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BACKGROUND: Antenatal care (ANC) is critical to reducing maternal and infant mortality. However, sub-Saharan Africa (SSA) continues to have among the lowest levels of ANC receipt globally, with half of mothers not meeting the WHO minimum recommendation of at least four visits. Increasing ANC coverage will require not only directly reducing geographic and financial barriers to care but also addressing the social determinants of health that shape access. Among those with the greatest potential for impact is maternal education: past research has documented a relationship between higher educational attainment and antenatal healthcare access, as well as related outcomes like health literacy and autonomy in health decision-making. Yet little causal evidence exists about whether changing educational policies can improve ANC coverage. This study fills this research gap by investigating the impact of national-level policies that eliminate tuition fees for lower secondary education in SSA on the number of ANC visits. METHODS: To estimate the effect of women's exposure to tuition-free education policies at the primary and lower secondary levels on their ANC visits, a difference-in-difference methodology was employed. This analysis leverages the variation in the timing of education policies across nine SSA countries. RESULTS: Exposure to tuition-free primary and lower secondary education is associated with improvements in the number of ANC visits, increasing the share of women meeting the WHO recommendation of at least four ANC visits by 6-14%. Moreover, the impact of both education policies combined is greater than that of tuition-free primary education alone. However, the effects vary across individual treatment countries, suggesting the need for further investigation into country-specific dynamics. CONCLUSIONS: The findings of this study have significant implications for policymakers and stakeholders seeking to improve ANC coverage. Removing the tuition barrier at the secondary level has shown to be a powerful strategy for advancing health outcomes and educational attainment. As governments across Africa consider eliminating tuition fees at the secondary level, this study provides valuable evidence about the impacts on reproductive health outcomes. While investing in free education requires initial investment, the long-term benefits for both human development and economic growth far outweigh the costs.

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Intimate partner violence (IPV) affects an estimated 641 million women and girls globally with far-reaching consequences for the health of women and children. Yet, laws that prohibit domestic violence (DV) are not universal. Countries actively debate the effectiveness of DV laws in improving conditions given the inconclusive evidence on deterrent effects within households particularly in low- and middle-income countries that have limited infrastructure, and fewer resources to implement and enforce policy changes. This is the first study to rigorously examine the impact of DV laws on women's health decision-making and the intergenerational impact on children's wasting, a key predictor of mortality. We used the Demographic and Health Surveys (DHS) data collected between 2000-2020 across 23 African countries. Exploiting the staggered adoption of laws, we used a difference-in-differences study design to estimate the impact of DV laws in the treated countries compared to countries without such laws. We find that DV laws increased women's decision-making autonomy in healthcare by 16.7% as well as other measures of women's autonomy that matter for health such as financial autonomy by 6.3% and social mobility by 11.0%. The improvements in women's autonomy translated into reductions in the probability of wasting among children aged 0-23 months by 5.4% points, a 30.9% reduction from the mean. DV laws also reduced wasting among older children aged 24-59 months by 3.6% points, a 38.7% reduction from the mean. The laws were effective in all 6 countries analyzed individually that criminalized DV. A civil prohibition in the seventh country was not found to be effective. The effect was positive and significant for all wealth and geographical categories. Our findings demonstrate the value of enacting criminal laws that prohibit domestic violence as one important tool to reducing the profound health impacts of IPV, a critical health and human rights issue.

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OBJECTIVE: Parental leave and breastfeeding breaks influence the ability to initiate and continue breastfeeding. We investigated how eligibility criteria in the Family and Medical Leave Act (FMLA) and Affordable Care Act (ACA) affect access to unpaid parental leave and breastfeeding breaks and assessed affordability and alternative policy models. METHODS: We used family income data to assess the affordability of unpaid leave by race and ethnicity. We used 2017-2018 US Current Population Survey data to determine the percentage of private sector workers aged 18-44 years who met the minimum hour (1250 hours of work during a 12-month period), tenure (12 months), and firm size (≥50 employees) requirements of FMLA and ACA. We analyzed eligibility by gender, race and ethnicity, and age. We also examined parental leave and breastfeeding break policies in 193 countries. RESULTS: Most Latinx (66.9%), Black (60.2%), and White (55.3%) workers were ineligible and/or unlikely to be able to afford to take unpaid FMLA leave. Of 69 534 workers, more women (16.9%) than men (10.3%) did not meet the minimum hour requirement. Minimum tenure excluded 23.7% of all workers and 42.2% of women aged 18-24 years. Minimum firm size excluded 30.3% of all workers and 37.7% of Latinx workers. Of 27 520 women, 28.8% (including 32.9% of Latina women) were excluded from ACA breastfeeding breaks because of firm size. Nearly all other countries guaranteed mothers paid leave regardless of firm size or minimum hours and guaranteed ≥6 months of paid leave or breastfeeding breaks. CONCLUSIONS: Adopting a comprehensive, inclusive paid parental leave policy and closing gaps in breastfeeding break legislation would remove work-related barriers to breastfeeding; reduce racial, ethnic, and gender inequities; and align US national policies with global norms.

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One in five child deaths under age 5 are a result of severe wasting. Malnutrition at early ages is linked to lifelong consequences, such as reduced cognitive skills, reduced earnings in adulthood and chronic health conditions. Countries worldwide have committed to addressing child undernutrition, and ending hunger is foundational to the Millennium Development Goals. In this paper, we study the intergenerational effect of providing free tuition in secondary school on future children's nutrition. We combined a novel longitudinal dataset that captures educational policies for 40 African countries from 1990 to 2019 with the Demographic and Health Survey (DHS). We identified three countries that introduced free secondary education several years after implementing free primary education. Exploiting this variation in timing we estimate the additional impact of providing free secondary education over free primary education. Using a difference-in-difference approach, we find that introducing free secondary education significantly reduced wasting. Cohorts exposed to free secondary had an 18% relative decrease in wasting. The impact on cohorts exposed only to free primary was smaller and not statistically significant. Expanding free secondary education has long-term, intergenerational benefits and is an effective path to reducing malnutrition. Results are robust to different specifications.

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The COVID-19 pandemic has highlighted the extent to which national laws and policies shape public health and economic security. Paid leave policies enable parents to meet children's health needs while maintaining job and income security. These policies matter immensely to children's health every year. Yet, little is known about the extent to which policies exist to support the full range of childhood health needs. Using a novel dataset constructed from legislative text in 193 countries, this study assesses whether laws in place in 2019 are adequate to support meeting children's everyday, serious, and disability-related health needs. Globally, only half of the countries guaranteed working parents access to any paid leave that could be used to meet children's health needs. Only a third addressed everyday health needs, including leave that matters to reducing infectious disease spread. For serious health needs, even when paid leave was available, it was often too short for complex health conditions. Moreover, although all children require parental presence at medical appointments and for serious illness, fewer countries guaranteed paid leave to care for older children than younger. Addressing these gaps is crucial to supporting child health and working families during times of public health crisis and every year.

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In April 2020, nearly 1.6 billion learners were out of school. While a growing body of literature has documented the detrimental impact of these closures on children, less attention has been devoted to the steps countries took to mitigate the impact of these closures on working families. Paid leave is recognized as an important policy tool to enable working parents the time they need to respond to family needs without risking job or income loss. This article uses a novel data set to assess whether countries had policies in place prior to the pandemic to respond to increased care needs and the extent to which policies were introduced or expanded during the pandemic to fill the gap. Only 48 countries had policies in place prior to the pandemic that could be used to respond to the care needs created by school and childcare center closures. In the vast majority of these countries, the duration of leave in these policies was too short to meet the care needs of the pandemic or relied on parents reserving extended parental leave options. Only 36 countries passed new legislation during the pandemic, but the majority of those that did covered the full duration of closures. As countries continue to face COVID-19 and consider how to better prepare for the next pandemic, emergency childcare paid leave policies should be part of pandemic preparedness frameworks to prevent further exacerbating inequalities. The policies introduced during the pandemic offer a wide range of approaches for countries to identify feasible solutions.

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Women and workers over 50 disproportionately provide care for aging family members worldwide, including the 101 million who are care-dependent. Paid leave for adult health needs, which temporarily replaces employment income for workers providing care, can critically support both caregivers' economic outcomes and care recipients' wellbeing. We created quantitatively comparable data on paid leave policies that can be used to meet adult family members' health needs in all United Nations member states. Globally, 112 countries fail to provide any paid leave that can be used to meet the serious health needs of an aging parent, spouse, or adult child. These gaps have profound consequences for older workers providing care as well as care access by aging, ill, and disabled adults.

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Research has demonstrated that paid sick leave reduces the spread of COVID-19 and other infectious diseases and improves preventive care and access to treatment across a wide range of conditions. However, the US has no national paid sick leave policy, and even unpaid leave via the Family and Medical Leave Act (FMLA) of 1993-often viewed as a foundation for new paid leave legislation-is often inaccessible to workers. We analyzed data from a nationally representative survey to determine the extent to which specific FMLA features produce gaps and disparities in leave access. We then used comparative policy data from 193 countries to analyze whether these policy features are necessary or prevalent globally, or whether there are common alternatives. We found that the FMLA's minimum hours requirement disproportionately excludes women, whereas its tenure requirement disproportionately excludes Black, Indigenous, and multiracial workers. Latinx workers also face greater exclusion because of employer size requirements. Of the 94 percent of countries that provide permanent paid sick leave, none broadly restrict leave based on employer size, and 93 percent cover part-time workers without a minimum hours requirement. Enacting permanent paid sick leave that is accessible regardless of employer size, tenure, or hours is critical and feasible.

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From education to working conditions, from income to discrimination, social determinants of health (SDH) shape the majority of health outcomes. Governments are often best positioned to address the major SDH on a population-wide basis. In 2015, governments around the world committed to improving all core SDH when all countries agreed to a set of goals that would improve education, work, income, and equal opportunity, among other areas, in the Sustainable Development Goals (SDGs). Using data from the WORLD Policy Analysis Center, this article highlights how quantitative policy measures can be used to hold governments accountable for their commitments to the SDGs and thus to improve the SDH. Three areas are examined in detail to illustrate this approach to monitoring policy change: ensuring an adequate income, enhancing equal opportunities at work by prohibiting discrimination and sexual harassment, and enabling children and youth to complete their education.

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Well-designed paid sick leave is critical to ensure workers stay home when sick to prevent the spread of SARS-CoV-2 and other infectious pathogens, both when the economy is open and during an economic shutdown. To assess whether paid sick leave is available in countries around the world, we created and analysed a database of legislative guarantees of paid leave for personal illness in 193 UN member states. Original labour and social security legislation and global information on social security systems for each country were obtained and analysed by a multilingual research team using a common coding framework. While strong models exist across low- middle- and high-income countries, critical gaps that jeopardise health and economic security remain. 27% of countries do not guarantee paid sick leave from the first day of illness, essential to encouraging workers to stay home when they are sick and prevent spread. 58% of countries do not have explicit provisions to ensure self-employed and gig economy workers have access to paid sick leave benefits. Comprehensive paid sick leave policies that cover all workers are urgently needed if we are to reduce the spread of COVID-19, and be ready to respond to threats from new pathogens.

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The marriage of children below 18 is widely recognized in international human rights agreements as a discriminatory global practice that hinders the development and well-being of hundreds of millions of girls. Using a new global policy database, we analyze national legislation regarding minimum marriage age, exceptions permitting marriage at earlier ages, and gender disparities in laws. While our longitudinal data indicate improvements in frequencies of countries with legal provisions that prohibit marriage below the age of 18, important gaps remain in eliminating legal exceptions and gender discrimination.

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There is recognition that social protection policies such as raising the minimum wage can favourably impact health, but little evidence links minimum wage increases to child health outcomes. We used multi-year data (2003-2012) on national minimum wages linked to individual-level data from the Demographic and Health Surveys (DHS) from 23 low- and middle-income countries (LMICs) that had least two DHS surveys to establish pre- and post-observation periods. Over a pre- and post-interval ranging from 4 to 8 years, we examined minimum wage growth and four nutritional status outcomes among children under 5 years: stunting, wasting, underweight, and anthropometric failure. Using a differences-in-differences framework with country and time-fixed effects, a 10% increase in minimum wage growth over time was associated with a 0.5 percentage point decline in stunting (-0.054, 95% CI (-0.084,-0.025)), and a 0.3 percentage point decline in failure (-0.031, 95% CI (-0.057,-0.005)). We did not observe statistically significant associations between minimum wage growth and underweight or wasting. We found similar results for the poorest households working in non-agricultural and non-professional jobs, where minimum wage growth may have the most leverage. Modest increases in minimum wage over a 4- to 8-year period might be effective in reducing child undernutrition in LMICs.

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BACKGROUND: The Sustainable development goals (SDGs) have the potential to have a significant impact on maternal and child health through their commitments both to directly addressing health services and to improving factors that form the foundation of social determinants of health. To achieve change at scale, national laws and policies have a critical role to play in implementing the SDGs' commitments. One particular policy that could advance a range of SDGs and importantly improve maternal and infant health is paid parental leave. METHODS: This article analyzes literature on paid leave and related policies relevant to SDG 1 (poverty), SDG 3 (health), SDG 5 (gender equality), SDG 8 (decent work), and SDG 10 (inequality). In addition, this article presents global data on the prevalence of policies in all 193 UN Member States. RESULTS: A review of the literature finds that paid parental leave may support improvements across a range of SDG outcomes relevant to maternal and child health. Across national income levels, paid leave has been associated with lower infant mortality and higher rates of immunizations. In high-income countries, studies have found that paid leave increases exclusive breastfeeding and may improve women's economic outcomes. However, factors including the duration of leave, the wage replacement rate, and whether leave is made available to both parents importantly shape the impacts of paid leave policies. While most countries now offer at least some paid maternal leave, many provide less than the 6 months recommended for exclusive breastfeeding, and only around half as many provide paternal leave. CONCLUSIONS: To accelerate progress on the SDGs' commitments to maternal and child health, we should monitor countries' actions on enacting or strengthening paid leave policies. Further research is needed on the duration, wage replacement rate, and availability of leave before and after birth that would best support both child and parental health outcomes and social determinants of health more broadly. In addition, further work is needed to understand the extent to which paid leave policies extend to the informal economy, where the majority of women and men in low- and middle-income countries work.

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BACKGROUND: Mothers who work away from home tend to stop breastfeeding earlier than their nonworking counterparts due to workplace barriers. Barriers to breastfeeding discriminate against women and may lead to inequities in children's health outcomes. Guaranteeing paid breastfeeding breaks at work is 1 mechanism that can improve mothers' opportunity to breastfeed in the workplace. OBJECTIVE: This study aimed to assess the trends in the share of countries guaranteeing breastfeeding breaks in the workplace and paid maternal leave that lasts until the infant is 6 months old (the World Health Organization recommended duration for exclusive breastfeeding), between 1995 and 2014. METHODS: Legislation and secondary source data were collected and reviewed for 193 United Nations member states. Legislation was analyzed for content on breastfeeding breaks and maternal leave guarantees. RESULTS: Fifty-one countries (26.7%) in 2014 did not guarantee breastfeeding breaks in any form and 4 countries provided only unpaid breaks or breaks that did not cover the first 6 months of life; since 1995, around 15 countries (10.2%) legislated for such a policy. In 2014, out of 55 countries that did not guarantee paid breastfeeding breaks for the first 6 months after birth, 7 countries guaranteed paid maternal leave for the same duration; 48 countries (25.1%) provided neither paid maternal leave nor paid breastfeeding breaks. CONCLUSION: Progress in the number of countries guaranteeing breastfeeding breaks at work is modest. Adopting measures to facilitate breastfeeding at work can be a critical opportunity for countries to increase breastfeeding rates among the growing number of women in the labor force.

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OBJECTIVE: To explore the extent to which national policies guaranteeing breastfeeding breaks to working women may facilitate breastfeeding. METHODS: An analysis was conducted of the number of countries that guarantee breastfeeding breaks, the daily number of hours guaranteed, and the duration of guarantees. To obtain current, detailed information on national policies, original legislation as well as secondary sources on 182 of the 193 Member States of the United Nations were examined. Regression analyses were conducted to test the association between national policy and rates of exclusive breastfeeding while controlling for national income level, level of urbanization, female percentage of the labour force and female literacy rate. FINDINGS: Breastfeeding breaks with pay are guaranteed in 130 countries (71%) and unpaid breaks are guaranteed in seven (4%). No policy on breastfeeding breaks exists in 45 countries (25%). In multivariate models, the guarantee of paid breastfeeding breaks for at least 6 months was associated with an increase of 8.86 percentage points in the rate of exclusive breastfeeding (P < 0.05). CONCLUSION: A greater percentage of women practise exclusive breastfeeding in countries where laws guarantee breastfeeding breaks at work. If these findings are confirmed in longitudinal studies, health outcomes could be improved by passing legislation on breastfeeding breaks in countries that do not yet ensure the right to breastfeed.

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United Nations (UN) member states have universally recognised the right to health in international agreements, but protection of this right at the national level remains incomplete. This article examines the level and scope of constitutional protection of specific rights to public health and medical care, as well as the broad right to health. We analysed health rights in the constitutions of 191 UN countries in 2007 and 2011. We examined how rights protections varied across the year of constitutional adoption; national income group and region; and for vulnerable groups within each country. A minority of the countries guaranteed the rights to public health (14%), medical care (38%) and overall health (36%) in their constitutions in 2011. Free medical care was constitutionally protected in 9% of the countries. Thirteen per cent of the constitutions guaranteed children's right to health or medical care, 6% did so for persons with disabilities and 5% for each of the elderly and the socio-economically disadvantaged. Valuable next steps include regular monitoring of the national protection of health rights recognised in international agreements, analyses of the impact of health rights on health outcomes and longitudinal multi-level studies to assess whether specific formulations of the rights have greater impact.

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Childhood vaccination is a proven and cost-effective way to reduce childhood mortality; however, participation in vaccination programs is not universal even where programs are free or low cost. Studies in diverse countries have reported work conflicts as limiting parents' ability to vaccinate their children. Using policy data for 185 UN member countries, we explore the hypothesis that an increased opportunity for parents to bring children to vaccination sites will translate into higher childhood vaccination rates. To do so, we use OLS regression to examine the relationship between the duration of adequately paid maternal leave and the uptake of vaccines. We find that a higher number of full-time equivalent weeks of paid maternal leave is associated with higher childhood vaccination rates, even after controlling for GDP per capita, health care expenditures, and social factors. Further research is needed to assess whether this association is upheld in longitudinal and intervention studies, as well as whether other forms of leave such as paid leave to care for the health of family members is effective at increasing the ability of parents to bring children for needed preventive care.

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