Postponing Adolescent Parity in Developing Countries through Education: An Extended Cost-Effectiveness Analysis

Despite substantial progress in the achievement of Millennium Development Goal 5 to reduce the maternal mortality ratio—the number of maternal deaths per 100,000 live births—by two-thirds between 2000 and 2015, substantial inequalities remain in maternal mortality across countries worldwide (Kassebaum and others 2014; UN 2013; UN MME 2015; Verguet and others 2014). Maternal mortality ratios remain unacceptably high in South Asia and Sub-Saharan Africa, particularly West Africa (Kassebaum and others 2014; UN MME 2015). Together, South Asia and Sub-Saharan Africa account for 86 percent of the world’s maternal deaths (WHO and others 2014). Building on the momentum gathered by the Millennium Development Goals, the post-2015 agenda and its Sustainable Development Goals set the ambitious target of further reducing the maternal mortality ratio, currently about 200 deaths per 100,000 live births globally (UNICEF 2016), to 70 per 100,000 by 2030 (UNW 2016). Women ages 15–19 years face elevated risks of pregnancy-related mortality and morbidity. In low- and middle-income countries (LMICs), these risks are disproportionately higher (IHME 2013; WHO and others 2014), and the maternal mortality ratios are much larger, on average (Kassebaum and others 2014; UN MME 2015). Furthermore, among girls younger than age 16 years, the relative risk of pregnancy-related mortality is up to five times higher compared with women ages 20–24 years (Huang 2011; Mayor 2004). Although the education of girls has been expanded worldwide (Gakidou and others 2010), early marriages remain common; up to 65 percent and 76 percent of women are married by age 18 years in Bangladesh and Niger, respectively (UNICEF 2016). As a result, the rates of adolescent pregnancies remain very high in many LMICs (Bates, Maselko, and Schuler 2007; Beguy, Ndugwa, and Kabiru 2013; Chloe, Thapa, and Mishra 2004; Dixon-Mueller 2008). Maternal and adolescent health need to be examined through a wider perspective beyond mortality—notably, morbidity outcomes, such as long-term sequelae for both mothers and their children, and the financial vulnerability of women and adolescents (Ashford 2002; Dale, Stoll, and Lucas 2003; Filippi and others 2006; Langer and others 2015). Pregnant young women present higher chances of school dropout (Lloyd and Mensch 2008; Marteleto, Lam, and Ranchhod 2008; Meekers and Ahmed 1999), and they could face high risks of pregnancy-related impoverishment and negative economic consequences (Arsenault and others 2013; Ilboudo, Russell, and D’Exelle 2013; Powell-Jackson and Hoque 2012) if they choose to carry their pregnancy to term. Out-of-pocket (OOP) medical payments in LMICs can lead to impoverishment and related coping strategies, such as borrowing money or selling assets, to pay for health care (Kruk, Goldmann, and Galea 2009; Xu and others 2003). In the absence of other financing mechanisms, such as private health insurance or fee exemptions, household medical expenditures can be catastrophic (Wagstaff 2010), exceeding a specified percentage of total household expenditures. For example, with increased incidence of complicated deliveries owing to pregnancies at young ages, the OOP costs associated with maternal delivery in facilities are likely to be higher and may subsequently put pregnant adolescents at increased risk of medical impoverishment. In particular, this increased likelihood of financial risk would be expected to be greater among poorer socioeconomic groups; these groups have less disposable income and higher rates of adolescent pregnancies (IIPS 2010; INS and ICF International 2013). This hypothesis is one of several that this chapter examines. Protection from health care financial risks has become a critical component of national strategies in many countries (Boerma and others 2014; WHO 2010, 2013). Reduction of these financial risks is one objective of public sector policies. For example, public investment in education to increase girls’ educational levels could reduce adolescent pregnancies and subsequent risks of both mortality and impoverishment, especially among the poorest women. Health economic evaluations (cost-effectiveness analyses) have traditionally focused on estimating an intervention’s cost per health gain (Jamison and others 2006). Extended cost-effectiveness analysis (ECEA) (Verguet, Gauvreau, and others 2015; Verguet, Kim, and Jamison 2016; Verguet, Laxminarayan, and Jamison 2015; Verguet and others 2013; Verguet, Olson, and others 2015) supplements traditional economic evaluation by incorporating evaluation of financial risk protection (FRP)—prevention of medical impoverishment. ECEA quantifies how much FRP, equity, and health can be purchased for a given expenditure. ECEA can provide answers to help policy makers select the optimal policies for increasing FRP and equity and for improving the distribution of health benefits (WHO 2010, 2013). Many determinants of adolescent pregnancy and fertility have long been reported in the scientific literature, notably by John Bongaarts (Bongaarts 1978; Bongaarts and Potter 1983). In this chapter, we restrict our analysis to one specific underlying factor of fertility—female educational attainment—and examine its impact on adolescent maternal mortality and medical impoverishment associated with complicated delivery in facility. For this purpose, this chapter uses ECEA to measure the potential mortality, FRP, and equity benefits that could be gained through public financing of increased education of adolescent girls in two illustrative country examples: Niger and India.