Mellington 1999
Mellington 1999
Mellington 1999
115–44
University of Melbourne
This paper uses a sample of 6,620 women from the 1994 Indonesian
Demographic and Health Survey to examine the relationship between
female education and child mortality in Indonesia. Female education is
measured in terms of both years of education and literacy. Both primary
education and secondary schooling significantly decrease the probability
of child death, while literacy plays an insignificant role. When the sample
is divided into urban and rural locations, primary and secondary education
are significant in both areas in reducing the likelihood of a mother
experiencing child mortality. The benefits of public and private
infrastructure appear to differ in rural and urban areas. The results confirm
that investment in female human capital lowers the probability of child
mortality.
INTRODUCTION
The Indonesian child mortality rate has fallen significantly over the past
20 years. Infant mortality fell from 125 to 51 deaths per thousand births
between 1960 and 1995 (World Bank 1980, 1997). Information on child
mortality is harder to come by, but there is evidence of a similar decline.1
Apart from the obvious micro-level benefits to mothers and families,
lower child mortality is also desirable at the macro level. High child
mortality is often cited as a significant determinant of high fertility rates
and high population growth. In an environment where there is very little
public financial support for the elderly, it is important for individuals to
ensure that they have offspring who will survive to look after them in
old age. If child mortality rates are high then there is an incentive to have
more children to guarantee that some survive. Risk-averse parents tend
to overcompensate for the risk of child death, and high population growth
results. Thus, lower child mortality rates reduce the incentive to have
116 Nicole Mellington and Lisa Cameron
large families, and over time result in lower fertility rates and a consequent
lowering of the population growth rate.2
A lower rate of population growth has long been a goal of the
Indonesian government. Under its highly successful family planning
program, the fertility rate dropped from five to three children per woman
in the 20 years between 1971 and 1991 (Jensen 1996). Given the research
interest in these fertility changes (for example, Jensen 1996; Gertler and
Molyneaux 1994; and Hull 1993), and the continuing government view
of fertility and population control as an important policy objective, it is
surprising that so little research has been conducted on child mortality.3
We are specifically interested in examining the relationship between child
mortality and the mother’s level of education.
The only previous studies of Indonesian child mortality of which we
are aware are Cho, Suharto, McNicoll and Mamas (1980), McDonald
(1980) and Martin, Trussel, Salvails and Shah (1983). Cho et al. examined
differences in infant mortality rates across urban and rural areas in the
1960s, but did not analyse the determinants of these differentials.
McDonald’s paper is a short note that examines the proportion of children
dying before the age of five in 1976. He presents cross-tabulations of
deaths by the education of the mother and of the father. Child mortality
was highest among households in which the father had no education,
and next highest among those in which the mother had no education. He
found the effect of primary school education to be quite small, however.
The largest decrease in child mortality occurred with secondary education.
Without the ability to control for household expenditure or income,
however, it is not clear whether he was identifying a pure education effect
or the result of higher incomes.
Martin et al. (1983) conducted a more sophisticated statistical analysis
using a hazard model to estimate the probability of child death. Their
study used data from the 1976 Indonesian Fertility Survey, which covered
only Java and Bali. They examined the effect of the mother’s education,
but the data did not allow them to control for household income or
expenditure. Husband’s education level was included as a proxy for
household income. They were also unable to control for household and
community infrastructure. The study found that one to six years of
maternal education did not affect the probability of child death, but more
than six years of education lowered it.
This paper contributes to the literature in a number of ways. First, it
provides only the second multivariate study of child mortality in
Indonesia. Second, it uses data from the 1994 Demographic and Health
Survey (DHS), and so significantly updates this field of inquiry and is
able to study the entire nation, rather than just Java and Bali. Third, we
Female Education and Child Mortality in Indonesia 117
are able to control for household expenditure, and so can separate out
the income-enhancing effect of education from its other roles. Fourth,
we use data on literacy as well as years of formal schooling to assess
more accurately the type of education or knowledge that impacts on child
mortality. Finally, the DHS provides information on household
infrastructure such as toilet facilities and piped water, and we merge this
with provincial level data on the provision of health services. As a result,
we are able to examine the previously unstudied effect of such facilities
on child mortality in Indonesia.
DATA
The 1994 Indonesian Demographic and Health Survey contains
individual, household and community level information pertaining to
28,168 Indonesian ‘ever-married’ women between the ages of 15 and 49.6
It provides detailed data on health and demographic variables and on
Female Education and Child Mortality in Indonesia 119
METHODOLOGY
Child mortality is here defined as the death of a child before the age of
five. Of the women in the sample, 22% have had a child die before this
age.10 There are a number of ways to model child death. We model the
probability of a mother experiencing the death of a child using probit
estimation. Another alternative would have been to estimate tobits, with
the proportion of the woman’s children who died as the dependent
variable, and upper censoring at 1.0 and lower censoring at zero. A tobit
specification theoretically uses the data more efficiently because it utilises
more information than just the 0/1 nature of accounting for a child death.
We estimated tobits but found the results did not differ significantly from
the probit results. This suggests that little differentiates a woman who
has had one child die from women who have experienced multiple child
deaths. In the interests of clarity we have chosen to present the probit
results.11
A further alternative would have been to structure the data with one
observation per ever-born child, and then to have estimated the
probability of each child having died before the age of five. The main
advantage of this would have been to allow us to control for some of the
intermediate determinants of child death. However, as discussed above,
we wish to capture the full effect of socio-economic determinants on child
death and so do not wish to apportion them over the various intermediate
factors. In addition, data limitations make it impossible to control for
variables such as the duration of breast-feeding (reported only for children
born in the last three years) and immunisation (reported only for children
who were alive at the time of the survey). The DHS does provide data on
preceding birth intervals for all children and the birth age of the mother,
but these variables are likely to be endogenous. It is well established that
fertility and mortality are jointly determined, so any variable that is a
function of fertility is endogenous to child mortality. For instance, the
birth age of the mother is a function of her fertility behaviour and so is
endogenous, as is any variable that is a function of previous or current
mortality experience. Barrera (1991) argues that breast-feeding is
endogenous because whether to breast-feed or not is a function of child
health. Since the length of the preceding birth interval is likely to be a
function of whether the previous child survived or not, it is similarly
endogenous.
Given that little is gained from using the child as the unit of
observation, and that the focus of the paper is on the effect of maternal
education on child mortality, we present results from a sample with one
observation per woman. Results obtained from samples with one
Female Education and Child Mortality in Indonesia 121
observation per child are qualitatively identical, and are available from
the authors on request.
The probit model assumes that there is a latent variable yi* which can
be written as a linear function of variables that affect the probability of a
child dying. Hence, we can write:
yi∗ = βX i + ε i (1)
yi = 1 if yi* > 0
= 0 otherwise
The probit model assumes that the error term, ε i , is distributed
according to the cumulative normal distribution function. If this is the
case, then the probability of at least one child dying can be written as:
β X i −0.5t 2
1 e dt
2π ∫
P= (2)
−∞
Explanatory Variables
Household Level Variables. The probability of a child dying will reflect
characteristics of both the mother and father and the household’s socio-
economic status. The geographic region in which the household lives
and the extent of social and household infrastructure in the region may
also be important determinants of child mortality.
The characteristic of the mother that has received the most attention
as a determinant of child mortality is her educational attainment (Aly
and Grabowski 1990; Singh 1994), which can affect child mortality through
the channels discussed above. We are interested in determining the level
of education that is effective in reducing child mortality. Some studies
have suggested that it is literacy rather than years of formal education
that is of importance. United Nations (1991), for example, states that
‘literacy is a better measure of education than enrollment since it usually
reflects a minimal level of completing schooling’. Obviously, literacy and
years of education are closely related variables. In the DHS data they are,
however, independent enough to allow us to include both as explanatory
122 Nicole Mellington and Lisa Cameron
σ2
Var(ε i ) = (3)
childreni
The sanitation facilities of the household are also likely to affect the
probability of child death. We control for access to piped water and for
whether the household has a toilet.
We also control for the woman’s religion. Child mortality may differ
across religious groups because of differences in traditions (such as the
practice of circumcision) and in the cultural importance of children.
Provincial Level Variables. In addition to household level variables,
we supplement the DHS data with some provincial level indicators. Rice
is the dominant subsistence food in Indonesia, so we include provincial
retail rice prices to control for the effect on child health of differences in
purchasing power across regions. We also control for different inflation
rates across provinces by including a clothing price index, a general price
index and a housing price index.18 The average monthly rainfall in each
province in the wet and dry seasons may also be relevant. Rainfall may
impact upon child mortality, as it is linked to the prevalence of certain
infectious diseases and parasites, and is correlated with agricultural
conditions (Benefo and Schultz 1994: 9–10).19
We also control for the number of public health centres per province.20
A potential problem with the inclusion of infrastructure variables is the
possible endogeneity of government policy. Interregional variation in
policies and programs may not be independent of household resources
and preferences. For example, health programs may be set up in regions
with particularly serious health problems. Immunisation and disease
control may be targeted to poorer areas where the populace is less
educated. Hence some public health programs could be associated with
higher child mortality. Additionally, there is the problem of endogenous
migration. People may relocate toward healthier environments and
specially targeted public health programs. If these migrants also invest
relatively more in the health of their family for unobserved reasons, then
this type of migration may lead to bias in regionally based policy
evaluation studies. We do not attempt to endogenise these policy
variables, but such issues need to be kept in mind when interpreting
their coefficients.
We also wished to control for child immunisation. The proportion of
each woman’s children who were immunised is likely to be endogenous,
however, because women who have had a child die may be more inclined
to have their remaining children immunised. Also, it is an inappropriate
measure in practice, because the DHS reports it only for living children.
To overcome this problem, the provincial average immunisation rate was
constructed from the DHS data. The provincial average reflects the
prevalence of immunisation in the province, and so will control for
community attitudes to immunisation and the existence and effectiveness
of immunisation programs, while avoiding the problem of endogeneity.
Female Education and Child Mortality in Indonesia 125
Dependent variable
At least one of the mother’s offspring died 0.221 0.415 0 1
before the age of five
Explanatory variables at the individual and household levels
Women’s completed years of schooling
Primary 4.398 2.253 0 6
Secondary 1.437 2.306 0 6
Tertiary 0.151 0.906 0 6
Literacy dummy 0.810 0.393 0 1
Logarithm of annual household 13.02 0.587 10.65 15.81
expenditure per capita
Predicted logarithm of annual household 13.00 0.394 12.29 14.45
expenditure per capita
Woman’s age: 15–24 0.252 0.434 0 1
25–29 0.288 0.453 0 1
30–34 0.236 0.425 0 1
35–39 0.149 0.356 0 1
40–49 0.075 0.263 0 1
Husband’s occupation
Administration 0.010 0.100 0 1
Agriculture 0.452 0.498 0 1
Clerical 0.065 0.247 0 1
Industry 0.222 0.416 0 1
Professional 0.074 0.261 0 1
Sales 0.104 0.306 0 1
Service 0.048 0.215 0 1
Other 0.004 0.059 0 1
Current rural resident 0.734 0.442 0 1
The family owns its own land 0.309 0.462 0 1
Religion: Catholic 0.083 0.276 0 1
Christian 0.089 0.285 0 1
Buddhist 0.009 0.092 0 1
Hindu 0.034 0.180 0 1
Other 0.002 0.049 0 1
Toilet facility in residence 0.426 0.495 0 1
Protected water source, including piped water 0.119 0.324 0 1
Provincial level variables
Average monthly rainfall: Dry season 2.181 1.929 0 7.02
Wet season 9.469 2.778 3 16.3
Average immunisation rate 0.444 0.102 0.27 0.67
Price of: Rice 743.0 85.97 589.2 969.5
Housing 209.5 219.1 128.0 1167.2
Clothing 135.6 11.57 119.7 166.9
General items 153.4 6.405 139.9 169.2
Number of public health centres 287.6 270.5 78 951
N = 6,620
126 Nicole Mellington and Lisa Cameron
EMPIRICAL RESULTS
Preliminary Results
Figures 1a and 1b present the raw relationship between female education
and child mortality in the DHS data. The negative relationship is clearly
depicted. The results suggest that the benefits of education are
concentrated in the first six years of education (the completion of primary
school). This is at odds with the conclusions drawn in Martin et al. (1983)
and McDonald (1980). Women with no education experience child
mortality rates 35% higher than those who have entered, but not
completed, primary school, and 97% higher than those who have
completed primary school. The mean child mortality rate drops even
further from 5% for women who have entered secondary education to
Female Education and Child Mortality in Indonesia 127
0.12
0.08
0.04
0
None Incomplete Complete Incomplete Complete Higher
primary primary secondary secondary
Urban
0.12
Rural
0.08
0.04
0
None Incomplete Complete Incomplete Complete Higher
primary primary secondary secondary
128 Nicole Mellington and Lisa Cameron
Estimation Results
Table 2 presents the probit results. The marginal effects and z-statistics
are reported; the probit coefficients are not reported, but are available
from the authors on request.
The Endogeneity of Expenditure in the Child Mortality Regression.
Column 1 presents the results without instrumenting for the logarithm
of per capita expenditure and without the inclusion of provincial
dummies. A comparison of the results in column 1 with those in column
2, which instrument for expenditure, confirms the expectation that
expenditure is endogenous. When expenditure is not treated as
endogenous, the coefficient on expenditure is positive and statistically
significant. This suggests that the greater the level of expenditure per
capita in a household, the higher child mortality is likely to be. This is
clearly counter-intuitive.22 Once one addresses the possible endogeneity
of the variable, the coefficient remains statistically significant but becomes
negative. The marginal effect indicates that a household with 10% higher
current per capita household expenditure than another household has
on average a 0.97 percentage point lower probability of having had a
child die.23 The first stage regression is reported in appendix table A1.
The instruments were jointly significant (F-stat = 36.92; p-value = 0.000).
Education Variables. The results in column 2 of table 2 show that
additional years of either primary or secondary school education
significantly reduce the probability of child death. (Tertiary education is
negatively correlated with child mortality, but the relationship is not
significant.) In contrast, the literacy dummy is insignificant. If literacy is
the only control for education in the regression, it comes in as being
strongly negatively related to child mortality, but when we also control
for years of education, literacy is no longer statistically significant. This
suggests that literacy is an important determinant of child death, but
that it is more than just literacy skills that reduces the probability of child
death. Involvement in formal education, even beyond the years in which
literacy skills are acquired, is an important factor.24
Female Education and Child Mortality in Indonesia 129
not surprisingly, slightly larger than when we include the full set of
explanatory variables. An extra year of primary school is now estimated
to reduce the probability of a woman experiencing child death by 2.2
percentage points (compared to the earlier 1.7 percentage points in column
3 of table 2) and a year at secondary school is estimated to lower the
probability by 3.3 percentage points (compared to the previous 2.0 points).
The education categories now pick up the effects of all of the omitted
time-varying variables with which they are correlated. So, for instance,
as education generally results in higher incomes and hence higher
expenditure, the education variables are now also picking up the negative
effect of expenditure on child mortality. To avoid this omitted variable
bias, because we expect the time-varying variables to be highly correlated
across time, and furthermore because, as mentioned earlier, the results
were found to be robust to restricting attention to just a subset of more
recent deaths, we proceed using both time-varying and non-time-varying
variables.28
a
Log per capita expenditure has been instrumented for. These regressions also
controlled for all of the other variables shown in table 2. Only variables of specific
interest and of distinct difference between the models have been reported. The
results for the unreported coefficients are available from the authors on request.
urban centres. Rural residents benefit little from greater numbers of health
centres if they remain geographically isolated from such services.
a
The other explanatory variables used in the previous regressions were also con-
trolled for in this regression. In addition, this regression allowed the effect of years
of education to differ across rural and urban areas.
Female Education and Child Mortality in Indonesia 137
CONCLUSION
Child mortality and the health of young children are important issues in
all countries, but particularly in developing nations, where child mortality
rates are high by international standards. The empirical results obtained
in this study suggest that increased investment in the human capital of
women is one way of lowering these mortality rates. In Indonesia, the
benefits are obtained via primary and secondary level education. An extra
year of maternal primary schooling is estimated to reduce the probability
of child death by 1.7 percentage points, and an extra year of secondary
schooling by 2.0 percentage points.
The separate regressions for urban and rural women display patterns
similar to those of the full sample. However, education in years completed
appears to have a greater influence over the probability of child mortality
in urban areas. This may be due to lower educational quality in remote
rural regions. Moreover, the relatively low educational attainment of
females in rural areas suggests that much can still be achieved in reducing
child mortality through rural education programs aimed at women.
Public health variables were found to be statistically significant, but
the impact differed by rural/urban residence. While immunisation rates
are significant in both regions, the benefits are greatest in urban areas. In
contrast, the number of public health centres per province is significant
only in the urban sample. Having a toilet in the household reduces child
mortality in rural areas, whereas in urban areas access to piped water is
more important.
The results obtained in this study indicate that encouraging women
to complete secondary education is likely to be effective in reducing child
mortality in Indonesia. The extent to which lowered child mortality results
in a consequent lowering of fertility rates and a slowing of population
growth is an interesting area for further research.
NOTES
* We thank Joe Hirschberg and Chris Worswick for their helpful comments and
assistance with the data, and acknowledge funding from Australian Research
Council. Any errors are our own. The authors may be contacted by e-mail at:
<[email protected]>.
1 Child mortality is defined in this study as the death of a child aged up to five
years. World Bank (1980) provides figures for deaths of children aged between
one and four years. These fell from 31 per thousand in 1960 to 20 per thousand
in 1978.
2 Ray (1998) and Dasgupta (1994) discuss these linkages in detail.
138 Nicole Mellington and Lisa Cameron
3 None of the empirical studies of which we are aware includes child mortality
as a determinant of fertility.
4 Hodinott and Haddad (1994) and Thomas (1990) find that mother’s income
has a positive effect on child anthropometric measures (weight for height,
height for age). Thomas (1997) and Quisumbing and de la Briere (1998) find
that households in which mothers have higher income spend a larger
proportion of the household budget on education. Doss (1997) finds that the
completed level of schooling of children is positively related to current assets
owned by women. Galasso (1999) finds that child labour is less likely in
Indonesian households where the woman would receive more assets if the
couple were to divorce.
5 Better educated mothers may be better able to process information and
therefore less likely to repeat the fertility behaviour of previous generations.
Lower child mortality rates may be factored into fertility decisions more readily
by women with higher levels of education. They may also place more
confidence in modern medicine and child care practices. In this way, education
can serve to reduce expected child mortality as well as actual child mortality,
thus lowering the ex ante response of fertility to child mortality.
6 The data collection was managed by Macro International Inc. and funded by
USAID.
7 Interestingly, current per capita expenditure has greater explanatory power
over deaths more than 10 years ago than over more recent deaths. This may
be due to the lower coverage of public health programs in years past and the
greater reliance on families’ own financial resources.
8 A lack of data corresponding to the period of death is common in studies of
this kind (Martin et al. 1983).
9 Restricting the sample in this way results in an over-representation of high
fertility women, because they are more likely to have had a child in any given
period. However, this is also the case in studies that use the child as the unit
of observation.
10 We do not attempt to differentiate between the determinants of infant mortality
and those of the death of older children. Benefo and Schultz (1996) and Barrera
(1990) studied child mortality and infant mortality separately, and found their
determinants not to be significantly different.
11 Another possibility was to estimate ordinary least squares with the proportion
of child deaths as the dependent variable. This has the disadvantage of not
restricting the proportion to lie between zero and one. We could, of course,
have estimated logits rather than probits, the only difference being that the
underlying distribution of the errors is assumed to be the cumulative logistic
distribution function. Probits were chosen because their estimation makes it
easier to calculate the marginal effect on the dependent variable of changes in
the explanatory variables.
12 Ideally equivalence scales would be used in order to take into account the fact
that consumption is likely to differ among household members. For example,
Female Education and Child Mortality in Indonesia 139
one would expect that children would consume less than their parents. The
use of equivalence scales is highly controversial, however, because of the
difficulty of determining appropriate scales.
13 No attempt has been made in this paper to correct any heteroscedasticity that
may arise from the use of the predicted regressor.
14 Even though the sample includes only women who have had a child in the
past five years, the dependent variable equals one if any of her children has
died before the age of five.
15 See Schultz (1984) for a study that recognises the endogeneity of the number
of children, and models child mortality and fertility simultaneously.
16 To see this, recognise that a zero value of the dependent variable for a woman
who has had eight children has a higher information content than a zero value
for a woman who has only ever had one child.
17 In practical terms, the weighted and non-weighted probit results differ only a
little.
18 All price data are for the capital city of each province, as published in BPS
(1995).
19 For instance, greater rainfall acts against water-borne diseases such as cholera,
although malaria is more prevalent during the wet season.
20 The rainfall data and the number of public health centres are the 1994 figures
from Statistik Indonesia (BPS 1995).
21 Because they are perfectly collinear with the provincial dummies.
22 The more likely causality is that if a child dies, there are fewer household
members and so expenditure per capita is higher.
23 Note that the interpretation of the marginal effect on this variable differs from
that for all of the other variables, because expenditure is measured in
logarithms. As a result, the marginal effect corresponds to a 100% increase in
the explanatory variable, as opposed to a one-unit increase, as is the case for
variables measured in levels.
24 In the data it is possible to be literate and not to have attended school, and
vice versa. The correlations between literacy and years spent in primary,
secondary and tertiary education are as follows: 0.80, 0.30, 0.08.
25 Specifically, we included dummy variables reflecting the husband’s highest
level of schooling as primary, secondary or higher, with and without the
inclusion of husband’s professional status. In both formulations, the coefficient
on husband’s education was positive but statistically insignificant.
26 The price data, like the other variables, are for the year 1994, and so may
differ from those that prevailed around the time of the offspring’s early
childhoods. We are implicitly assuming that the woman has not moved
provinces since the birth of her children and that price differences and other
provincial level variables are relatively stable across time and provinces. This
is a common problem in studies of this kind (Martin et al. 1983, for example),
and must be borne in mind when interpreting the results.
140 Nicole Mellington and Lisa Cameron
27 It could be argued that we should study the effect of the number of health
centres per head of population. We have used the absolute number of centres
because we believe that this better captures access to a health centre: individuals
who live in a sparsely populated province with a high number of centres per
head may not have easy access to a centre, because they are likely to live at a
long distance from one.
28 Although the results are robust to restricting attention to births in just the last
10 years, we prefer to report the results where the dependent variable reflects
all child deaths that a woman has experienced: it is somewhat arbitrary to
treat as having experienced child death a woman whose child died 10 years
ago and not one whose child died 11 years ago. Also, using all deaths results
in the regressions having much higher explanatory power.
29 See Hill (1996: 211–12) for an outline of problems relating to the quality of
education in Indonesia’s more remote areas.
30 Hill (1996: 213) notes that public funding of hospitals (normally based in urban
centres) absorbs a larger portion of the health budget than does funding of
rural health centres and services.
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Female Education and Child Mortality in Indonesia 141
a
Dummy variables reflecting the province of residence and religion of the house-
hold were also included.