Elsevier

Social Science & Medicine

Volume 63, Issue 12, December 2006, Pages 2999-3012
Social Science & Medicine

Women's status and child well-being: A state-level analysis

https://doi.org/10.1016/j.socscimed.2006.07.013Get rights and content

Abstract

We conducted an ecologic analysis of the relation between women's status and child well-being in the 50 United States. State-level women's status was assessed via four composite indices: women's political participation, economic autonomy, employment and earnings, and reproductive rights. Child well-being was measured via five outcomes: percentage of low birthweight babies, infant mortality, teen mortality, high school dropout rate, and teen birth rate. Higher state-level women's status on all indicators was associated with significantly better state-level child well-being in unadjusted analyses. Several associations remained significant after adjusting for income inequality and state racial composition. Women's political participation was associated with a significantly lower percentage of low birthweight babies (p<.001) and lower teen birth rates (p<.05). Women's employment and earnings was associated with lower infant mortality (p<.05) and teen birth rates (p<.05). More economic and social autonomy for women was associated with better child outcomes on all measures (p<.01 all). Greater reproductive rights were associated with significantly lower infant mortality (p<.01). We conclude that child well-being is worse in states where women have lower political, economic, and social status. Women's status is an important aspect of children's social context which may impact their well-being. Multi-level analyses of the association between state-level women's status and child well-being are needed.

Introduction

The United States continues to compare poorly to other industrialized countries on a range of child outcomes despite being one of the wealthiest countries in the world in terms of per capita income (United Nations, 2005). In an effort to identify societal determinants of child well-being in the United States, we examined the state-level association between five child health outcomes (percent low birthweight babies, infant mortality, teen mortality, high school drop out rate, and teen birth rate) and four composite indices of women's status: political participation, employment and earnings, economic and social autonomy, and reproductive rights. Our focus on women's status as a societal determinant of child well-being was inspired by research in developing countries where the positive correlation between women's social status and child well-being is well-documented (Institute for Food Policy Research [IFPR], 2003). In fact, improving gender equality is argued as a necessary step in the effort to improve child outcomes in such countries (World Bank, 2003).

In countries where women exert more economic and political power, children experience more positive nutritional outcomes, even after accounting for differences in economic development between countries (IFPR, 2003). Investment in women's education in developing countries has been shown to significantly reduce child mortality rates; higher levels of maternal education are associated with enhanced child nutrition, improved quality of child care, and lower fertility rates (World Bank, 2003). Better child health outcomes are also associated with women's income control in the household. Increases in overall household income are associated with reduced child mortality. However, when household income is controlled by women, risk of child mortality is substantially lower than in households where income is controlled by men (World Bank, 2003). Thus, data from developing countries suggest that women's social status may be an important societal level determinant of children's well-being.

Social epidemiology seeks to identify the social determinants of population health (Krieger, 2001). The ecosocial theory from the field of social epidemiology provides one framework for understanding the association between women's status and child well-being. Ecosocial theory recognizes that humans are at once social and biological beings, and that bodies come to incorporate and reflect structural social inequalities (Krieger, 2001; Krieger & Gruskin, 2001). A central construct of ecosocial theory is embodiment. Embodiment has been defined as “a concept referring to how we literally incorporate, biologically, the material and social world in which we live, from in utero to death” (Krieger, 2001, p. 672). There are multiple explanations for the association between women's status and child well-being in developing countries that are consistent with the construct of embodiment (IFPR, 2003 adapted from Engle, Menon, & Haddad, 1999). Here we outline some examples that can be extended to women in the United States.

Women's status in a society is determined in part by women's access to education, medical care, and economic autonomy, each of which has direct implications for child well-being. Women with access to education are more likely to be exposed to knowledge about the importance of positive health behaviors; they are less likely to smoke during pregnancy. If women have poor access to pre- and post-natal medical care, they are unlikely to receive information on proper nutrition during pregnancy and on the benefits of breastfeeding, both of which have direct consequences for child outcomes such as birthweight (WHO, 1995). Lower status women may not have control over household income and, therefore, may not have the resources to purchase foods recommended during pregnancy and avoid others (e.g. foods at risk for listeriosis). Thus, during pregnancy and early childhood, children literally “embody” (biologically incorporate) the social status of their mothers.

Embodiment, as a way of explaining the association between women's status and child well-being, can be extended well past the postnatal period. Like women in the developing world, women in the United States are the primary caretakers for children (Hochschild, 1989). Children who are not in the care of their mothers are most often in the care of other women, whether in day care situations or in a school setting. Women as caretakers, therefore, provide children's primary connection to the larger social structure. In fact, assets controlled by women are more likely than those controlled by men to be spent in ways that benefit children (e.g. Quisumbing & Maluccio, 2003). Women’ status may also indirectly affect children through exposure to domestic violence and maternal depression. In the United States, state-level gender inequality is associated with rates of severe marital violence (Yllo, 1983). Domestic violence puts women at increased risk of depression, and maternal depression adversely impacts child well-being (Moses-Kolko & Roth, 2004).

Despite evidence in the international arena of the importance of women's status on children's health, a comprehensive state-level analysis of the association between women's status and child well-being in the United States has not been conducted. The one exception is a study by Kawachi, Kennedy, Gupta, and Prothrow-Stith (1999) which focused primarily on adult health outcomes. Using the same Institute for Women's Policy Research indicators of state-level women's status (political participation, employment and earnings, social and economic autonomy, and reproductive rights) examined in the present study, Kawachi et al. (1999) found that women and men experience higher morbidity and mortality in states where women have lower social status. Kawachi et al. (1999) also reported that states ranked higher in terms of women's economic autonomy and reproductive rights had lower infant mortality after controlling for income inequality. This finding provides initial evidence that women's status may be associated with children's health outcomes at the state-level.

An ecologic analysis of the association between state-level income inequality and child well-being was recently conducted by McLeod, Nonnemaker, and Call (2004). McLeod et al. (2004) concluded that state-level income inequality was not a predictor of child well-being after adjusting for state racial composition. Rather, the larger the proportion of the state's population identified as black, the higher percentage of low birthweight babies, infant mortality rate, teen birth rate, and high school drop out rate, after adjusting for state-level income inequality. McLeod et al. (2004, p. 249) stated that “the effects of racial composition on child well-being appear to be compositional (e.g. they reflect less positive outcomes observed among racial/ethnic minorities) rather than contextual (e.g. representing the independent influences of social context)”. However, McLeod et al. (2004) did not consider the effect of state-level women's status on child well-being.

This paper examines the association between state-level women's status and child well-being in the 50 United States. Taking into account the previous work of Kawachi et al. (1999) and McLeod et al. (2004), we test whether any significant association is independent of both the effects of income inequality and state racial composition. States exert a great deal of control over the construction of public policy relevant to women's status and child welfare. States are, therefore, appropriate entities for an ecologic study of the aggregate effects of women's status on child well-being. In conducting this analysis, we hope to motivate multi-level investigations on the effect of women's status on child well-being in the United States.

Section snippets

Methods

Following the work of Kawachi et al. (1999) and McLeod et al. (2004) this study consists of an ecologic analysis of the relation between women's status and child well-being in the 50 United States. Complete data on women's status indicators and outcomes were not available for the District of Columbia, Puerto Rico and the US Virgin Islands and, therefore, they are not included in this analysis.

Descriptive statistics and correlations for women's status indices and covariates

Table 2 presents descriptive statistics and correlations for women's status indices, covariates, and child outcomes. The women's status indexes were moderately to highly correlated (range r=0.410.85). Greater women's political participation at the state level was associated with a lower proportion of the state population being black. Greater women's reproductive rights at the state level were associated with a large proportion of the state population being Hispanic. The other women's status

Discussion

Our findings suggest a robust association between state-level women's status and child outcomes. Indices of women's status were significantly correlated with a range of child outcomes in unadjusted models. Moreover, several of these associations remained significant after controlling for both state-level income inequality and racial composition. Table 7 summarizes the significant associations between women's status indicators and child outcomes in the fully adjusted models. Women's status

Conclusions

Despite these methodological limitations, this study illustrates that the study of women's status and child well-being should not be limited to developing countries. Our findings extend those of Kawachi et al. (1999) to children, suggesting that the political, economic, and social power women exert at the state level may influence children's health. McLeod et al. (2004) reported that the association between income inequality and child outcomes was attenuated to non-significance after adjusting

Acknowledgment

Dr. Koenen is supported in part by US-NIMH K08 MH070627.

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