Parental Education and Child Health – Understanding the Pathways of Impact in Pakistan

By Monazza Aslam and Geeta Kingdon

This study investigates the relationship between parental schooling on the one hand, and child health outcomes  (height and weight) and parental health-seeking behaviour (immunisation status of children), on the other. While establishing a correlational link between parental schooling and child health is relatively straightforward, confirming a causal relationship is more complex. Using unique data from Pakistan, we aim to understand the mechanisms through which parental schooling promotes better child health and health-seeking behaviour. The following pathways’ are investigated: educated parents’ greater household income, exposure to media, literacy, labour market participation, health knowledge and the extent of maternal empowerment within the home. We find that while father’s education is positively associated with the ‘one-off’ immunisation decision, mother’s education is more critically associated with longer-term health outcomes in OLS equations. Instrumental variable (IV) estimates suggest that father’s health knowledge is most positively associated with immunisation decisions while mother’s health knowledge and her empowerment within the home are the channels through which her education impacts her child’s height and weight respectively.

Introduction

While the significance of establishing good health during infancy and childhood is evident from the documented link between childhood health and later economic and life outcomes such as education, learning, health and earnings (Grossman 2005; Currie and Madrian 1999; Alderman, Behrman, Levy and Menon, 2001; Case, Fertig and Paxson 2003; Oreopoulous et al. 2006) there is a curious absence of evidence for Pakistan. This is surprising because Pakistan ranks very poorly in terms of child health indicatorswith 38 per cent and 42 per cent children aged less than 5 being under the requisite weight and height-for-age (UNDP, 2007-08) parental education. Thus, it is useful to understand the relation between parental education with child health status in Pakistan. This is the key objective of the paper. Firstly, we seek to document the association between parental education and child health in Pakistan. Secondly, and more interestingly, we attempt to identify the ‘causal’ impact of parental education (if any) on child health. In doing the latter we probe the pathways and mechanisms through which parental schooling impacts child health. 

The importance of parental education in the production of child health is well-established (Behrman and Deolalikar, 1988; Strauss and Thomas, 1995). Indeed, it has even been argued that education has contributed more to mortality decline than the provision of health services (Mosley, 1985 cited in Sandiford, Cassel, Montenegro and Sanchez, 1995). The association of parental education with child health may arise because educated parents are more efficient ‘producers’ of child health (‘productive efficiency’) through adopting better child-care practices or superior hygiene standards. Alternatively, it may be because they choose health input mixes that generate more health output (‘allocative  efficiency’) than selected by less-educated parents. This may be because education instils greater knowledge of the health production function or the ability to respond to new knowledge more rapidly (Grossman, 2005, pp. 12-13). Since Caldwell’s (1979) seminal work it has been generally maintained that mother’s education is the more critical determinant of child health. This is consistent with a division of labour within the household in which child-care is the larger responsibility of the mother (Grossman, 2005). Indeed, studies in several developing countries demonstrate that there is no ‘threshold’ level of maternal education that needs to be reached before the benefits of maternal education on child health materialise and even small levels of education improve child survival (Hobcraft, McDonald and Rutstein, 1984; Mensch, Lentzner and Preston, 1985). While a major body of evidence confirms the larger association of mother’s than father’s education with child health, some recent studies find otherwise. Breievrova and Duflo (2002) find that mother’s and father’s education is equally important in reducing child mortality in Indonesia. In Bangladesh, father’s education is found to be a more consistent determinant of childhood stunting than maternal education (Semba, de Pee, Sun, Sari, Akhter and Bloem, 2008). This finding corroborates past evidence from Bangladesh and the Philippines (Rahman and Chowdhury 2006; Ricci and Becker 1996).  Parental education in child health functions may therefore be proxying for different factors (at the level of the individual, household or even the community in which the child resides). For example, sceptics wonder whether the association between parental schooling and child health merely picks up differences in socioeconomic status of households. It is well known that credit constraints in developing countries are a major factor hindering access to health services and potentially translating into inferior child nutrition and health. The evidence from past studies explicitly controlling for household socioeconomic status is somewhat mixed. For instance, Alderman and Garcia’s (1994) study (the only quality study on child health outcomes in Pakistan we are aware of) discovers significant positive effects of maternal education on children’s heights and weights even after controlling for income. Likewise, a study by Thomas, Strauss and Henrique (1990) confirms both parents’ education to have large, independent and significant positive associations with child height in Brazil. The effect of maternal education in their study doesn’t operate through income augmenting effects. Similar findings are et al., 2008). Alternatively, it may be thatkinds of health decisions such as ‘one-off’ immunisation et al., 2008).

Some critics maintain that mother’s education encapsulates unobserved maternal characteristics (such as the values or beliefs they inherited from their own families when they were young) that may in turn be correlated with the health and nutritional status of their children. In this case, a positive coefficient on mother’s schooling could be fully or partially ‘picking up’ the effect of the intergenerational transfer of values rather than a causal impact of maternal schooling. Behrman and Wolfe (1987) are the strongest proponents of this critique and use data from Nicaragua to test their concern. Their findings suggest that when measures of ‘maternal childhood endowments’ are  included, mother’s schooling has strong positive effects on child health and nutrition but that inclusion of maternal endowments causes the effect of maternal schooling to disappear suggesting that, at least in their sample, it is picking up the effect of intergenerational transfer of values and ‘cultural capital’. Handa (1999) also finds that using household fixed-effects in Jamaica causes the positive association between maternal schooling and child height to disappear. Conversely, Strauss (1990) finds that mother’s schooling has a positive effect on child weight and height in the Cote d’ Ivoire even after using family fixed-effects estimators.

Unsurprisingly, the literature on the relationship between maternal schooling and child health has moved towards underpinning the ‘pathways’ through which mother’s education translates into improved child health. While a majority of the evidence hasn’t directly controlled for the endogeneity of maternal schooling, introducing different ‘pathways’ is one way of isolating the ‘true’ impact of maternal education from the effect of confounding factors.

One such pathway that has received little attention (largely because of unavailability of data) is the impact of mother’s education on mother’s empowerment mother’s empowerment as a pathway are by Strauss (1990) in the Cote d’ Ivoire and Handa (1999) in Jamaica height but also find that maternal education does not reflect maternal bargaining power (or empowerment) within the household. Another channel through which maternal education may act on child health is via increasing the probability of maternal labour force participation. This relationship is complex because on the one hand a child may suffer through lack of attention (in the case of infants this may mean they forgo the benefits of breast feeding, for example) while on the other hand, participating in the labour force may augment. The only two studies we are aware of that use. Both studies find some evidence to suggest that maternal education has a direct effect on child .  

Read the full paper (PDF)