do cash transfers to the poor affect birth...

Veronica AmaranteUniversidad de la República, Uruguay

Marco ManacordaQueen Mary University of London,

CEP (LSE), CEPR and IZA

Edward MiguelUniversity of California, Berkeley and NBER

Andrea VigoritoUniversidad de la República, Uruguay

Do Cash Transfers to the Poor Affect Birth Outcomes?

Evidence from Matched Vital Statistics, Social Security and Program Administrative Data

Motivation

Can (temporary) cash transfers to the poor break the cycle of inter-generational poverty?

Little evidence on cash in-hand, unrestricted cashsocial assistance during pregnancy on birth outcomes

What is the right timing (targeting)?

2

Marco Manacorda - QMUL and CEP (LSE) Cash Transfers and Birth Outcomes

INTRODUCTION DETERMINANTS OF LBW PROGRAM DATA MODEL RESULTS CONCLUSIONS

Data and Findings Plan de Atención Nacional a la Emergencia Social (PANES) De facto unconditional cash program

Matched Administrative program micro data Vital statistics Social security data

Channels

Considerable decline in incidence of LBW We can rule out most “behavioral” channels

3



Structure1. Effects and determinants of LBW (Social Assistance )2. Program description3. Data and summary statistics4. Empirical model5. Estimates 6. Conclusions

4



Effects of LBW Significant negative effect of LBW on health and economic

and non-economic outcomes (Behrman and Rosenzweig 2004, Almond et al., 2005, Almond, 2006, Black et al., 2007, Currie and Moretti, 2007, Royer, 2010)

5



Determinants of LBWIUGR/Pre-term delivery - Almond and Currie (2010)

Mother’s health, nutrition (Kramer, 1987) Smoking, risky behavior, pollution (Currie and

Schmieder, 2009, Currie et al., 2009, Currie, 2010) Stress, conflict and violence (Camacho, 2008, Aizer,

2010) Mother’s work involvement (Del Bono et al., 2008) Ante-natal care utilization, quality of care (Kramer, 1987,

Alexander and Korenbrot, 1995)

6



Socio economic determinants of LBWChallenges• Exogenous variation in income• Data limitations(survey or aggregate)• Behavioral effects • Substitution/complementarities with other social programs• Conditionalities

Income during pregnancy (Conley and Bennett, 2000) Maternal education (Currie and Moretti, 2003, McCrary

and Royer, 2010) Unemployment and economic crises (Dehejia and Lleras-

Muney, 2003, Bozzoli and Quintana, 2010)

7



Social assistance and LBW

US evidence on social assistance (Bitler and Currie, 2004,Currie and Cole, 1993, Currie and Moretti, 2008, Almond et al., 2009)

In-kind/restricted Passport role of SA

Large effects from Oportunidades (Barber and Gertler, 2008)

8



Effects of LBW Significant negative effect of LBW on health and economic

and non-economic outcomes (Behrman and Rosenzweig 2004, Almond et al., 2005, Almond, 2006, Black et al., 2007, Currie and Moretti, 2007, Royer, 2010)

9



Do cash transfers (to poor mothers) matter?• Nutrition• Ante-natal care• Credit constrains (investment)• Labor supply• Psychological effects/empowerment

10



Do cash transfers (to poor mothers) matter?• Selective fertility, abortion and foetus survival• Consumption of “bads”• Work disincentives and health insurance• IG commitment /altruism (paternalism and CCTs)• Substitution between ante-natal and post-natal care• Reversion to the mean• Migration/household structure• (Domestic violence)

11



Background: Uruguay

12



Background: Uruguay

13

Human development

index

GDP per capita (PPP)

Uruguay 0.852 9,962 USA 0.951 41,890 Argentina 0.869 14,280 Brazil 0.800 8,402 Chile 0.867 12,027 Colombia 0.791 7,304 Mexico 0.829 10,751 Venezuela 0.792 6,632



Background: Uruguayan PANES2001/02 economic crisis

Plan de Atención Nacional a la Emergencia Social

Temporary antipoverty program, April 2005 -December 2007

Target population: bottom quintile below poverty line

14



Table 1: Birth outcomes and poverty rates in selected LAC countries

15



Country

Infant mortality rate (per

1,000 births)

% Low weight at

birth

% Births assisted by

health personnel

% with at least one prenatal visit

Poverty rate

Poverty rate

Children 0-14

Uruguay 14 8 99 97 17.7 33.6

Argentina 17 7 99 99 21.0 34.5Brazil 28 10 97 97 33.3 51.6Chile 9 5 100 - 13.7 21.1Cuba 6 6 100 100 - -Mexico 22 9 94 - 31.7 43.2Peru 36 11 73 91 44.5 48.49

USA 7 8 99 - - -

PANES :enrollment, eligibility and components

190k applicant - 100k beneficiary HH (14% population)

Monthly cash transfer US$56 (=PPP US$102) – (IC)

Food Card -US$13 -US$30 (delayed until mid 2006)

+other smaller ingredients (TxU, RdS..)

Assignment based on poverty score: RDD Does not depend on child bearing status No manipulation Means-tested

Conditionalities (school attendance and health checks) not enforced

16



Data1. Baseline socio-demographics at time of enrollment – (700k

individuals) (05→)

2. Vital statistics: registered births 2003-2007

3. Social security data 2004-2007

4. Administrative program data (2005→)

All linked by cedula and across individuals in same HH

Restrict to applicants: 68,174 births 2003-2007

17



Figure A1: Timing of PANES, program, vital statistics and social security data

18



Application

Apr. 2005 →

Assessment visit

Apr 2005 →

Program ends

Dec 2007

Administrative decision: eligibility

Payment of IC to successful applicants (+ arrears to application time)

May 2005 →

Vital statistics

Jan 2003 - Dec 2007

Baseline survey

Apr 2005 →

Social security data Mar 2004 -Dec 2007

Administrative program data

May 2005 -Dec 2007

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20

Panel A: Time of application Panel B: Time of baseline survey Panel C: Time of first payment of income transfer

0.1

.2.3

.4F

rac

tio

n

01 jan2 005 01jan2006 01jan2007 01 jan2008

0.0

5.1

.15

.2F

rac

tio

n01 jan2 005 01jan2006 01jan2007 01 jan2008

date_visi ta

0.0

5.1

.15

.2.2

5F

rac

tio

n

01 jan2 005 01jan2006 01jan2007 01 jan2008

Panel D: Time of first payment of food card Panel E: Time of baseline survey – timeapplication

Panel F: Time of first payment of incometransfer – baseline survey

0.2

.4.6

Fra

cti

on

01 jan2 005 01jan2006 01jan2007 01 jan2008

0.0

5.1

.15

.2F

rac

tio

n

0 .5 1 1.5 2

0.1

.2.3

.4.5

Fra

cti

on

0 .5 1 1.5 2

Figure A2: Distribution of PANES program dates



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PANES Applicants Non-PANES Applicants

All

Vital statistics

Eligible Non-Eligible

Weight <2,500g. 0.10 0.09 0.08 0.09 Weight 3,144 3,165 3,220 3,199 APGAR 1 8.48 8.49 8.51 8.50 APGAR 5 9.60 9.60 9.62 9.62 Weeks gestation 38.49 38.52 38.55 38.53 Prenatal visits 6.56 7.60 8.38 7.90 Week of first visit 16.39 15.67 13.64 14.44 Birth assisted by doctor 0.49 0.56 0.73 0.66 Multiple birth 0.00 0.00 0.02 0.01 Cesarean 0.19 0.25 0.34 0.30 Not covered by private insurance 0.72 0.50 0.28 0.40 Public hospital 0.77 0.52 0.32 0.44 Average weight health centre 3,170 3,185 3,208 3,198 Average weight area of residence 3,193 3,196 3,201 3,199 Montevideo 0.41 0.43 0.54 0.50 Out of wedlock 0.80 0.73 0.52 0.60 Observations 2003-2007 47,554 20,877 160,175 228,606

Table 2: Descriptive statistics - All births: Uruguay 2003-05 – by PANESstatus

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PANES Applicants Non-PANES Applicants

All

Eligible Non-Eligible

Vital statistics Mother characteristics

Age 25.39 24.74 27.54 26.81 Incomplete primary 0.12 0.05 0.03 0.05 Not employed 0.88 0.82 0.56 0.65 Single mother 0.31 0.32 0.20 0.24 # previous births 2.37 1.43 1.23 1.50 # alive children 2.14 1.24 1.03 1.30

Father characteristics Missing 0.62 0.52 0.31 0.40 Incomplete primary 0.12 0.06 0.03 0.05 Not employed 0.11 0.09 0.05 0.06

Program data

Ever treated (05-07) 0.97 0.14 Social Security data Mother positive earnings 0.08 0.15

Mother earnings 43 133 Maternity leave 0.03 0.05 Household total income 1,359 2,700 Observations 2003-2007 47,554 20,877 160,175 228,606

Table 2: Descriptive statistics - All births: Uruguay 2003-05 – by PANES status (cont.d)

23

Table 3: Correlation between LBW and observable characteristics., 2003-04Marco Manacorda - QMUL and CEP (LSE) Cash Transfers and Birth Outcomes


Mother’s education – completed primary -0.019***(0.003)

- completed secondary -0.024***(0.004)

- completed college -0.034***(0.004)

Out of wedlock 0.009***(0.002)

Visits first week -0.006***(0.001)

Visits second week 0.002***(0.001)

Visits third week -0.007***(0.001)

Week first visit -0.0002(0.0001)

Number of previous births -0.002***(0.001)

Weeks gestation -0.068***(0.001)

Birth attended by medical personnel 0.012***(0.002)

Public health center 0.007**(0.003)

Not covered by private insurance -0.005*(0.003)

Mean weight center (in kg) -0.140***(0.011)

Cesarean 0.041***(0.001)

Multiple birth 0.026***(0.007)

Model specification and identificationTwo identification strategies

•Birth after entry into program (eligible) – Diff-in-diff

•Discontinuity in income (poverty) score - RD

24



Model specification and identification D-D

tim date of birth (quarters)t0m date first IC payment (quarters)

Timt=I(tim>t0m): treatment=payment in 1st semester of pregnancy

Yimt= β0 + β1 Timt + dt + d0m+ uimt

d0m time of entry dummiesdt birth dummies

+ Mother fixed effectsUse both eligible and ineligible

25



Model specification and identification D-D

Imperfect enforcement: IV

Sm income scoreS* eligibility threshold

Em=I(Sm<S*) PANES eligibility dummy

Eimt=Pimt Em treatment =0 for ineligible

First stage:

Timt= γ0 + γ1 Eimt + dt + d0m+ eimt

26



Model specification and identification - RD Yimt= β0 + β1 Timt + f(Sm) + dt + d0m + vimt

Timt= δ0 + δ1Em + g(Sm) + ft+ f0m + ωimt

Estimated on post-program data

Use pre-program data to enhance precision

Yimt= β0 + β1 Timt + ft(Sm) + dt + d0m + vimt

Timt= δ0 + δ1t Em + gt(Sm) + ft + f0m + ωimt

+ Mother fixed effects27



Potential endogeneity concerns

Endogenous fertility (selective survival rates, abortion) (Endogenous time of entry)

28



Figure 1: Low Birth weight as a function of time to/from first payment

-.04

-.02

0.0

2.0

4

-3 -2 -1 0 1 2date birth - date first payment

29



Channels Length of gestation Ante-natal care Household resources - Cash/in-kind Mother’s / household LS Residential mobility/household structure Fertility

30



Table 4: Program effects on birth outcomes 2003-2007 - D-D IV estimates1. Low birthweight (<2,500 g.) -0.017*** -0.017*** -0.021**

(0.005) (0.005) (0.009)

2. Birthweight 29.510*** 27.238*** 25.992*(10.236) (9.725) (15.162)

3. Weeks gestation 0.048 0.036 0.035(0.036) (0.035) (0.064)

4. Visits first week -0.027** -0.029** 0.011(0.013) (0.013) (0.023)

5. Visits second week 0.055** 0.052** 0.008(0.024) (0.023) (0.042)

6. Visits third week 0.148*** 0.151*** 0.096(0.045) (0.044) (0.078)

7. Total visits 0.179*** 0.178*** 0.122(0.060) (0.058) (0.099)

8. Week first visit 0.118 0.142 -0.365(0.143) (0.142) (0.296)

9. Birth assisted by doctor 0.017** 0.014 0.014(0.009) (0.009) (0.015)

10. Not privately insured -0.022*** -0.019** 0.030**(0.008) (0.008) (0.013)

11. Public health center -0.006 -0.003 0.036***(0.008) (0.008) (0.012)

12. Average weight health center -4.872*** -3.954*** -3.557**(1.308) (1.261) (1.564)

13. Average weight area of residence -1.579** -1.342* -0.361(0.735) (0.720) (0.814)

14. Out of wedlock -0.019*** -0.016** -0.001(0.007) (0.007) (0.008)

15. Mother in work -0.010* -0.012** -0.025**(0.006) (0.006) (0.010)

16. Treated (First stage) 0.833*** 0.834*** 0.848***(0.004) (0.004) (0.006)

Additional controls No Yes Yes

Mother fixed effects No No Yes

32

Table 4A: Program effects on the incidence of low birthweight: by length of exposure – reduced form estimates

(1) (2)

1. By quarter3rd trimester of pregnancy -0.011 0.002

(0.007) (0.015)2nd trimester of pregnancy -0.018** -0.019

(0.007) (0.014)1st trimester of pregnancy -0.022*** -0.009

(0.007) (0.014)1 trimester before conception -0.014* -0.013

(0.008) (0.015)2 trimesters before conception -0.008 -0.022

(0.008) (0.014)3 trimesters before conception -0.018** -0.038**

(0.008) (0.015)4 trimesters before conception -0.016* -0.009

(0.009) (0.016)5 or more trimesters before conception -0.013 -0.014

(0.008) (0.015)2. Before/after conception

During pregnancy -0.018*** -0.015(0.006) (0.010)

Before pregnancy -0.012** -0.019**(0.005) (0.009)

Additional controls Yes YesMother fixed effects No Yes


Figure 2: Estimated proportional program effects by birth weight

33INTRODUCTION DETERMINANTS OF LBW PROGRAM DATA MODEL RESULTS CONCLUSIONS


-.4

-.3

-.2

-.1

0.1

1500 20 00 2500 3000 3500 4000 4500 5000we ight

Figure 3: RD estimates: March 2006-December 2007Treatment (ever treated) Low Birthweight

0.2

.4.6

.81

-.1 -.05 0 .05 .1poverty score

0.1

.2.3

-.1 -.05 0 .05 .1poverty score

34INTRODUCTION DETERMINANTS OF LBW PROGRAM DATA MODEL RESULTS CONCLUSIONS


Figure A4: Distribution of the standardized PANES income score

35

McCrary test: -0.1/+0.1

05

1015

-.1 -.05 0 .05 .1



Table 5: Program effects on low birthweight – RD estimates

36



IV estimates First stage Post program:3 mos after baseline (1) (2) (3) (4) (5) (6) 1. Post program - linear -0.005 -0.014 -0.030 0.582*** 0.578*** 0.564*** (0.013) (0.016) (0.023) (0.009) (0.013) (0.018) 2. Post program – quadratic -0.010 -0.026 -0.039 0.567*** 0.551*** 0.552*** (0.019) (0.026) (0.037) (0.014) (0.019) (0.027) 3. Pre and post program – -0.013 -0.020 -0.024 0.604*** 0.606*** 0.612*** Quadratic (0.016) (0.022) (0.031) (0.012) (0.017) (0.023) 4. Pre and post program - fixed -0.011 -0.011 -0.012 0.636*** 0.612*** 0.612*** Effects (0.014) (0.017) (0.024) (0.010) (0.013) (0.019) Post program: March 06 - Dece. 07 5. Post program - linear -0.004 -0.018 -0.032 0.632*** 0.626*** 0.604*** (0.013) (0.017) (0.025) (0.010) (0.013) (0.019) 6. Post program – quadratic -0.017 -0.035 -0.053 0.617*** 0.591*** 0.605*** (0.020) (0.028) (0.038) (0.015) (0.020) (0.029) 7. Pre and post program – -0.006 -0.003 -0.021 0.629*** 0.618*** 0.624*** Quadratic (0.017) (0.024) (0.033) (0.013) (0.018) (0.025) 8. Pre and post program - fixed -0.016 -0.006 -0.007 0.664*** 0.643*** 0.641*** Effects (0.016) (0.019) (0.026) (0.011) (0.013) (0.019) Interval -.2/.2 -.1/.1 -.05/.05 -.2/.2 -.1/.1 -.05/.05

37


Table 6: Program effects on income and labor supply - IV estimates


(1) (2 )

1. Income transfer 873.510*** 902.688***

(5.534) (9.549)

2. Food card 161.510*** 161.231***

(2.165) (3.954)

3. Mother’s earnings -55.007*** -77.619***

(12.075) (22.786)

4. Mother positive earnings -0.003 -0.003

(0.004) (0.009)

5. Household total income (inc. transfers) 753.206*** 837.297***

(44.845) (71.034)

6. Maternity leave – last trimester -9.504*** -3.635

(3.320) (6.014)

Additional controls Yes Yes

Mother fixed effects No No

Figure A5: RD estimates of program eligibility on formal earnings, by gender and month: March 2004–December 2009

38



Males Females

-50

0-3

00

-10

01

00

2004m 1 2005m 1 2006m 1 2007m 1 2008m1 2009m1 2010m1tim e

-50

0-3

00

-10

01

00

2004m 1 2005m 1 2006m 1 2007m 1 2008m1 2009m1 2010m1tim e

39


Table 7: Additional specifications – IV estimates


(1) (2)1. Controls for week of gestation, week of first visit and -0.013*** -0.023***total visits (0.004) (0.008)

2. Up to May 2006 (no food card) -0.009 -0.019(0.011) (0.022)

3. Controls for food card

Income transfer >0 -0.021*** -0.009(0.006) (0.011)

Food card >0 0.007 -0.025**(0.007) (0.012)

4. Saturated specification -0.017*** -0.020**(0.005) (0.009)

Additional controls Yes Yes

Mother fixed effects No Yes

Selective fertility

• Direct income effect (temporary vs. permanent transfer)• Selective survival• Informal/uninsured• (Built-in incentives)

• Effects unlikely to manifest immediately and probably not for women who have already conceived

40



41


.006

.007

.008

.009

ferti

lity

rate

-3 -2 -1 0 1 2time - time first payment

Figure 4: Fertility rates by as a function of time to/since first payment -PANES eligible women only


Figure 5: Fertility rates by PANES eligibility status as a function of time to/since baseline survey

42


Eligible women Ineligible women Eligible/ineligible women

.004

.006

.008

.01

ferti

lity

rate

-3 -2 -1 0 1 2time - time baseline survey

11.

21.

41.

61.

8fe

rtilit

y ra

te


.004

.006

.008

.01

ferti

lity

rate



Figure 6: Fertility rates by number of children born by baseline survey date and PANES eligibility status as a function of time to/since baseline survey

0 children 1 child 2 or more children

0.0

02.0

04.0

06


ineligible eligible

0.0

1.0

2.0

3.0

4


ineligible eligible

0.0

2.0

4.0

6.0

8


ineligible eligible

43



Table 8: Program effect on fertility

44



(1) (2) (3) -.0013*** -.0016*** -0.0002 (0.0001) (0.0002) (0.0001)

Additional controls No Yes Yes Number of previous pregnancies x controls

No Yes Yes

Summary of main findings• Reduction in incidence of LBW (-10% to -20%)

• No evidence that effects driven by:• - increased ante-natal care utilization• - increased gestational length• - selective fertility• - improvements in quality of ante-natal care• - reduced mother labor supply• - in-kind transfers

• Cash transfers in last trimester matter • Little evidence of accumulated effects• Rules out selective fertility

45



46

1. Income transfer 96.7 2. Food card 70.9 3. Public works employment 17.6 4. Education and training 16.0 5. Other components 12.7


Program components take up rates

47

02

46

8P

erce

nt

0 1000 2000 3000 4000 5000Birth weight

Figure A3: Distribution of birthweight


Figure B1: PANES eligibility and government political support

48

do cash transfers to the poor affect birth...

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