Full Terms & Conditions of access and use can be found at
Download by: [Universitas Maritim Raja Ali Haji] Date: 19 January 2016, At: 20:23
ISSN: 0007-4918 (Print) 1472-7234 (Online) Journal homepage: http://www.tandfonline.com/loi/cbie20
FAMILY SIZE, UNWANTEDNESS, AND CHILD HEALTH
AND HEALTH CARE UTILISATION IN INDONESIA
Eric R. Jensen & Dennis A. Ahlburg
To cite this article: Eric R. Jensen & Dennis A. Ahlburg (2002) FAMILY SIZE, UNWANTEDNESS, AND CHILD HEALTH AND HEALTH CARE UTILISATION IN INDONESIA, Bulletin of Indonesian Economic Studies, 38:1, 43-59, DOI: 10.1080/000749102753620275
To link to this article: http://dx.doi.org/10.1080/000749102753620275
Published online: 17 Jun 2010.
Submit your article to this journal
Article views: 55
View related articles
ISSN 0007-4918 print/ISSN 1472-7234 online/02/010043-17 © 2002 Indonesia Project ANU
Thispaperpresentsandestimatesamodelofthedeterminants ofchildhealthand health care utilisation in Indonesia. In particular, it estimates the impact of unwantedness andnumberofsiblingsonhealthoutcomesandtreatment.Itfinds evidencethatchildrenwhoareunwantedatbirtharemorelikelythanotherchil
Sinceatleastthe1970s,thegeneraltrend inIndonesiahasbeenoneofdeclining family size and improvements in the overall well-being of members of the
population.Lifeexpectanciesarelonger, earningsarehigher,andeducational at
-tainment has increased—by virtually
-erage Indonesianisbetteroff than his or her parents. Certainly, over time, health and educational infrastructures haveexpandeddramatically.Anunder
-ily sizesandchildrenofhigherquality (e.g.withbetterhealthandeducation). Withworseningeconomicandpolitical conditionsattheturnofthe21stcentury, therewaswidespreadconcernthatthese gainscouldbe wipedout(Booth1999; Jones, Hull and Ahlburg 2000). How
-ever,itappearsthat,despitesignificant economicshocks,educationandhealth havesofarnotsufferedlargereversals.
Ouraim inthispaperistoexamine, atthefamilylevel,theimpactonchild healthandhealthcaredecisionsofthe numberofchildrenandwhetherachild waswantedatbirthbyitsparents.Our premiseis thatfamilyresourcesarefi
-nite,andthereforethatallocativechoices mustbe made.These choices, or their consequences,maybeobservableinsur
-veydataonchildhealth.Toexaminethis contention, we investigate diarrhoeal andrespiratorydiseaseincidenceinchil
-dren for either illness. If fertility is imperfectlycontrolled,unwantedbirths arelikelytooccur,andfewerfamilyre
-sourcesper child are available than is desiredbytheparents.Therefore,many choicesrequiringresourcecommitments by parents,including ourmeasures of childhealth,willbeaffectedbytheoc
-currenceof unwantedbirths.Weview theoccurrenceofanunwantedbirthas a largely exogenous shock occurring
outside the parents’ decision making calculus.InIndonesia,theproportionof unwantedbirthsislow,sofora parent todeclarethatachildisunwantedisa strongsignal.Thus,Indonesiaisagood country inwhich totestfortheimpact ofunwantednessonchildhealth.
Educationalattainmentandchildhealth are two broad categories of indicators thathavebeenusedinthepasttoassess the human capital improvements ac
-companyingdevelopment (Kelley1996; Cassen1994).Literacyandnumeracyare important inmoving from traditional, largely agrarian economies to those based on modern manufacturing. Re
-turns to ed uc ation in the form o f increasedearningsprovideclearquan
-tificationofthevalueofattainingsuch education.Ontheotherhand,wellover adecadepassesbeforeanewbornchild completes his or her education. This makesitdifficulttoaddressdirectlythe impacts of fertility upon family-level
resource allocation and, through this mechanism,subsequently uponeduca
EvidencefromtheAsianeconomies, most notably Japan,shows theimpact ofchildhood nutrition onadult physi
-cal stature. When severe,malnourish
-mentinchildhoodcancausediminished intellectual function inadulthood,and alsomayharmtheperformance ofchil
-dren in school. Child malnutritionis problematic inAsia,which is hometo 75%ofthemalnourished childreninthe world (Ahlburg and Flint 2001). Ill healthandpoorgrowthinchildhoodare also related to adult morbidity and mortality (Fogel 1994), and to lower productivity andpoorerlabourmarket outcomes (Strauss and Thomas1998).
-ure of both current and future well
-being. Parents’ willingness and ability tocommit resourcestotheirchildren’s health is thereforeof interest. Empiri
-cally,examiningrelationships between fertilityornumberofsiblingsandchild healthisanappealingwaytogetatun
-derlying resourceallocation decisions, because observable consequences of thesedecisionsmaybegintoappearal
-mostimmediately afterachildisborn. The increasein mean adult heights observedinpostwarJapanshowsthat resourcesplayanimportantroleinhu
-erage, provided their children with moreprotein and calories thaninear
-liertimesbecausetheycould affordto doso.Thiswastrueinsuchalargepro
-pact in the entire po pulatio n was significant.Incomesperfamilymember rose both because family incomes in
-creased with rising productivity and becausetheaveragefamilysizefell.His
-torically,these phenomenaare deeply intertwined,andinferringacausalrole forfertilitydeclineisdifficult.Certainly, inpresent-day Japan,theoverwhelm
-ingmajority of parents wouldbeable toprovide adequatenutritiontonum
-bersofchildrenmuchgreaterthanthe numberstheycurrentlybear.However, duringthepost-Meijifertilitydeclinein
-offsbetweennumbersofchildrenand the nutrition (and subsequent health conditions)thesechildrenenjoyedwere starkerthancurrentlyisthecase.Inthis sense,thehistorical trade-off between
-tus was much like the present-day
trade-off betweennumber of children
andeducation, or betweennumber of childrenandsizeofbequests,inmany Asiansocieties.
One major problem in inferring re
-sources devotedto childhealth is em
-pirical. Child health, and indeed the broaderconceptofchildwell-being,has
manydimensions, andin thissense is difficulttomeasure.Thetiebetweenre
-tual health outcomes is a ‘noisy’ one. Genetic endowments and chance play animportantroleinmorbidity,forex
-ample. Very well nourished, well fed and clean children still get diarrhoeal and respiratory infections and, con
-versely, poorly nourished children are notalwaysill.Thepresumption under
-mitted to c hildren. Other in direct measuresofchildwelfareareavailable, butareequallyimperfect.Forexample, weight-for-height measurements are
takenaspartofsomesurveys(although notinthesurveyweuseforthispaper). Justaswithhealthoutcomes,thetiebe
-tween inputs, in theform of nutrition and so forth, andanthropometric out
-comes depends on a range of unob
-served facto rs , includ ing geneti c, metabolicandotherfactors.
Anadditional confounding factoris theoretical innature,andleadstostatis
-ticalproblemsofidentification. Parents aremakingchoicesaboutahostoffac
-torssimultaneously.Inthebroadestof terms,theyaremakingdecisionsabout numbersofchildren,resourcecommit
-mentper child, and non-child expen
-ditures. Som e parents may choose relativelymorechildren,withrelatively less committed per child, than other parents. As Montgomery and Lloyd (1996a)pointout,thesimplefindingof aninverserelationship betweenfertility andchildwell-beingthereforedoesnot,
of itself, constitute justification for
policy. Itis completelyconsistentwith standardeconomicmodelsoffamilyfor
-mation (e.g.BeckerandLewis1974)in which parents with a taste for lower quality perchild choose tohave more children, becausethepriceperchildis lower than that for children of higher quality. To show that fertility affects childwell-being,whatisneededisevi
-dence that changes the in number of children affect quality per child inde
-pendentlyoftheunderlyingvariationin tastes,incomeor pricesgeneratingthe initialdistributioninthenumberofchil
-dren.Such independent effects,by the nature ofthe quality–quantity interac
-tion inchildren,areinherentlydifficult toteaseout,renderingstatisticalidenti
child health as a measure of quality. Someworkontheimpactoffertilityon educational attainmenthas focusedon thequantity–quality trade-off,branch
-ingintwodirectionstowardanalysisof the within-household impactsof large
One path focuses on average well
-being within families, examining,for example,differencesinaverageeduca
-tion ofnumberofsiblings. Oneof the closestrelationshipsbetweenthenum
-berofsiblingsandaverageeducational attainment by family members is re
-portedintheworkofKnodel,Havanon and Sittitrai(1990)forThailand.Other studiesbasedonessentiallysimilarcon
-cludethosebyBaueretal.(1992)forthe Philippines; BehrmanandWolfe(1987) for Nicaragua; and Rosenzweig and Wolpin(1980)forIndia.Alloftheseau
-lies receive less education than do childrenfromsmallfamilies.Theeffects
are oftensmall, and again,causality is difficulttoinfer.Itmaybethatincreas
-ing competition among siblings forfi
-nitefamilyresourcesdecreasesaverage accesstoeducation.Thisisthe‘resource dilution’ modelassociated withJudith Blake(1981).
A second approach acknowledges thatparentswithapreferenceforlarger familiesmaybethosewhoseelessneed toeducatetheirchildren,sothatthecor
-relation between family size and chil
-dren’s educationalattainment reflects tastes and is not causal (Montgomery and Lloyd 1996a; Becker and Lewis 1974). The unsuitability of empirical models that do not account for the endogeneity offertilityinparents’deci
-cismsofmuch oftheworkinthefield (e.g. King 1987; Kelley 1996). Models that pay carefulattention tostatistical identification tendtofindsmalleffects offamilysizeonhouseholdresourceal
-enous componentof fertility, Rosen
-zweig andWolpin(1980)use asample oftwinbirths,andfindasmallimpact of exogenous fertility on subsequent educational attainment.3 Behrmanand Wolfe(1987)useasampleofadultsis
-terstowardsimilarstatisticalends.Work todatehasgeneratedlittlefirmsupport forthenotionthatnegativewithin-fam
-ily consequences of familysize on the welfare offamily membersareimpor
-tant,atleastwhenmeasuringwelfareby educational attainment.
In considering the decision making process of parents, we have thus far spent little time discussinghow their decisions translate into actual fertility. Conceptioncarrieswithitasubstantial elementofrandomness,andthereforeso does contraception im perfectly em
undesired births may occur, or births maycomeearlierorlaterthandesired. The occurrence of an unwanted birth representstheexogenousimpactoffer
-tility. Unless one makes the heroic assumptionthatparentsanticipate(per
-fectly)notonlythelikelihood, butthe actualoccurrence, ofcontraceptive fail
-ure, the unplanned nature of an un
-wantedbirth implies thatthe event is independent of the parents’ decision making calculus. Therefore, a ‘pure’ causal impact of unwanted births on measures of child quality may be estimable. For instance, in Thailand, Frenzen and Hogan (1982, cited in MontgomeryandLloyd1996b),found that children wantedby both parents have a significantly higher probability ofsurvivingtheirfirstyearthandochil
-ent.Theimpactmaybefeltbythechild inquestion,oritmaybedistributedover alargergroupofchildren.
allocation, a more fully developed strandintheliteratureexaminesdiffer
-entialallocations offamilyresourceson thebasisofanindirectmeasureofwant
-edness:thechild’ssex.Thisstrand,ina sense,isalogicalextensionofthework byRosenzweigandWolpin,inthatthe birth o f a gir l is o utside the pre
-conceptiondecisionmakingcalculusof parents. Work by Chen et al. (1981), Simmons et al. (1982) and Dasgupta (1987)hasshownthatSouthAsiangirls receivelessfoodthantheirmalesiblings, and are less lik ely to survive their childhood.TheSimmonset al.workis noteworthyin demonstratingtherela
-tionshipbetweensiblingcompetitionfor resources and the impact of an un
-wanted daughter’s birth. Rosenzweig andSchultz(1982)tiethistounfavour
-ablelabourmarketoutcomesforsome Indiangirls. Consistently in thelitera
-sourceallocation, asmeasuredbyfood, educationorothercostlyresourcesde
MontgomeryandLloyd(1996b)cite aFinnishstudybyMyhrmanetal.(1995), inwhich mothersinterviewed intheir sixth or seventh month of pregnancy wereaskedwhetherthepregnancywas wanted, mistimed or unwanted. The timingofthequestionsguaranteesthat theresponsesarenotinfluencedbythe characteristics ofthechild,becausethe wantednessinformation was collected beforethechildwasborn,andthecon
-upsurveydonemorethantwodecades later. Myhrmanet al. foundthatlower educational attainment for unwanted daughtersoccursforanynumberofsib
-lings,whileforunwantedsonsitoccurs only if therearetwo or moresiblings. Thisshowsastrongelementofparental choice, coupled with a resource con
-straint that appears to bind as the numberofsiblingsincreases,albeitwith differingstrengthsforsonsanddaugh
-ters. Thatresource constraints (meas
-ured by number of siblings, all else constant)bindlesstightlyforsonsthan for daughters shows that parents are abletocompensate, tosomedegree,for anincreasingnumberofsiblings.Onthe otherhand,thefactthatnumberofsib
-lingsmatters,evenforsons,impliesthat resource constraints are increasingly important as the number of siblings grows.
Wantednessofbirthsplaysakeyrole inouranalysis.MothersinIndonesia’s D em ographic and Health Surveys (DHS)areaskedspecificallyaboutwant
-ednessatthetimeofconceptionforeach livebirthinaperiodofthreetofiveyears precedingthesurvey.Becausetheyare askedretrospectively,responsestothese
questionsare oftenthoughttobe sub
-tion ofsuchrationalisation isnotclear, however. Knodel and Prachuabmoh (1973), for example, believetheir Thai dataunderstatethe degreeofunwant
-edness,asmothersarereluctanttosay thatagivenchildwasinfactunwanted. Rosenzweig andWolpin(1993),onthe other hand, claim that their US data show the opposite.On the basisofan undesirable outcome such as an un
-healthy baby,Rosenzweigand Wolpin claimthatsomewomen(perhapsnearly one-fourth) who, prior to conceiving,
said thattheywanteda birth changed their post-partum response to ‘un
-wanted’.Itseemsprudenttotakeboth arguments into account by allowing wantedness (potentially) to be endog
-teristicsofmother,ofsiblings,andofthe reference child, and we do so in our empiricalwork.
-beingas functionsofchild,familyand community characteristics: probability ofillnesswitheitherdiarrhoeaorfever/ cough;anduseofcurativecareforthese conditions. Pragmatic concernsdictate this strategy,asdiarrhoea andrespira
-toryinfectionsarethetwoillnessesmost readily observedinsurveydata.How
-ever,theyarealsoofpolicyinterest,as thesetwodiseasecategoriesaccountfor roughly one-third of infant and child
mortality inthedevelopingworld.We constructamodelbaseduponthecon
-cept of a child-specific index of ‘child
value’, orparents’ willingness tocom
-mitresourcestoaparticularchild.This indexis positedtobe afunctionofex
-ogenous individual, household and community variables. Household re
-source commitments are measured
-ciated monetary, time and othercosts; and indirectly by the incidence of morbidity.
DefineZ tobetheindexvalue fora givenchild,where,forX,avectoroffam
age,educational attainmentandwealth holding,w,ascalarindexofwantedness, ands,ascalarcountofnumberofsib
Z = f(X, w, s) (1)
anddefineAtobeavectorofvariables measuringfamilyaccesstohealthcare, andRtobeavectormeasuringrisksof illness. Then the following conditions characterise theincidenceofillnessand subsequentuseofcurative careforliv
Illness observed : I = 1
if Z *1 ³ Z | X, w, s, R (2)
Treatment observed : T = 1
if Z *2 £ Z | X, w, s, A, I = 1 (3)
whereZ*denotesunobservedthreshold variables.Thesearetheusualthresholds underlying discrete choice models which,althoughtheyarenotobserved directly,carryobservableconsequences. Inthissetting,illnessoccursiftheindex ofchildvalue,conditioned onchildand family specific covariates and risks of illness, falls below an unobserved thresholdvalue,andcurativetreatment occursifchildvalue,conditioned onac
-cess, covariates and illness, exceeds a minimum(unobserved) threshold.The presumption is that, all else constant, wantednessisassociatedwithdecreased probabilityofillnessandincreasedprob
-ability of curative treatment, while numberofsiblingsisassumedtowork in the opposite direction. Family-level
covariates associated with increased
wealth,income or socio-economicsta
-bilityandriskarepresumedtoincrease theprobability oftreatmentandillness, respectively.5
Wantednessresponses,becausethey are given after the birth has occurred, may be subject to the sort of post-hoc rationalisation we have dis cussed previously, and we therefore model wantednessasafunctionoffamilychar
-acteristics and number of sib lings. Numberofsiblingsisareflectionofpast valuesofchildvalueindices.Theseval
-ues arelikely to behighly correlated withcurrentvalues.Therefore,tocom
w = g(X ,s)w (4)
s = h( Z )-T (5)
-uring family-specific considerations,
includingcharacteristicsof thechild, such as sex, birth weight and non
-singleton status. Number of siblings is a function of Z–T,notational short
-handfor the setof past valuesofthe indexofchildvalue Z.
AnimportantpartoftheRosenzweig andWolpin(1993)study istheirclaim thatwantednessresponsesaresubjectto post-birth adjustment, conditional on
childcharacteristics (including, butnot limited to, child morbidity). Because DHS surveys only have information aboutchildmorbidityintheimmediate pre-survey period,it is notpossible to
subject the morbidity aspect of the RosenzweigandWolpinfindingtofull scrutiny. It is po ssible to ex amine whetherrecentorcurrentillnesshasan impactonwantednessresponses,how
-edness as an endogenous structural determinantof equations (2) and (3).
Ourmeasureofhealth,limitedasitisto the immediate pre-survey period,is a
-port to the notion that our outcome measuresarenotdeterminantsofwant
-edness,butsuchatestis lesspowerful than one might like inexamining the contention that child endo wments (broadlydefined)donotaffectwanted
-ness.Similarly,itisfeasibletoallowfor endogeneityofnumberofsiblings,6and toteststatistically forsuchapossibility. Comparable caveats apply,as the test specifically relates totheimpact ofill
(or treatment for this illness) upon numberofsiblings,andnottheimpact ofsomemoregeneralmeasureofchild endowmentsuponnumberofsiblings. Abirth generates anincrease in the numberofsiblings,andeachbirthmust be classified as either wanted or un
-wanted.Therefore,wantedbirthscarry with them only a (relative ly pure) number of siblings effect, while un
-wantedbirths areaccompanied by the differential impacts upon child well
-ilyandoftheaccompanying increasein numberofsiblings.Exceptwhereocca
-sionally contaminated by unwanted births,numberofsiblingsisareflection ofparents’desires.Unwantedbirths,on the otherhand, are reflective of exog
-enous shocks to the family-formation
process, and therefore areexpected to generatelargerimpactsonsubsequent resourceallocations.
The within-family mechanism
throughwhichunwantednessoperates could be one in which per capita re
-sourcedeclinesarespreadmoreorless evenlyoverhouseholdmembers,or,as seems more likely given models of within-householdallocation(Simmons et al. 1982; Rosenzweig and Schultz
1982), unequally according to prefer
-encesorpastinvestments.Childrenwho are older or otherwise relatively fa
-quences of the birth of an unwanted youngersibling,thereforeconcentrating the observable response on younger children, particularly the unwanted birthitself.Iftheresourcepressuresac
-companying an unwanted birth are spreadevenlyoverallchildrenandone examines—aswedo—theconsequences
only forthechildinquestionofhis or herunwantedness,theeffectwillbeto understate the apparent effect of un
-wantedness. Sincethe impacton only onechildisincludedinouranalysis,the estimated impacts ofunwanted status onthemost recent birthpresentedbe
-low are low er bounds to the total intrahousehold allocative response to unwantedness.7
Thedatacomefromthe1991Indonesian Demographic andHealthSurvey(Indo
-nesiaCentralBureauofStatistics, State MinistryofPopulationandMinistryof Health and MacroInternational 1992). Thesurveyusesinterviewswith22,909 ever-married women,ofwhom 21,109
weremarriedatthetimeofthesurvey, andreportsbirthsof14,393childrenin the fiveyears preceding theinterview date.Theestimatedtotalfertilityratefor 15–44year-oldswas2.99.
Forbirthsinthefiveyearspreceding the survey, detailed information on health was collected. Mothers were askediftheirchildrenhadexperienced diarrhoea or cough/fever in the two weeksprecedingthesurvey,aswellas whattreatmentthechildrenweregiven. Treatmentscanconsistofcommodities, advice,orsomecombinationofboth.As inmanydevelopingcountries,thereis anactivetraditional sectorinIndonesia providinghealthcare.Weareunableto
differentiate among various folk cures inmanyinstances.Forexample,‘herbs’ as atreatmentforanillnessisdifficult to assessin termsof effectiveness. We have therefore focused on treatment suppliedbythemodernsector.Thepre
-sumptionis thatmodernmethodscost atleastasmuchastraditional methods and areless accessible. Therefore, use of modern-sector treatments reflects
greaterwillingness on thepart of par
-ents to seek out effective care and commitresourcesthandoesuseoftra
The DHS question on wantedness comesinasectionofthequestionnaire extracting detailed information on re
-centbirths.Themotherisaskedwhether shewantedthecurrentbirthatthetime she became pregnant, whether she wantedthe birthbut wouldhave pre
-ferredthatithadcomelater,orwhether shewouldhavepreferredthatthebirth had not occurred at all. Inour regres
-sion analyses, we classify a birth as ‘wanted’ifthemotherreportsthatitwas wantedeitheratthetimeofconception orlater.Ofalllivebirths,95%wereclas
We first discuss the impacts of areal (community-levelandprovincial-level),
family, and individual-level determi
-berofsiblings,onchild morbidity.We thenexaminetheimpactofasimilarset of determinants on curative care. We employa linearspecification fornum
-bidity and treatment. We test for the potential endogeneity of wantedness andnumberofsiblingsonbothmorbid
-ity and treatment equations, again based onresidualsfromreduced-form
equationsonwantednessand number ofsiblings.
-metersoftheillness/treatmentsequence jointly.Thatis,iftheunderlyingissueis oneoftheresourcecommitments ofpar
-ents,thenthesusceptibility ofchildren to illnessand their subsequent use of care, conditional on illness, are two manifestations of an unobserved re
-naryoutcomes ofthetwo measures,a bivariateprobitmodelofsampleselec
-tion is most efficient. However, the processissufficiently ‘noisy’thatthebi
-vergereliably.9Wethereforeestimatethe determinants oftreatmentintwoways. Weestimateaunivariate probitforthe probabilityofreceivingtreatment,ignor
-ingthatthechildmustfirstbeillbefore receiving treatment.As analternative, weestimatethetreatmentequationasa lin ear probability with a two-stage
Heckman sample selectivity correc
-tion.10,11 Whentransformed toderiva
-tives evaluated at sample means, the simple probit gives virtually identical results totheHeckman estimates,and subsequentdiscussionoftheestimates appliestoeither formulation. Ineither instance,weestimateaunivariateprobit transformation ofthe determinants of morbidity.
Table1presentsdescriptivestatistics. Many variables are familiar,but some bearfurtherexplanation.Thefirstisour measureofpermanentincomeorwealth. DHSsurveysdonotcollectdirectdata onincomeorwealth.Instead,theyuse a collection of questions about asset ownership (vehicles and appliances), housingquality(roofandfloormateri
-als and plumbing) and access tofresh water. Usingfactor analysis, we have combined the responses to many of these questions into two factors. This makesthesubsequentregressionresults lesscluttered,whileallowingustocon
-evision or refrigerator ’ and housing attributes‘non-dirtfloor ’and‘in-house
electricity’ loadonthefirstfactor,while ‘ownershipofautomobileorstove’and ‘numbersofroomsforsleeping’loadon thesecond.Taken together,thesevari
-ables captureasset ownership, and as suchareproxiesforpermanentincome. Therearethreevariablesconstructed as provincial-level means: themean inci
-dence of fever/cough and diarrhoea, and themeantraveltime tohealth fa
-sponses for children of every eligible respondent in the province except the referencebirth,andthereforeareindica
faced by thereference birth. The vari
-ables for water and type of toilet are household-specific.Sinceweareexam
-ining caregiventolivingchildren,the sample is restricted tocurrently living children.12
Twosetsofresultsarediscussedhere. Thefirstsetrelatestotheimpactofareal, family and individual-level determi
-berofsiblings,onchildmorbidity.The secondrelatestotheimpactofasimilar set of determinants on curative child healthcare.Theresultsarebasedupon modelspecifications thatemployactual valuesofwantednessandnumberofsib
-lings rather than their instruments. TABLE1 Description ofVariablesUsedintheAnalysis,Indonesia,1991
Variable Definition Mean Standard
Fever/cough Childillwithfeverorcoughinthelasttwoweeks 0.35 0.48 Fevercare Modernadvicesoughtormoderncaregivenfor
fever/cough 0.83 0.38
Diarrhoea Childwithdiarrhoeainthelasttwoweeks 0.10 0.30 Diarrhoeacare Modernadvicesoughtormoderncaregivenfor
diarrhoea 0.78 0.42
wanted,thenorlater 0.95 0.22
Siblingsalive Numberofsiblingsaliveattimeofbirth 1.58 1.70 Male Dummyformale:1ifbirthismale 0.52 0.50 Child’sage Child’sageinmonths 29.24 16.92 Mother’sage Ageinyearsofmotheratchild’sbirth 29.09 6.15 Mother’seducation Mother’seducationinyears 6.22 5.29 Husband’seducation Educationofmother’scurrenthusbandinyears 7.40 5.47 Assets1 Factorscorebasedonassetownershipa
drinking:1ifyes 0.09 0.29
Typeoftoilet Dummyforflushorpittoiletaccess:1ifyes 0.18 0.39 Traveltime Meantraveltimetofamilyplanningservice
provisionpointinminutes 32.16 7.41
Seetextforamorecompletedescription oftheconstructed variables.
Becauseofthepossibleendogeneity of these variables, we generated instru
-mentsfor wantedness and numberof siblings by usingreduced-form equa
-tionstopredicttheirvalues.13 Wethen usedtheresidualsfromtheseequations asregressorsinourstructuralequations formorbidityandhealthcare,inorder to carryout Hausmantests forexoge
-lingsineachofthestructuralequations. Innocaseswereweabletorejectthenull hypothesis of exogeneity for either wantedness or number of siblings. In otherwords,wehavenoevidenceinthis samplethatillnessinthelasttwoweeks orhealthcareprovision tochildrenaf
-fectspost-hocwantednessornumberof siblings responses.14 Therefore,there
-mental variables for wantedness or numberofsiblings.
An additional question of model specification is the manner in which numberofsiblingsmightinfluence al
-locations to child ren. Kelley (1996) claims thatfailureto include potential non-linearitiesinstudiesoftheeffectof
number of siblings on educational at
-tainmentofchildrenisanerrorleading to overstatement of the impact of the number of siblings on resources allo
-catedperchild.Wefindnoevidencefor such scale effects on the incidence of morbidityorallocationofhealthcare.To testtheproposition, wespecifiedavari
-able that equalled 1 forlarge families and0otherwise,where‘large’wasde
-dren’.15 We used this ‘large family’ dummyvariable,interactedwiththefull setofcovariates, toperformWaldtests on jointly restricting the coefficients acrossvaluesofthelargefamilydummy, and were unable to reject the null hypothesisthattheywerethesame.In
associatedstatistical significance levels alsowerethesame.Inotherwords,we have no statistical groundstosupport thecontentionthattheimpactofanad
-ditional child differed between small andlargefamilies.Therefore,wepresent estimatesthatincludetheimpactoffam
-ily size(alone and untransformed) on illnessandtreatment.
-nessatbirthplaysanimportantrolein reducingmorbidity in Indonesia.The impactofwantednessistodecreasethe chanceofcontractingdiarrhoeabyap
-allprevalencelevelofdiarrhoea,avery large and statistically significant ef
-fect.16 Assetavailability,asmeasuredby theconstructed factors,shows noim
-pactondiarrhoeaincidence.Mother’s education,accesstoflushtoiletsandthe mean provincial prevalence of diar
-rhoeaareallstatistically significantand largely operate in expected fashion: children of more educated mothers, withaccess toflushtoilets, andliving inareaswherediarrhoeaprevalenceis lower, experience less diarrhoeal dis
-ease,allelseconstant.Childrenfroman areawith a prevalence rateone point higher than another area have a pre
-dictedprobability ofcontracting diar
-rhoea seven-tenths of a point higher
-itydifferentialexperiencedbychildren whose mother ’s educational attain
-ments differ by three and one-half
-bidityreductionattributabletohaving access to flush toilets, and approxi
-mately one-seventh of the diarrhoeal
child willcontract diarrhoea.The esti
-mateddeclinein diarrhoeal morbidity is approximately 4% per sibling. Two possible explanations suggest them
-selves.Oneconjectureisthatthisisnot duetoenhancedresistancetodiseaseof childrenwithlargenumbersofsiblings (inpartbecausetherearefewlargefami
-liesinthedata)but,rather,thatchildren with few or no siblings have higher morbidity. This draws on the well
-known claim of John Bongaarts(1987)
that familyplanning programs,when successful, increase mean infant and child mortality rates; this occurs be
-cause,asfertilityfalls,theproportionof birthsthatarefirstbirthsincreasesand, forphysiological reasons,firstbirthsare at higher risk of mortality. Unfortu
-nately, family sizes are so small that therearenotenoughcasestoallow us to say anything definite on this point, otherthanthatasmallereffectpersists when one-child families are removed
TABLE2 Coefficients ofProbitModelsofChildMorbidity,Indonesia,1991
Variablea Diarrhoea Fever/Cough
Wantedbirth –0.047 –0.083
Numberofsiblings –0.004 –0.011
Male 0.009 0.018
Child’sage 0.012 0.022
Child’sagesquared –0.008 –0.103
Mother ’seducation –0.002 –0.000
Husband’seducation 0.001 0.001
Assets1 0.006 0.019
Assets2 –0.002 0.001
Urban 0.001 –0.019
Water 0.011 0.027
Toilet –0.016 –0.038
Provincialmeanprevalence 0.754 1.02
Samplesize 13,118 13,231
fromthesample.Inthe1991Indonesia sample,mediannumberofsiblingswas 1, and mean number of siblings was 1.58.Ofthechildreninthesample,33% werefirstbirths,and59%hadeitherno siblingsoronesibling.Asecondpossi
-bilityisalearningeffect.Motherslearn from theirexperiences with their first child,and so motherswho havemore children are better at keeping them healthy.
RespiratoryInfection. Thepatternfor respiratory infections is much the same.Wanted birthsareroughly13% less likely to contract respiratoryin
-fections than are unwanted births. Onemeasureofassetownershipissta
-tistically significant but has an esti
-mated coefficient of the wrong sign. It is of little practical impo rtance, however: a one-standard deviation
-pared to the mean implies leapfrog
-gi ng o v er ab o ut o ne-thi rd o f th e
income distribution, would yield an increase of only 5% in fever/cough m o r b i d i ty. A s w a s th e c a s e w it h diarrhoealdisease,respiratoryillness ismorelikely tooccurinareaswhere itsprevalenceishigh.Accesstoapri
-vate flush toilet decreases the prob
-ability of contracting a respiratory illness. It is doubtful thatthis repre
-tion:perhapsthisvariableisactingas somesort of proxy forhousing qual
-ity.Boysare(barely)statisticallymore likelytocontractrespiratoryillnesses than girls. As was the case for diar
-rho ea, chi ldren w ith man y l ivi ng siblings arelesslikely tocontractres
-piratory disease than are those from smallerfamilies.Onceagain,themag
-nitude issmall, with each additional siblingaccountingforadropof3%in the probability of illness. Theappar
-ent beneficial impact of siblings is swampedifthatchildisunwanted.
Ofill children,78% of those with di
-arrhoeaand83%ofthosewithfever/ cough received modern sector treat
-ment.InthePhilippines,Costelloand Lleno (1995) found a preference for (typically incorrect) antibiotic-based
treatm ent regimens fo r diar rhoea. Thereis someevidence thatthis ten
-dencyalsoprevailsinIndonesia,with only about 20% of children ill with diarrhoea receiving oral rehydration salts(ORS).Itthereforeseemsunlikely thattherelativelyhightreatmentrates inIndonesiaareattributabletoadher
Themarginaleffectofbeingwanted wastoincreasetheprobabilityof be
-ing treatedfor diarrhoea by roughly 0.13(table3).Alternatively,compared to the mean probability of treatment ofdiarrhoeaof0.83(table1),awanted child was17% more likely to receive treatm ent th an was an un wan ted child. Children from larger families were less likely to receive treatment, although the latter variable was not statisticallysignificant.Theseimpacts wereverysimilarforbothestimation approaches.However,the size ofthe impactofthesevariablesontreatment forfever/coughwasnotstableacross d i ffe re n t e s ti m a ti o n a pp r o ac h e s. Household assets and prenatal care did have statistically significant and consistent im pacts. Mother ’s use of prenatal care inc reased treatment probabilityby13%.Bothassetowner
-neousone standarddeviation change accounting for an increase of 8% in treatment probability. None of the othervariablescouldaccountforade
-viation of more than 1% from mean treatmentprobability.
Thelarger and more consistentim
mentthanonfever/cough treatmentis puzzling,sincediarrhoea treatmentis, atleastintheory,somewhatcheaperand easier to obtain. Possibly, parentstake
fever/cough more seriouslythandiar
-rhoea (so thatcosts play a lessimpor
-tantroleinassessingtreatmentchoices). Ifso,onemightexpectfever/cough to TABLE3 Coefficients ofModelsofTreatmentforChildMorbidity,Indonesia,1991
Heckman ProbitPartial Heckman ProbitPartial Coefficient Derivative Coefficient Derivative Variablea (p
-value) (p-value) (p-value) (p-value)
Wantedbirth 0.127 0.137 0.218 –1.49
(0.05) (0.04) (0.60) (0.01)
Siblingsalive –0.002 –0.005 0.018 –0.063
(0.83) (0.66) (0.37) (0.01)
Male 0.001 0.014 0.011 0.008
(0.97) (0.65) (0.31) (0.53)
Child’sage 0.108 0.135 0.089 0.091
(0.03) (0.01) (0.00) (0.00)
Child’sagesquared –0.016 –0.026 –0.010 –0.014
(0.16) (0.01) (0.01) (0.00)
Mother ’sage 0.001 0.001 –0.003 –0.002
(0.68) (0.68) (0.07) (0.19)
Mother ’seducation 0.003 –0.001 0.002 0.004
(0.48) (0.78) (0.12) (0.01)
Husband’seducation 0.004 0.005 0.002 0.003
(0.20) (0.16) (0.03) (0.05)
Assets1 0.030 0.046 0.037 0.060
(0.15) (0.06) (0.00) (0.00)
Assets2 0.047 0.055 0.029 0.292
(0.01) (0.00) (0.00) (0.00)
Prenatalcare 0.054 0.046 0.053 0.079
(0.10) (0.18) (0.00) (0.00)
Traveltime –0.005 0.009 –0.000 –0.001
(0.01) (0.01) (0.93) (0.192)
Urban –0.011 0.009 0.053 0.025
(0.80) (0.85) (0.00) (0.208)
Outerislands –0.057 –0.052 0.013 0.003
(0.13) (0.19) (0.27) (0.83)
Java/Bali 0.031 0.066 0.046 –0.085
(0.45) (0.14) (0.18) (0.07)
Constant 0.840 0.682
Selectioncoefficient –0.137 –0.279
Samplesize 989 4,665
be morelikelytobetreated inany cir
-elscleardifferentials bydiseasearenot evidentinIndonesia.
-source pres sures on allocations to children. We use onemeasure of such pressures,numberofsiblings,whichis potentially endogenous to the overall decision makingprocess ofthefamily. Oursecondmeasure,unwantednessat conception, ismoreareflectionofexog
-ingcalculusoftheparents.Wefocuson the impacts upon measures of child health,becausehumancapitalimprove
-tantshareoftheeconomicgrowththat has occurred in many societies. Such human capital increases come from a willingness to commit resources to children.
Incomesarelow in Indonesia,and low incomes can imply harsh trade
-offs betweennumbersand qualityof
formofreductionsincalories,protein orothermeasuresofnutritionthatcan generate observable implications for child morbidity. Indeed we find that unwantedness leads to increases in morbidityanddecreasesinhealthcare treatment.Themorbidityimplications arequitelargeinapolicycontext.We do not find a consistent impact on treatmentprobabilitiesfornumberof siblings.Itappearsthat,inIndonesia, large families who face pressing re
-source constraints make other sacri
-fices to protect the health of their children. However, childrenwho are unwanted,a quite rare phenomenon inIndonesia,aredisadvantaged,and aremorelikelythanotherchildrento become ill, and less likely to receive treatmentwhen ill.Tothe extentthat continuingeconomicandpoliticalin
-stability in Indonesia leads to an in
-crease in unwanted births, a larger proportionofchildrenmaysufferthe adverse treatment identified in this paper.
* Theauthorsthank RonLee,AndyMa
-legeof Williamand Mary and World Bank for helpful comm ents, and Jeff Brown,Shi-JenHeandLixiaXuforca
1 Oneattempttoaddressthisisastudyfor FinlandbyMyhrmanetal.(1995),which usesdatafromabaselinesurveyandtwo revisits,thelatterofwhichcame24years aftertheinitialsurvey.
-erature on the relationship between childhoodnutritionandadultphysical stature.
3 Giventheextremelysmallnumberof multiplebirthsinthesurveytheseau
-tho rs e m ploy, the f in d ing of n on
4 Trusselland Kost (1987)provide esti
-mates ofannual contraceptivefailure rates,largelyfortheUS,thataretypically anorderofmagnitudegreaterthantheir theoretical minima.
5 Themodelisoneofresourceallocation tolivingchildren.Clearly,priorsibling mortalityisrelevantinselectingthesam
-dompriormortalityhasthepotentialto bias empirical results based on this model.However,inourinitialempirical work,wefoundnoevidenceofmortal
-fore,wetreatsurvivaltoselectioninour sampleasexogenously determined. 6 Onereasonthatthismightbedesirable
-rentnumberofsiblings,andthepastand currentdeterminantsof fertility,espe
7 Itwouldbedesirabletoincorporatesome sortoffamily-leveleffectinthismodel.
-style datasets, as thereare very few multiple-birthhouseholdsreportingthe
8 Areviewerofferedanalternative inter
-waysseek out modern care as a ‘last resort’.Ifthisistrue,useof traditional caredoesnotnecessarilyindicatelessde
-termination toseekouteffectivecare;it ratherreflectsmoretraditional waysof viewingtheworld.
9 Pitt(1997)reportssimilardifficultiesina modeloffertilityandmortality. 10 Thelinearprobabilitymodelyieldscon
-sistentestimators, evenwiththe Heck
-man l as a covariate. However, itis
inefficient,heteroscedastic (inknown fashion),andcanyieldpredictions out
-sidetheunitinterval(see,forexample, VandeVenandVanPraag1981). 11 For each illness, we firstestimatethe
structuralequation for morbidity,and thenusetheestimatedparametersincon
12 Ifmorbidityisareflectionofchoice,then mortality might be a reflectionof the same phenomenon. Therefore, in an analysisnotreportedhere,weexamined thepossibilityofselectivitybiasinduced
by excluding dead children. Using a two-stageHeckmanapproachinmod
-ject the null hypothesis of random mortality.Inotherwords,hadthechil
-dren who died in fact survived, we wouldnotpredicttheincidenceofdis
-ease to be any greater among them thanamongtheactualsurvivors. 13 Reducedformsforthesevariablesare
-mentsforsubsequentHausmantests. Allpredeterminedvariablesfromthe structural equations for illness and treatment, aswellas yearssincefirst marriage,whetherparentsexpectedto receive financial suppor t from their childrenortolivewiththeminretire
-ment, birth w eight categories , and whetherthereferencebirthwasoneof a multiplebirth,are used inestimat
14 Note that child healthand theprovi
-sionof care are indicatorsof quality, w hic h in the B e ck e r–L e w is ( 19 7 4)
framework determine the price per child.It is thereforepossiblefor cur
-renthealthtoplayacausalroleinthe determination of numberof siblings, althoughwefindnoempiricalsupport forthisnotion.
15 This value was chosen because it is slightly larger than the current total fertility rate.The findings are robust to a variable definedon family sizes oftwo and seven children,which we chose to represent low and high ex
16 Thenegativeimpactsofunwantedness onchildhealtharealsofoundwhenin
Ahlburg,DennisA.,andDarlaJ.Flint(2001), ‘PublicHealthConditionsandPoliciesin the Asia–PacificRegion’, Asian–Pacific EconomicLiterature15(2):1–17.
Bauer,John, DanteCanlas, MariaTheresa Fernandez and Andrew Mason (1992), ‘Family Size andFamilyWelfare inthe
Human Capital, Universityof Chicago Press,ChicagoIL.
Behrman, Jere R., and Barbara L. Wolfe (1987),‘InvestmentsinSchoolinginTwo Generations inPrerevolutionary Nicara
-gua:TheRolesofFamilyBackgroundand School Supply’,Journal of Development Economics27(1–2):395–419.
Blake,Judith (1981), ‘FamilySizeandthe QualityofChildren’,Demography18(4): 421–42.
Bongaarts, John(1987),‘Does familyplan
-ningreduceinfantmortalityrates?’,Popu -lation and Development Review 13 (2): 323–334.
Booth,Anne(1999),‘TheSocialImpactofthe Asian Crisis:What Do We Know Two YearsOn?’,Asian–PacificEconomicLitera -ture13(2):16–29.
Cassen, Robert(ed.) (1994),Populationand Development:OldDebates,NewConclusions, Transaction Publishers, NewBrunswick andOxford.
Chen,LincolnC.,E.HuqandStanD’Souza (1981),‘SexBiasintheFamilyAllocation ofFoodandHealthCareinRuralBangla
Costello, MichaelA., and Lauro C.Lleno (1995),SocialandEconomicDifferentials in Treatment Patterns for Infant and Childhood Diseases:Philippines, 1993, ResearchInstituteforMindanaoCulture, CagayandeOroCity(mimeo).
Dasgupta, Monica (1987), ‘Selective Dis
-crimination against FemaleChildren in RuralPunjab,India’, Population andDe -velopmentReview13(1):77–100.
Fogel,Robert (1994), ‘EconomicGrowth, Population Theory and Physiology’,
Frenzen,PaulP.,andDennisP.Hogan(1982), ‘The Impact of Class,Education and HealthCareonInfantMortalityinaDe
IndonesiaCentralBureauofStatistics, State MinistryofPopulation andMinistryof Health andMacro International (1992),
IndonesiaDemographic and HealthSurvey 1991, Central Bureauof Statistics and MacroInternational, CalvertonMD.
-graphic Impact ofthe SoutheastAsian Crisisof1997–99’, JournalofPopulation Research17(1):39–62.
Kelley,Alan(1996),‘TheConsequencesof Rapid Population Growth on Human Resource Development: The Case of Education’,inDennisA.Ahlburg,Allen C. Kelley and KarenOppenheim Ma
-so n ( e ds ) , T he Im p a ct o f P op u la tio n Gro wth o n W ell Be ing in D ev elopin g Countries,Springer-Verlag,Heidelberg:
King,Elizabeth(1987),‘TheEffectofFamily Size on Family Welfare’, in D. Gale JohnsonandRonaldD.Lee(eds),Popula -tionGrowthandEconomicDevelopment: Is -suesandEvidence,UniversityofWisconsin Press,MadisonWI:373–411.
Knodel,John,andV.Prachuabmoh (1973), ‘DesiredFamilySizeinThailand:Arethe ResponsesMeaningful?’,Demography10: 495–506.
Knodel,John,andMalineeWongsith(1990), ‘FamilySizeandChildren’sEducationin Thailand:EvidencefromaNationalSam
Knodel, John, Napaporn Havanon and WerasitSittitrai(1990),‘FamilySizeand theEducationofChildrenintheContext ofRapidFertilityDecline’,Populationand Development Review16(1):31–62.
Montgomery,MarkR.,andCynthiaB.Lloyd (1996a),‘FertilityandMaternalandChild Health‘,inDennisA.Ahlburg,AllenC. Kelley and Karen Oppenheim Mason (eds),TheImpactofPopulationGrowthon W ell B ei ng in D e ve lop in g C ou n trie s, Springer-Verlag,Heidelberg:37–66. ______ (1996b),HighFertility,UnwantedFer
-pared for the N ational Academy of Sciences workshop on ‘Education and Fertility in the Developing World’, 29 February– 1 March, Washington DC
My hrman , Antero, Paiv i Olsen, Paula Rantakallio andEsaLaara(1995),‘Does theWantednessofaPregnancyPredicta Child’sEducationalAttainment?’,Family PlanningPerspectives 23:116–19.
-minants ofChild HealthWhen Fertility and MortalityAre Selective’, Journalof HumanResources32(1):129–58.
Rosenzweig, MarkR., andT. PaulSchultz (1982),‘MarketOpportunities,GeneticEn
-ral Experiment’, Econometrica 48 (1): 227–40.
______ (1993),‘MaternalExpectations andEx
Post Rationalisation:The Usefulnessof SurveyInformationontheWantednessof Children’,JournalofHumanResources28 (2):205–29.
-neonatalMortalityinRuralNorthIndia: Implications ofanEconomicModel’,De -mography19(3):371–90.
Steckel, Richard (1995), ‘Stature and the Standard ofLiving’, JournalofEconomic Literature33(4)(December): 1,903–40.
Strauss, John,and DuncanThomas(1998), ‘Health,Nutrition,andEconomicDevel
Trussell, James,andKathryn Kost(1987), ‘Contraceptive Failure in the United States:ACritical ReviewoftheLitera
-ture’,Studies in Family Planning18 (5): 237–83.
VandeVen,WynandP.M.M.,andBernard M.S.vanPraag(1981),‘TheDemandfor Deductibles in Private Health Insur
-lection’,Journalof Econometrics 17 (2): 229–52.