Malaysia New Zealand Papua New Guinea Philippines
102 106
102 105
56 86 16
57 88 9
76 109 104 113
65 113
71
71
Republic 01 Korea Singapore VietNam
104 110
89 68
84 70
105
99
43
40
• Gross enrolment ratios may exceed 100 percent because some students are younger or older than the country's standard primary school age. Source: UNESCO 1991 World Education Report
Given the existing data, the Philippines seems to be the only developing country in the Region where more women (10.5 per cent) have acquired a college education than men (9.2 per cent). While the data from the Philippines do not
identify the types of courses or kinds of education the women received, official statistics show that they are concentrated in the teaching, nutrition and nursing professions (National Statistics Office, 1992).
Educational status of women In the Westem Pacific Region
4.4
Illiteracy rates
In most WPRO member states, there are more illiterate women than men (Table 8). Table 8. Illiteracy rate in selected countries in the Western Pacific Illiteracy Rate (%) Country American Samoa China Cook Islands FIJI Guam Japan Lao PDR Macao Malaysia Com. Mariana Islands Palau Philippines Republica of Korea Tokelau Tonga VietNam
Year 1990 1987 1991 1986 1983 1989 1992 1992 1980 1990 1992 1990 1990 1990 1992 1993
Male 0.5 15.8 0.0 10.0 3.6 0.0 35.0 20.7 20.0 1.0 45.0 16.0 0.9 1.0 3.7 7.0
Female 0.5 38.0 0.0 16.0 3.6 0.0 64.0 29.4 36.0 1.0 56.0 17.0 6.5 1.0 4.4 15.0
Note: Illiteracy rate computed from adult litemcy mte reported in the WPRO Data Btmk on Socioeconomic and Health Indicators, 1994.
5. Constraints to women's education
Why are there fewer girls than boys in school? There are many impediments to increasing girls' enrolment in school. A UNICEF publication sums up the problem, "Education issues cannot be separated from the broader issue of the status of the girl in society" (UNICEF, 1992). This status extends to the position of women in society, which translates to their economic standing relative to men.
5.1
Macroeconomic constraints
there have been substantial reductions in the education budgets of developing countries. Consequently, there are not enough schools nor enough teachers to accommodate the growing numbers of children needing education. A UNESCO report indicates that the number of children without access to any form of schooling is close to 100 million and it is growing yearly. The report warns that if the trend continues, nearly one third of the world's population will be without access to basic skills by the end of the century (UNESCO, 1995).
5.2 In any CrISIS, it is always the children who suffer most. The global economic crisis which peaked in the 1980s lead to the erosion and decline of basic education, especially in developing countries. Economic measures and structural adjustment policies forced governments to make massive cuts in public spending. As a result,
Household economic constraints
Direct costs. Even in countries where education is free, parents still have to shoulder expenses for books, clothing, transportation etc. Among poor families, school costs can be a big drain on meagre financial resources. When
Maternal Education and Child Health In the Western Pacific Region
parents have to decide whether to send a boy or a girl to school, the choice becomes an economic decision. Sons are favoured over daughters because of a culturally-defined notion that girls are less likely than boys to get a well-paid job. The daughter will marry and be part of another household, while the son will need to eam for his own family and will provide for them in their old age. Opportunity costs. Studies in many countries have revealed that parents depend more on girls than on boys to do household work such as fetching wood and water, caring for younger siblings and helping with food production and preparation. This greater responsibility for household chores means that girls are more likely to be kept away from school than their brothers.
5.3
Constraints dictated by culture and tradition
In many parts of the world, cultural norms and traditions limit girls' access to education. In some societies, parents will not allow their daughters to travel far to attend school, or to attend schools that do not have separate facilities for girls and boys. For instance, in Papua New Guinea, parents fear sexual harrassment of their daughters by male students and teachers (Gillett, 1990).
5.4
Domestic chores are not the only constraints to female education. In many countries, children join the labour force to augment the family income. Children also help on family farms as unpaid labourers.
Low status of women
Summers (1992) underscored that the low status of women today is the consequence of a vicious cycle. Parents do not invest in 'their daughters' education because they do not expect their daughters to be able to
Constraints to women's education
make an economic contribution to the family. Instead, the daughters are kept at home to do household work while the sons are sent to school. When the girls grow up, they can't compete with men for higher wages, which reinforces the parents' perception that girls eam less.
Methods to minimize losses in opportunity costs include developing a flexible schedule so that girls can fulfil their household duties without missing so many classes that they feel impelled to drop out of school. Providing scholarships for girls has doubled female enrolment in Bangladesh and Guatemala
5,5
Dealing with the constraints
In order to accommodate the growing numbers of children seeking education, some countries have introduced shift systems in schools. In the Philippines, children of different age groups attend the same school, but at different times of the day. Some countries have introduced 'buildings-for-teachers' schemes, whereby the community provides school buildings and .then negotiates with their government to provide teachers.
Establishing 'girl-friendly' schools goes a long way towards dealing with cultural constraints. Hiring female teachers, building schools and satellite schools close to the communities where their pupils live so that girls do not have to travel long distances, building separate washrooms and toilet facilities for girls and introducing flexible schedules have increased female enrolment in several countries.
5,6 I
Educating adult women
Measures to reduce direct costs include rent-a-book schemes, where parents are no longer obliged to buy a new set of text books each year, and building school canteens that serve free meals.
There are many women in the Region who had little or no education when they were children for some or all of the reasons cited above. Adult literacy programmes would give them the chance to function and
Maternal Education and Child Health In the Western Pacific Region
participate in a literate society. It has been found that literacy programmes which not only teach women how to read, write and calculate, but also provide them with the tools to cope with life, have better chances of success
(UNESCO, 1995). Gender-oriented literacy materials that are relevant to women's lives and recognize their indigenous knowledge and skills lead to greater improvements than simply learning to read and write.
6. Conclusions and recom mendations
The benefits of educating women and girls are clear from numerous studies. Health and economic indicators are related to the educational status of women. Child and infant mortality are directly linked to the amount of schooling the mother has had. Better-educated women have a higher status in society, fewer and healthier children and more opportunities for sociai and economic advancement. Different countries are at different stages of development with regards to female education, due to variations in economic, political, socio-cultural and historical evolution. Consequently, the policies and programmes needed to address problems of female education will differ, because what may work in some countries will not work in others. Programmes of action must therefore be products of consensus of the various stakeholders, such as governments, educators, funding agencies, health workers and women.
Issue No. 1 information
Lack of
An initial step in the formulation of a comprehensive and integrated agenda for action on female education is an analysis of the current situation in a country. In pursuing reforms in the field of education, assessing the factors that facilitate or obstruct education of women will facilitate the adoption of more focused and appropriate strategies. A nuYor difficulty lies in the scarcity of information in most countries.
Recommendations:
1.
Governments, international agencies and concerned organizations should analyse the educational status of women across the Region and in individual countries and areas.
Maternal Education and Child Health In the Western Pacific Region
2.
Consultations should be held with the various stakeholders where quality information on female education is lacking, although in the long term, detailed research is essential. The information obtained should be used to identify priority areas for improvements in female education.
2.
It should be made clear that investing in female education is a long-term prospect and that some of the benefits will not accrue for many years.
3.
3.
Issue No. 2 - The perceived value of female education Where female education is not valued by society, efforts to improve access to education must be accompanied by efforts to change attitudes to female education in the population at large.
The perceived value of female education should be enhanced through meetings and conferences on women's education and child health, production and dissemination of materials advocating female education, formation of lobby groups to put forward the right of women to education, using different forms of media exposure and conducting and publicizing research on the social and economic returns of female education.
Issue No. 3 - Policies and programmes concerning education of girls Many countries do not have policies or programmes that are specifically concerned with the education of girls. Without these policies and programmes, progress in female education is slow. One of the major policy recommendations of the
Recommendations: 1.
Policy-makers and other stakeholders should be made aware of the benefits of educating girls and women by quantifying the social and economic returns of investment in female education.
Conclusions and recommandaUons
World Bank in its 1993 report, Investing in Health, is the adoption of primary education for girls. It rightfully concludes that health gains would parallel refonn in the field of female education.
cheap textbooks and meals should be included to defray the direct and opportunity costs of sending girls to school. 3. Relevant curricula should be developed. If girls bring home from school useful infonnation which can be put to good use by the family, parents will appreciate the value of female education more. Information on health and nutrition as well as other vocational skills must be incorporated. Education programmes should include the establishment of daycare centres so that women and girls who would not nonnally have access to education because they have to care for younger children are free to attend classes, or so that mothers have more time for the household work that their daughters would nonnally do instead of attending school.
Recommendations: 1. Govenunents should adopt a policy of compulsory education for primary and secondary levels. Governments should provide the necessary environment to promote enrolment of girls. Compulsory education is not an assurance that girls will be sent to school. An educational environment that takes into account the cultural and practical needs of girls - female teachers, having schools close to home and having separate facilities - is essential. Incentives such as scholarships for girls and free or 4.
2.
Matemal Education and Child Health In the Western Pacific Region
Issue No. 4 - Adult literacy Adult women and their adolescent daughters who never had the chance to attend formal schooling and grew up illiterate can have access to education through literacy programmes.
Issue No. 5 Enhancing women's economic returns
Recommendations: 1. Adult literacy programmes, and the value of the participation of women, should be actively promoted. Literacy activities should be combined with health and nutrition training, agriculture, handicraft making, small-scale industry and skills that can help women and adolescents improve their lives and status in society. A summary of the essential needs of a successful literacy project is shown in Annex 3.
Narrowing the gender disparity in education cannot be achieved through education policies alone. Although parents make the fmal decision to send their daughters to school, this decision will be influenced by how they see their society value its women. Improving women's productivity and earning capacity will raise the status of women in society and consequently raise the demand for female education.
2.
Recommendations:
1.
Governments should assess the economic, legal and cultural impediments to the participation of women in the labour force. Governments should implement policies and programmes that address these impediments and give women equal status in the workforce.
2.
Annex 1
Female gross enrolment ratio at the primary and secondary level (1979-1982), infant mortality rate and life expectancy at birth (1989-1991) in selected countries in the Western Pacific!
Country
Female Enrolment Ratio Prlm ary2 Secondary'
IMR (per 1000)
LEB (years)
Australia China
110 103 129 106
72 37 59 66
9.0 30.0 27.0 6.5
76 70 70 78
FII Hong Kong Japan Lao PDR Malaysia New Zealand Papua New Guinea Philippines Republic 01 Korea SIngapore VietNam
101 104 92
94 16 46 84
5.0 110.0 13.5 11.0
79 49 70 75
111
51 109 111 106
8
72.0 51.0 12.3 6.9
49 64 71 74
69 71
57
106
40
47.0
66
I
Data sources:
Worhl Bank, 1993; UNESCO World Education Report, 1991; UN Statistical Yearbook, 38th issue; WHO, WPRO Data Bank on Socioeconomic and Health Indicators, 1994.
2
Figures are expressed as the ratio of students to the population of school age children. For some countries with universal primary education, the gross enrolment ratios may exceed 100 per cent because some students are younger or older than the country's standard primary school age. Data on secondary enrolment are calculated in the same manner.
3
Annex 2
Female illiteracy rate (1979-1982), infant mortality rate and life expectancy at birth (1989-1991) in selected countries in the Western Pacific'
Country
Female iIIiteray rate (%)
IMIl (per 1000)
LEB (years)
Australia Brunei Darussalam China
4.0 31.0 45.0 15.0
9.0 10.0 30.0 26.5
76.0 73.0 70.0 70.0
Cook Island FIJI French Polynesia Guam Hong Kong
26.0 14.0 3.5 22.0
27.0 16.4 10.0 6.5
70.8 69.0 75.0 78.0
Japan Lao PDR Macao Malaysia
1.0 24.0 26.0 40.3
5.0 110.0 9.0 13.5
79.0 49.0 71.5 70.0
Marshall Island New Caledonia New Zealand Papua New Guinea PhIlippines Republic of Korea
10.0 9.7 4.0 65.0 17.2
63.0 11.2 11.0 72.0 51.0
61.0 69.0 75.0 49.6 64.0
Samoa Singapore Tongo
6.5 2.1 26.2 22.5
12.3 24.9 6.9 8.8
71.0 72.0 74.0 67.0
Vanuatu VietNam
52.2 21.7
60.0 47.0
64.0 66.0
Data sources:
World Bank, 1993; UNESCO World Education Report, 1991; UN Statistical Yearbook, 38th issue; WHO, WPRO Data Bank on Socioeconomic and Health Indicators, 1994.
Annex 3 Literacy programmes: summary of essential needs!
1. Political priority and community support, in order to: • • • • • • • mobilize women help them complete literacy courses sensitize groups hostile to women's participation mobilize the general population make more resources available enhance coordination with other activities help the community become aware of women's roles and rights
2. An integrated approach, in order to: • move easily to women's needs • help improve women's condition and position in society • increase motivation to learn • provide useful information in many areas of life 3. Literacy and post-literacy as a single educational process, in order to: • foster the creation of a literate environment • support lifelong-education • prevent relapse into illiteracy • increase women's chances of continuing formal education 4. Linkage of literacy to development projects and programmes to meet women's needs, in order to: • integrate the literacy process into community development • link programmes or projects to local conditions 5. Providing for women's active participation at every stage of a programme or project: fostering the organization of grass-roots groups forlby women, in order to: • increase the chance of success and continuity of literacy and development programmes and projects • help in the quest for solutions of shared concerns Source: Ballars, Marie, 1992 Women and Literacy, pp. 28-29.
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Maternal Education and Child Health In the Western Pacific Region
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