Are tuition-free primary education policies associated with lower infant and neonatal mortality in low- and middle-income countries?

Robust evidence from low- and middle-income countries (LMICs) suggests that maternal education is associated with better child health outcomes. However, whether or not policies aimed at increasing access to education, including tuition-free education policies, contribute to lower infant and neonatal mortality has not been empirically tested. We joined country-level data on national education policies for 37 LMICs to information on live births to young mothers aged 15-21 years, who were surveyed as part of the population-based Demographic and Health Surveys. We used propensity scores to match births to mothers who were exposed to a tuition-free primary education policy with births to mothers who were not, based on individual-level, household, and country-level characteristics, including GDP per capita, urbanization, and health expenditures per capita. Multilevel logistic regression models, fitted using generalized estimating equations, were used to estimate the effect of exposure to tuition-free primary education policies on the risk of infant and neonatal mortality. We also tested whether this effect was modified by household socioeconomic status. The propensity score matched samples for analyses of infant and neonatal mortality comprised 24,396 and 36,030 births, respectively, from 23 countries. Multilevel regression analyses showed that, on average, exposure to a tuition-free education policy was associated with 15 (95% CI=-32, 1) fewer infant and 5 (95% CI=-13, 4) fewer neonatal deaths per 1000 live births. We found no strong evidence of heterogeneity of this effect by socioeconomic level.