Family Allowance and Family Planning in Chile S. J. PLANK, MD, DRPH
Abstract: Family allowances designed to promote maternal and child health and welfare could be selfdefeating if they stimulated otherwise unwanted births, as often assumed. That assumption, with its public health and demographic implications, needs testing. An attempt to test it was made in Chile in 1969-1970 through interviews with 945 wives receiving an allowance and 690 non-recipients. Recipients practiced contraception significantly more than did non-recipients. This was not explained by wives' educational attainment or employment, the couples' earnings, or number of living children, but was associated with a 50 per cent greater utilization of professional prenatal care by recipients during the most recent pregnancy;
women with such care (regardless of allowance status) were 75 per cent more likely than others to control their fertility. Prenatal care was probably sought more by recipients in part because an additional stipend was provided as soon as pregnancy was confirmed, usually at clinics with integrated family planning. Greater family income, attributable to the allowance, probably also contributed to the recipients' better prenatal attention and to contraceptive practice. Noteworthy, too, was the finding that with the number of living children controlled, contraceptive practice was significantly greater among couples who had never lost a child. (Am. J. Public Health 68:989-994, 1978.)
Family allowance systems providing an additional stipend for each child might discourage family planning, as a Planned Parenthood Federation editorial cautioned,' but this has not yet been demonstrated. "An extensive literature about whether pronatalist government policies, such as family allowances, can increase fertility is inconclusive," wrote Freedman,2 probably expressing the consensus among scholars. Heer and Bryden found "it is not possible to offer conclusive proof concerning the effects of any family allowance program,"3 and Moynihan declared "whatever else changes the birth rate, the family allowance does not."4 Although most of the studies have focused on the economically advanced countries, Whitney was persuaded that "whether ... less developed countries have any form of family or children's allowances appears wholly unrelated to the level of fertility."5 Concurring that the postulated relationship had not been documented, Simon concluded "the only source of a response estimate must be studies of actual programmes. And useful data are practically non-existent.' '6 Some useful data may be obtained from Chile where family allowances for selected employees were initiated in 1923.7 The program was expanded to cover a much broader spectrum of workers in 1953. Parents became entitled to the stipend from the fourth month of pregnancy in 1961 and from the time of conception in 1964.8 The 1953 legislation was
credited by one author with having "stimulated population growth" and the later modifications with having "started a population explosion".8 The United Nations' demographic data do not confirm this, however, but show instead that in each instance the legislative change was followed by a drop in the birth rate the next year.9 Instead of the predicted "explosion", births fell from 36.1 per thousand in 1961 to 32.8 in 1964 and then to 25.0 by 1969. While the decline might possibly have been even more rapid without the presumed pronatalist incentive, any effect of the successive extensions of eligibility was apparently either so small as to be offset by counter influences coinciding in time or it was in the opposite direction to that postulated. To see what effects the allowance might have on family planning, pertinent questions were included in an extensive survey on health and fertility in rural Chile.
Address reprint requests to Dr. S. J. Plank, Staff Member, Health Sciences, The Rockefeller Foundation, C.P. 511, 40.000 Salvador, Bahia, Brazil. At the time of the study, Dr. Plank was Lecturer on Population Studies, Harvard School of Public Health. This paper, submitted to the Journal November 23, 1977, was revised and accepted for publication April 18, 1978.
AJPH October, 1978, Vol. 68, No. 10
Materials and Methods Fifteen villages of 1,000 to 2,500 inhabitants were selected in the principal agricultural zone of Chile for a prospective controlled study of the effects on natality and maternal and child health indicators of incorporating family planning into the programs of rural health posts. One of each pair of communities, matched on demographic characteristics and dominant economic activity, was to offer primary health services only, while its matched community was to provide these plus family planning services. The comparisons were to be replicated seven times to minimize effects of extraneous factors. The fifteenth town, data for which are included here, was not successfully matched. 989
FAMILY ALLOWANCE SYSTEM IN CHILE
Considering the criteria for selecting the sites (presented in more detail in reference 10), the sample cannot be regarded as representative of all of Chile or even of its entire rural population. Following complete mapping of the communities, including the surrounding area dependent on the health post, a de jure census was made and interviews attempted with all women of reproductive age (15-44). Cooperation was excellent, with a refusal rate of less than 1 per cent. The interviews, covering a variety of topics related to health and reproduction, were carried out by women social work students at the University of Chile's branches in Talca and Temuco. Immediate supervision was always provided by the author and his associate, a woman public health physician. In addition to complete reproductive histories, married women provided data on their own and their husbands' education, work, income, contraceptive practice, health care, and the amount (if any) of family allowance received. The basic distinction between families receiving the allowance and non-recipient families was that the latter were self-employed-farmers working their own land, share croppers, fishermen, village merchants, artisans, day laborers, etc. The employed group was composed principally of agricultural workers but also included some lumbermen, bus drivers, shop clerks, and others, all of whom were taxed 20 per cent of their earnings to help support their Social Security program regardless of the number of their dependents. Their employers contributed a matching sum. Participating employees were entitled to an allowance of about 10 percent of their month's wages for each dependent. They were also eligible for family medical care and for pensions on retirement. Any independent effects of these latter benefits were indistinguishable from those of the allowance per se. The National Health Service theoretically provided medical care for all who could not afford it elsewhere but there was ignorance of this right among the non-participants and in practice, according to others, considerable difficulty in obtaining help if not covered by Social Security. At the time of the investigation, only about one man in ten in the 15 rural communities studied was earning more than 750 escudos (about US$75) per month. In addition to their cash incomes, independent farmers produced much of their own sustenance and agricultural workers were often provided with housing and some payment in kind. Because equivalent monetary values could not be determined with precision, these components were not included in the income estimates. Reasoning that, in these villages where one-third of couples were practicing contraception, use or non-use of fertility control objectively reflected attitudes toward having another child, current contraceptive practice was chosen as the measure of possible pronatalist influence of the family allowance. Statistical significance was tested by chi-square. Due to the marked skewness of the values for income and educational levels, statistical consultants advised against use of methods for which normality must be assumed. The nonparametric sign test was therefore used when family size and levels of earnings were simultaneously controlled and in ana990
lyzing the data in some of the tables (see Tables 2 and 3 below). The sign test is less sensitive than parametric tests so significance may be underestimated.
Results and Discussion Contraception was practiced significantly more by couples with the allowance than by those without it (35.3 per cent vs. 27.4 per cent p < .001), and as a corollary there were fewer currently pregnant wives among the former group. Furthermore, as the monthly stipend per child rose from less than 10 escudos a month to over 60, fertility control increased at every family size. That is, the greater the monetary incentive to have another baby, the greater the effort to prevent its conception. However, since earnings showed this same relation to family planning and determined the amount of the stipend, it could not be concluded that the larger stipends themselves promoted contraceptive practice. In the absence of any hypothesis to explain why the family allowance would be associated positively with contraception, mediating factors were sought through comparisons of the two groups by level of earnings, number of children, education and employment of wife, child mortality experience, and health care. Couples' Earnings and Number of Children A couple's economic condition and the number of children they already have can strongly affect their family planning decisions. This was reflected by a fairly linear progression of contraceptive use as the husband's and wife's combined earnings (allowance not included) rose (Table 1). At all but the lowest of the seven earnings levels, couples receiving the allowance controlled their fertility more than the others. Although the proportion earning more than 400 escudos was the same for those with and without the stipends (29.2 per cent and 29.5 per cent), there was a tendency for non-recipients to fall into the very poorest categories where contraception was practiced least. One-quarter of non-recipients were earning less than 150 escudos per month, whereas fewer than 10 per cent of those with the allowance were at that earning level. The distinctive distributions of earning therefore explained part of the difference in contraceptive practice. Family size was not so systematically associated with fertility control as were earnings. The smallest as well as the largest families were less likely to control fertility than were those with four to six children (Table 2). Table 2 also shows that allowance families were larger on the average than were the others. While this suggests that the program may have had a pronatalist effect in the past, the families receiving the allowance in 1969-70 were not necessarily the same as those in previous years. Also, the advent of fertility control measures was quite recent. The United Nations' Latin American Demographic Center found almost no contraceptive practice in rural Chile only a few years before the present study.1' In a population not practicing contraception, the number of children would reflect the ages of the parents and their years of marriage rather than their family planning attitudes and AJPH October, 1978, Vol. 68, No. 10
PLANK
TABLE 1-Percentage of Contraceptors by Couple's Earnings in Escudos and Family Allowance Status, Rural Chile, 1969-70 Family Allowance
0-150
Recipients
19.7
27.9
33.7
(76)*
(219)
(101)
NonRecipients TOTAL
151-250
19.1 (110) 24.9 (329)
19.8 (131) 19.8 (207)
251-300
18.9 (37) 29.7 (138)
551-750
35.2
42.3
46.5
58.8
36.3
(236)
(104)
(43)
(114)
(893)
34.1 (82) 34.9 (318)
31.3 (67) 38.0 (171)
39.3 (28) 43.7 (71)
751 +
Total
401-550
301-400
48.2 (56) 55.3 (170)
27.6 (511) 33.1 (1404)**
*The numbers in parentheses are the cell sizes. "Excludes 231 respondents for whom earnings could not be determined.
practices. For larger families to concentrate in the allowance group would also seem an inevitable consequence of economic self-interest. As noted, 20 per cent of participants' salaries were withheld for Social Security and 10 per cent returned for each dependent. Therefore, workers with the largest number of children actually received more in stipends than in wages. Younger couples with fewer children had less incentive to seek for or stay with jobs offering the allowance, and those with the fewest dependents had a real disincentive since more would be withheld to support the program than could be obtained from it. Differences in family size could contribute to the differential fertility control observed here, however, after contraceptives had become more accessible. The family size variable is controlled in Table 2 which shows comparisons TABLE 2-Percentage of Contraceptors by Number of Living Children and Family Allowance Status, Rural Chile, 1969-70 Family Allowance Living Children 0
Recipients
Non-Recipients
Total
5.6
5.1
22.7
4.9 (62) 18.2
(88) (123) 34.5 (1 1 9)
(99) (115) 27.1 (118)
(36)* 1
2
3 4
5 6 7
8 9+
TOTAL
32.5
47.8
(113) 40.9 (115) 48.5
(98) 20.3
(187) (238) 30.8 (237)
32.2
32.4
35.4 (82) 41.9
42.6
(195) 41.3
(74)
(189)
26.7
41.7
(99) (68) 22.5 (80) 38.5 (104)
(45) (42) 40.0 (30) 26.1 (23)
(144) (110) 27.3 (110) 36.2 (127)
(945)
(690)
35.3
35.3
21.4
27.4
*The numbers in parentheses are the cell sizes.
AJPH October, 1978, Vol. 68, No. 10
30.0
32.0 (1635)
between allowance recipients and non-recipients with exactly the same number of children. In eight of the ten comparisons, the proportion of contraceptors was greater among recipients. Because of presumed interactions between earnings and family size, both were controlled simultaneously in another analysis with 140 cells (not shown due to space limitations). The percentage of couples practicing contraception was greater among the recipients in 41 of the 58 possible comparisons (p < .005), suggesting that earnings and family size distributions explained only a part of the difference in the two groups' family planning practices. Women's Employment and Education Only about 15 per cent of the wives worked at anything beyond their household tasks. Since working women were more likely than others to control their fertility, a difference in their distribution could have contributed to the observed contraceptive discrepancy. That it did not was evident in the slightly lower employment rate of the eligible wives (14.5 per cent vs. 16.8 per cent.) Education appeared to exert no effect on contraceptive use unless continued beyond five years. The percentage of couples practicing contraception rose from 27.3 per cent when the wife had zero to five years of school, to 38.4 per cent when she had completed the sixth grade, and to 54.5 per cent when she had finished seven years or more. The respective educational levels of those with and without the allowance did not explain the contraceptive difference between them. In fact, women receiving the stipends were significantly less likely to have gone beyond the ffth grade (29.5 per cent vs. 35.9 per cent, p < .05); of those who had completed more than five years of education, fewer recipient than nonrecipient women had completed seven years or more.
Child Mortality The perception of risk of a child's dying may influence family planning attitudes. Parents might be unwilling to stop having children without reasonable assurance that those already born will survive. Bolstering this thesis, couples in the study population who had lost at least one child were less likely to control their fertility than those who had lost none in 14 of the 18 possible comparisons (p < .05) in Table 3. This was probably not a spurious association determined by 991
FAMILY ALLOWANCE SYSTEM IN CHILE TABLE 3-Percentage of Contraceptors by Numbers of Living Children, Experience of Child Death, and Family Allowance Status, Rural Chile, 1969-70 Child Death No
Yes Living
Children
Recipients
Non-Recipients
Recipients
Non-Recipients
Total
0
0.0
1
(3)* 22.2
6.1 (33) 22.8
1.8 (56) 18.2
5.1 (98) 20.3
2
23.1
33.3 (6) 18.2 (1 1) 33.3
36.9
31.9
33.3
35.0 (80) 45.8 (72) 47.5 (59) 63.4
(88) (91)
32.4
3
(79) (84)
28.2 (78) 35.0 (40) 43.2 (37) 38.9
30.8 (237) 42.6 (195) 41.3 (189) 41.7
(9) (39) (39)
4
5 6 7
8 9+
TOTAL
51.2 (41) 33.9 (56) 37.9
(58)
(24)
25.0 (40) 35.7 (42) 40.5 (37) 18.5
(27)
(41)
(18)
(187) (238)
(144)
31.6 (38) 19.1
17.9 (28) 40.0
40.0 (30) 27.3
28.6 (14) 40.0
30.0 (110) 27.3
(47) (64) 33.0 (394)
(15) (16) 29.3 (246)
(33) (40) 37.0 (551)
(15) (7) 26.4 (444)
(110) (127) 32.0 (1635)
35.9
25.0
42.5
28.6
36.2
*The numbers in parentheses are the cell sizes.
dependence of both mortality and contraception on common socioeconomic factors since in these poorly sanitated communities, infant mortality rose as parental earnings and education improved, apparently because of progressively earlier weaning. 12 Although the difference was not significant, the probability of having lost a child was less among families receiving the allowance than among those that did not. Since this factor could contribute to their contraceptive differences, comparison of contraceptive practice was restricted to parents who had never lost a child. Except for the eight-child families, contraception was still practiced more often by those with the allowance (Table 3). Health Care
Quite uniformly overlooked in studies of variables affecting family planning is previous acquaintance with the medical sector. It is not among the eight primary or even the 45 secondary influencing factors listed in The Population Council's Manual for KAP Studies.13 But just as exposure to schools, the mass media, and an urban environment may facilitate the adoption of fertility control, so too can contact with health professionals. Having overcome inhibitions and developed confidence in medical personnel during pregnancy and delivery, a woman might be expected to be more receptive to their recommendations on contraception. Similarly, those acquainted with doctors or nurses for treatment of illness or well baby care might be more likely to consult them when pregnant. Most health professionals serving the 992
study population treated family planning as a regular medical responsibility. Table 4 shows the contraceptive practice of: 1) those women who had made prenatal visits to physicians or hospital clinics, 2) those who had attended only their village health posts (staffed by paramedical auxiliaries), and 3) those who had seen no health personnel at all during their last pregnancy. Family planning was adopted by twice as many of the first group as of the last (44.5 per cent vs. 22.3 per cent). While the prior decision to seek professional attention was influenced by other factors such as education and income, at every year of schooling the proportion of women controlling their fertility was greater for those having had that prenatal care. Illiterate wives who had sought prenatal care practiced contraception more often than women who had completed the sixth grade but had not sought prenatal care. Similarly, couples with total incomes below 300 or 400 escudos where the wife had professional attention practiced contraception to the same degree as those with total incomes above those levels where the wife had not had such care. For this population, then, medical attention was evidently at least as influential as educational attainment or income. Supporting the inference that health care was probably the crucial explanatory variable was the observation that, in spite of their generally smaller families, non-recipients used contraception more than the recipients of family allowance if they had made prenatal visits to a physician or hospital (46.2 per cent vs. 43.9 per cent). This is consistent with the higher educational and occupational level of this selected group of AJPH October, 1978, Vol. 68, No. 10
PLANK
TABLE 4-Percentage of Contraceptors by Type of Prenatal Care and Total Income,* Rural Chile, 1969-70 Prenatal Care
Physician
Village Post None
0150
151250
Total Income in Escudos 251301401300 400 550
551750
751 +
Total
37.5
28.9
27.6
37.9
36.6
54.4
67.4
44.5
(24)**
(45)
(29)
(66)
(131) 34.8 (89) 33.7
(79)
38.5 (39) 47.6
(89)
21.7 (23) 55.2
27.4 (390) 33.1
(288)
(143)
(145)
(1140)
22.2 (45) 22.8
16.9 (71) 17.7
22.2 (45) 22.4
30.8 (78) 28.9
(114)
(158)
(98)
(194)
(463)
*Care prior to most recent delivery within preceding 5 years. Total income is the sum of husband's and wife's earnings plus the amount received as family allowance. Excluded are 495 couples for whom eamings could not be determined or who had not had a baby in past 5 years. "Numbers in parentheses are the cell size.
families. The bulk of evidence, from the days of Malthus, suggests that the small landholders and self-employed would probably adopt family limitations more readily than the agricultural laborers and other wage earners. The generally greater fertility control of couples receiving a family allowance seems to be attributable, at least in part, to the fact that these wives were 50 per cent more likely to have had professional care (Table 5). This in turn reflected the medical coverage the program provided and the incentive effect of the additional stipend payable on confirmation of pregnancy. Along with the economic benefits they sought, many of these women must have gained contraceptive information as well as familiarity with medical personnel and procedures. In this way, the extension of the family allowance to cover the fetus could have acted to promote rather than discourage family planning.
sional care tripled in a step-wise fashion, disregarding eligibility status. The importance of this health care link between income and contraception is evident in Table 4 where, for instance, among those having had professional care an independent effect of income was apparent only above 550 escudos. From Tables 4 and 5 it is inferred that a considerable part of the dependence of contraceptive use on income may be explained by the greater access to medical care that money provided. The allowance provided money, and while perceptions and aspirations relating to health and fertility may have been affected by this added income, the implementation of relevant decisions was certainly aided by it. Whether the money was used for bus fare to the city and hospital or for buying contraceptive pills, money facilitated effective choice.
Money is Money Further contributing to their better prenatal care, parents eligible for family allowances had more money on the average: 63.2 per cent of them had total incomes exceeding 400 escudos compared to 26.0 per cent of non-recipients* (Table 5). As total incomes rose, the utilization of profes-
Conclusions
*In Table 1, with slightly different N's, equal proportions had this much in earnings alone.
The hypothesis that family allowances have pronatalist effects apparently rests on the assumptions that parents perceive the stipend as large enough to leave them some surplus after the child's needs are met and/or that they want and would have more children if they could afford them. Neither assumption seemed to be borne out in rural Chile in the late 1960s. The stipend of less than a dollar a week for 70 per cent of recipients was evidently recognized as inadequate to cov-
TABLE 5-Percentage of Women Having Had Professional Prenatal Care by Total Income* and Family Allowance Status, Rural Chile, 1969-70 Family Allowance
0150
151250
Total Income in Escudos 301401251400 550 300
Recipients
33.3
29.0
33.8
39.0
46.7
(69)
(65)
(136)
(242)
(58)
(46)
(21)
(34)
(389)
34.0
45.5
55.2
61.4
40.6
(194)
(288)
(143)
(145)
(1140)
NonRecipients TOTAL
(6)**
20.4
28.1
21.2
(108)
(89) 28.5 (158)
(33) 29.6 (98)
21.1
(114)
22.4
39.1
551750
751 +
Total
55.7
61.3
46.1
(122)
(111)
52.4
61.8
(751)
30.1
*See legend for table 4. "The numbers in parentheses are the cell sizes.
AJPH October, 1978, Vol. 68, No. 10
993
FAMILY ALLOWANCE SYSTEM IN CHILE
er the costs of an additional child. And that larger families were not wanted was shown by responses to direct questions10 and by the progressive adoption of birth control as financial ability to raise another child improved. Since the recipients differed from non-recipients in type of employment, effective access to health care, pension benefits, and perhaps in other unidentified ways, hard and fast conclusions on the effect of the family allowance per se on reproduction cannot be drawn. The evidence presented suggests, however, that the monetary incentive to seek prenatal care helped to promote contraceptive practice as did the greater family income which the allowance provided. More importantly, the absence of any evidence of a pronatalist effect may be helpful to policymakers apprehensive about the assumed demographic and welfare consequences of family allowance programs.
ACKNOWLEDGMENTS The author gratefully acknowledges the support received from The Rockefeller Foundation and the United States Agency for International Development; the technical assistance of the Department of Public Health and Social Medicine of the University of Chile; the cooperation of the Chilean National Health Service; and the invitation and facilities to work in Chile provided by Dr. Benjamin Viel.
REFERENCES 1. Viel B: Pronatalism in Latin America, News Service (International Planned Parenthood Federation/Western Hemisphere Region) 1:2-3, 1972. 2. Freedman R: The sociology of human fertility: A trend report and bibliography. Current Sociology, 10-11:1-121, 1961-1962. 3. Heer DM and Bryden J: Family allowances and fertility in the Soviet Union. Soviet Studies, 18:153-163, 1966. 4. Moynihan D: The Case for a Family Allowance, New York Times Magazine, February 5, 1967. 5. Whitney WV: Fertility Trends and Childrens' Allowance Programs. In: Childrens' Allowances and the Economic Welfare of Children: The Report of a Conference. EM Burns, editor. Citizens Committee for Children of New York, 1968. 6. Simon JL: The effect of income on fertility. Population Studies, 23:327-341, 1969. 7. Ley No. 7295, Actualizada para 1972. Ediciones Gutenberg, Santiago, Chile, 1972. 8. Cruz-Coke R: The population explosion in Chile, Lancet 2:434435, 1965. 9. United Nations, Demographic Year Books for 1965, 1966, 1971. 10. Plank SJ and Milanesis ML: Fertility in rural Chile. Social Biology, 20:151-159, 1973. 11. CELADE, La Fecundidad Rural en Latino America. Demography 2:97-114, 1965. 12. Plank SJ and Milanesi ML: Infant feeding and infant mortality in rural Chile. Bulletin of the World Health Organization, 48:203210, 1973. 13. A Manual for Surveys on Fertility and Family Planning: Knowledge, Attitudes, and Practice. The Population Council, New York Citv 1970.
In Memory of Doctor Jacob Kittredge Who Died July 28th 1813 Aged 63 B eneath the sacred honors of the tomb In awful silence and majestic gloom The man of mercy here conceals his head Amidst the awful mantions (sic) of the dead No more his liberal hand shall help the poor Relieve distress and scatter joy no more While he from death did others seek to save Death threw a dart and plunged him in the grave.
994
AJPH October, 1978, Vol. 68, No. 10
Abstract: Family allowances designed to promote maternal and child health and welfare could be selfdefeating if they stimulated otherwise unwanted births, as often assumed. That assumption, with its public health and demographic implications, needs testing. An attempt to test it was made in Chile in 1969-1970 through interviews with 945 wives receiving an allowance and 690 non-recipients. Recipients practiced contraception significantly more than did non-recipients. This was not explained by wives' educational attainment or employment, the couples' earnings, or number of living children, but was associated with a 50 per cent greater utilization of professional prenatal care by recipients during the most recent pregnancy;
women with such care (regardless of allowance status) were 75 per cent more likely than others to control their fertility. Prenatal care was probably sought more by recipients in part because an additional stipend was provided as soon as pregnancy was confirmed, usually at clinics with integrated family planning. Greater family income, attributable to the allowance, probably also contributed to the recipients' better prenatal attention and to contraceptive practice. Noteworthy, too, was the finding that with the number of living children controlled, contraceptive practice was significantly greater among couples who had never lost a child. (Am. J. Public Health 68:989-994, 1978.)
Family allowance systems providing an additional stipend for each child might discourage family planning, as a Planned Parenthood Federation editorial cautioned,' but this has not yet been demonstrated. "An extensive literature about whether pronatalist government policies, such as family allowances, can increase fertility is inconclusive," wrote Freedman,2 probably expressing the consensus among scholars. Heer and Bryden found "it is not possible to offer conclusive proof concerning the effects of any family allowance program,"3 and Moynihan declared "whatever else changes the birth rate, the family allowance does not."4 Although most of the studies have focused on the economically advanced countries, Whitney was persuaded that "whether ... less developed countries have any form of family or children's allowances appears wholly unrelated to the level of fertility."5 Concurring that the postulated relationship had not been documented, Simon concluded "the only source of a response estimate must be studies of actual programmes. And useful data are practically non-existent.' '6 Some useful data may be obtained from Chile where family allowances for selected employees were initiated in 1923.7 The program was expanded to cover a much broader spectrum of workers in 1953. Parents became entitled to the stipend from the fourth month of pregnancy in 1961 and from the time of conception in 1964.8 The 1953 legislation was
credited by one author with having "stimulated population growth" and the later modifications with having "started a population explosion".8 The United Nations' demographic data do not confirm this, however, but show instead that in each instance the legislative change was followed by a drop in the birth rate the next year.9 Instead of the predicted "explosion", births fell from 36.1 per thousand in 1961 to 32.8 in 1964 and then to 25.0 by 1969. While the decline might possibly have been even more rapid without the presumed pronatalist incentive, any effect of the successive extensions of eligibility was apparently either so small as to be offset by counter influences coinciding in time or it was in the opposite direction to that postulated. To see what effects the allowance might have on family planning, pertinent questions were included in an extensive survey on health and fertility in rural Chile.
Address reprint requests to Dr. S. J. Plank, Staff Member, Health Sciences, The Rockefeller Foundation, C.P. 511, 40.000 Salvador, Bahia, Brazil. At the time of the study, Dr. Plank was Lecturer on Population Studies, Harvard School of Public Health. This paper, submitted to the Journal November 23, 1977, was revised and accepted for publication April 18, 1978.
AJPH October, 1978, Vol. 68, No. 10
Materials and Methods Fifteen villages of 1,000 to 2,500 inhabitants were selected in the principal agricultural zone of Chile for a prospective controlled study of the effects on natality and maternal and child health indicators of incorporating family planning into the programs of rural health posts. One of each pair of communities, matched on demographic characteristics and dominant economic activity, was to offer primary health services only, while its matched community was to provide these plus family planning services. The comparisons were to be replicated seven times to minimize effects of extraneous factors. The fifteenth town, data for which are included here, was not successfully matched. 989
FAMILY ALLOWANCE SYSTEM IN CHILE
Considering the criteria for selecting the sites (presented in more detail in reference 10), the sample cannot be regarded as representative of all of Chile or even of its entire rural population. Following complete mapping of the communities, including the surrounding area dependent on the health post, a de jure census was made and interviews attempted with all women of reproductive age (15-44). Cooperation was excellent, with a refusal rate of less than 1 per cent. The interviews, covering a variety of topics related to health and reproduction, were carried out by women social work students at the University of Chile's branches in Talca and Temuco. Immediate supervision was always provided by the author and his associate, a woman public health physician. In addition to complete reproductive histories, married women provided data on their own and their husbands' education, work, income, contraceptive practice, health care, and the amount (if any) of family allowance received. The basic distinction between families receiving the allowance and non-recipient families was that the latter were self-employed-farmers working their own land, share croppers, fishermen, village merchants, artisans, day laborers, etc. The employed group was composed principally of agricultural workers but also included some lumbermen, bus drivers, shop clerks, and others, all of whom were taxed 20 per cent of their earnings to help support their Social Security program regardless of the number of their dependents. Their employers contributed a matching sum. Participating employees were entitled to an allowance of about 10 percent of their month's wages for each dependent. They were also eligible for family medical care and for pensions on retirement. Any independent effects of these latter benefits were indistinguishable from those of the allowance per se. The National Health Service theoretically provided medical care for all who could not afford it elsewhere but there was ignorance of this right among the non-participants and in practice, according to others, considerable difficulty in obtaining help if not covered by Social Security. At the time of the investigation, only about one man in ten in the 15 rural communities studied was earning more than 750 escudos (about US$75) per month. In addition to their cash incomes, independent farmers produced much of their own sustenance and agricultural workers were often provided with housing and some payment in kind. Because equivalent monetary values could not be determined with precision, these components were not included in the income estimates. Reasoning that, in these villages where one-third of couples were practicing contraception, use or non-use of fertility control objectively reflected attitudes toward having another child, current contraceptive practice was chosen as the measure of possible pronatalist influence of the family allowance. Statistical significance was tested by chi-square. Due to the marked skewness of the values for income and educational levels, statistical consultants advised against use of methods for which normality must be assumed. The nonparametric sign test was therefore used when family size and levels of earnings were simultaneously controlled and in ana990
lyzing the data in some of the tables (see Tables 2 and 3 below). The sign test is less sensitive than parametric tests so significance may be underestimated.
Results and Discussion Contraception was practiced significantly more by couples with the allowance than by those without it (35.3 per cent vs. 27.4 per cent p < .001), and as a corollary there were fewer currently pregnant wives among the former group. Furthermore, as the monthly stipend per child rose from less than 10 escudos a month to over 60, fertility control increased at every family size. That is, the greater the monetary incentive to have another baby, the greater the effort to prevent its conception. However, since earnings showed this same relation to family planning and determined the amount of the stipend, it could not be concluded that the larger stipends themselves promoted contraceptive practice. In the absence of any hypothesis to explain why the family allowance would be associated positively with contraception, mediating factors were sought through comparisons of the two groups by level of earnings, number of children, education and employment of wife, child mortality experience, and health care. Couples' Earnings and Number of Children A couple's economic condition and the number of children they already have can strongly affect their family planning decisions. This was reflected by a fairly linear progression of contraceptive use as the husband's and wife's combined earnings (allowance not included) rose (Table 1). At all but the lowest of the seven earnings levels, couples receiving the allowance controlled their fertility more than the others. Although the proportion earning more than 400 escudos was the same for those with and without the stipends (29.2 per cent and 29.5 per cent), there was a tendency for non-recipients to fall into the very poorest categories where contraception was practiced least. One-quarter of non-recipients were earning less than 150 escudos per month, whereas fewer than 10 per cent of those with the allowance were at that earning level. The distinctive distributions of earning therefore explained part of the difference in contraceptive practice. Family size was not so systematically associated with fertility control as were earnings. The smallest as well as the largest families were less likely to control fertility than were those with four to six children (Table 2). Table 2 also shows that allowance families were larger on the average than were the others. While this suggests that the program may have had a pronatalist effect in the past, the families receiving the allowance in 1969-70 were not necessarily the same as those in previous years. Also, the advent of fertility control measures was quite recent. The United Nations' Latin American Demographic Center found almost no contraceptive practice in rural Chile only a few years before the present study.1' In a population not practicing contraception, the number of children would reflect the ages of the parents and their years of marriage rather than their family planning attitudes and AJPH October, 1978, Vol. 68, No. 10
PLANK
TABLE 1-Percentage of Contraceptors by Couple's Earnings in Escudos and Family Allowance Status, Rural Chile, 1969-70 Family Allowance
0-150
Recipients
19.7
27.9
33.7
(76)*
(219)
(101)
NonRecipients TOTAL
151-250
19.1 (110) 24.9 (329)
19.8 (131) 19.8 (207)
251-300
18.9 (37) 29.7 (138)
551-750
35.2
42.3
46.5
58.8
36.3
(236)
(104)
(43)
(114)
(893)
34.1 (82) 34.9 (318)
31.3 (67) 38.0 (171)
39.3 (28) 43.7 (71)
751 +
Total
401-550
301-400
48.2 (56) 55.3 (170)
27.6 (511) 33.1 (1404)**
*The numbers in parentheses are the cell sizes. "Excludes 231 respondents for whom earnings could not be determined.
practices. For larger families to concentrate in the allowance group would also seem an inevitable consequence of economic self-interest. As noted, 20 per cent of participants' salaries were withheld for Social Security and 10 per cent returned for each dependent. Therefore, workers with the largest number of children actually received more in stipends than in wages. Younger couples with fewer children had less incentive to seek for or stay with jobs offering the allowance, and those with the fewest dependents had a real disincentive since more would be withheld to support the program than could be obtained from it. Differences in family size could contribute to the differential fertility control observed here, however, after contraceptives had become more accessible. The family size variable is controlled in Table 2 which shows comparisons TABLE 2-Percentage of Contraceptors by Number of Living Children and Family Allowance Status, Rural Chile, 1969-70 Family Allowance Living Children 0
Recipients
Non-Recipients
Total
5.6
5.1
22.7
4.9 (62) 18.2
(88) (123) 34.5 (1 1 9)
(99) (115) 27.1 (118)
(36)* 1
2
3 4
5 6 7
8 9+
TOTAL
32.5
47.8
(113) 40.9 (115) 48.5
(98) 20.3
(187) (238) 30.8 (237)
32.2
32.4
35.4 (82) 41.9
42.6
(195) 41.3
(74)
(189)
26.7
41.7
(99) (68) 22.5 (80) 38.5 (104)
(45) (42) 40.0 (30) 26.1 (23)
(144) (110) 27.3 (110) 36.2 (127)
(945)
(690)
35.3
35.3
21.4
27.4
*The numbers in parentheses are the cell sizes.
AJPH October, 1978, Vol. 68, No. 10
30.0
32.0 (1635)
between allowance recipients and non-recipients with exactly the same number of children. In eight of the ten comparisons, the proportion of contraceptors was greater among recipients. Because of presumed interactions between earnings and family size, both were controlled simultaneously in another analysis with 140 cells (not shown due to space limitations). The percentage of couples practicing contraception was greater among the recipients in 41 of the 58 possible comparisons (p < .005), suggesting that earnings and family size distributions explained only a part of the difference in the two groups' family planning practices. Women's Employment and Education Only about 15 per cent of the wives worked at anything beyond their household tasks. Since working women were more likely than others to control their fertility, a difference in their distribution could have contributed to the observed contraceptive discrepancy. That it did not was evident in the slightly lower employment rate of the eligible wives (14.5 per cent vs. 16.8 per cent.) Education appeared to exert no effect on contraceptive use unless continued beyond five years. The percentage of couples practicing contraception rose from 27.3 per cent when the wife had zero to five years of school, to 38.4 per cent when she had completed the sixth grade, and to 54.5 per cent when she had finished seven years or more. The respective educational levels of those with and without the allowance did not explain the contraceptive difference between them. In fact, women receiving the stipends were significantly less likely to have gone beyond the ffth grade (29.5 per cent vs. 35.9 per cent, p < .05); of those who had completed more than five years of education, fewer recipient than nonrecipient women had completed seven years or more.
Child Mortality The perception of risk of a child's dying may influence family planning attitudes. Parents might be unwilling to stop having children without reasonable assurance that those already born will survive. Bolstering this thesis, couples in the study population who had lost at least one child were less likely to control their fertility than those who had lost none in 14 of the 18 possible comparisons (p < .05) in Table 3. This was probably not a spurious association determined by 991
FAMILY ALLOWANCE SYSTEM IN CHILE TABLE 3-Percentage of Contraceptors by Numbers of Living Children, Experience of Child Death, and Family Allowance Status, Rural Chile, 1969-70 Child Death No
Yes Living
Children
Recipients
Non-Recipients
Recipients
Non-Recipients
Total
0
0.0
1
(3)* 22.2
6.1 (33) 22.8
1.8 (56) 18.2
5.1 (98) 20.3
2
23.1
33.3 (6) 18.2 (1 1) 33.3
36.9
31.9
33.3
35.0 (80) 45.8 (72) 47.5 (59) 63.4
(88) (91)
32.4
3
(79) (84)
28.2 (78) 35.0 (40) 43.2 (37) 38.9
30.8 (237) 42.6 (195) 41.3 (189) 41.7
(9) (39) (39)
4
5 6 7
8 9+
TOTAL
51.2 (41) 33.9 (56) 37.9
(58)
(24)
25.0 (40) 35.7 (42) 40.5 (37) 18.5
(27)
(41)
(18)
(187) (238)
(144)
31.6 (38) 19.1
17.9 (28) 40.0
40.0 (30) 27.3
28.6 (14) 40.0
30.0 (110) 27.3
(47) (64) 33.0 (394)
(15) (16) 29.3 (246)
(33) (40) 37.0 (551)
(15) (7) 26.4 (444)
(110) (127) 32.0 (1635)
35.9
25.0
42.5
28.6
36.2
*The numbers in parentheses are the cell sizes.
dependence of both mortality and contraception on common socioeconomic factors since in these poorly sanitated communities, infant mortality rose as parental earnings and education improved, apparently because of progressively earlier weaning. 12 Although the difference was not significant, the probability of having lost a child was less among families receiving the allowance than among those that did not. Since this factor could contribute to their contraceptive differences, comparison of contraceptive practice was restricted to parents who had never lost a child. Except for the eight-child families, contraception was still practiced more often by those with the allowance (Table 3). Health Care
Quite uniformly overlooked in studies of variables affecting family planning is previous acquaintance with the medical sector. It is not among the eight primary or even the 45 secondary influencing factors listed in The Population Council's Manual for KAP Studies.13 But just as exposure to schools, the mass media, and an urban environment may facilitate the adoption of fertility control, so too can contact with health professionals. Having overcome inhibitions and developed confidence in medical personnel during pregnancy and delivery, a woman might be expected to be more receptive to their recommendations on contraception. Similarly, those acquainted with doctors or nurses for treatment of illness or well baby care might be more likely to consult them when pregnant. Most health professionals serving the 992
study population treated family planning as a regular medical responsibility. Table 4 shows the contraceptive practice of: 1) those women who had made prenatal visits to physicians or hospital clinics, 2) those who had attended only their village health posts (staffed by paramedical auxiliaries), and 3) those who had seen no health personnel at all during their last pregnancy. Family planning was adopted by twice as many of the first group as of the last (44.5 per cent vs. 22.3 per cent). While the prior decision to seek professional attention was influenced by other factors such as education and income, at every year of schooling the proportion of women controlling their fertility was greater for those having had that prenatal care. Illiterate wives who had sought prenatal care practiced contraception more often than women who had completed the sixth grade but had not sought prenatal care. Similarly, couples with total incomes below 300 or 400 escudos where the wife had professional attention practiced contraception to the same degree as those with total incomes above those levels where the wife had not had such care. For this population, then, medical attention was evidently at least as influential as educational attainment or income. Supporting the inference that health care was probably the crucial explanatory variable was the observation that, in spite of their generally smaller families, non-recipients used contraception more than the recipients of family allowance if they had made prenatal visits to a physician or hospital (46.2 per cent vs. 43.9 per cent). This is consistent with the higher educational and occupational level of this selected group of AJPH October, 1978, Vol. 68, No. 10
PLANK
TABLE 4-Percentage of Contraceptors by Type of Prenatal Care and Total Income,* Rural Chile, 1969-70 Prenatal Care
Physician
Village Post None
0150
151250
Total Income in Escudos 251301401300 400 550
551750
751 +
Total
37.5
28.9
27.6
37.9
36.6
54.4
67.4
44.5
(24)**
(45)
(29)
(66)
(131) 34.8 (89) 33.7
(79)
38.5 (39) 47.6
(89)
21.7 (23) 55.2
27.4 (390) 33.1
(288)
(143)
(145)
(1140)
22.2 (45) 22.8
16.9 (71) 17.7
22.2 (45) 22.4
30.8 (78) 28.9
(114)
(158)
(98)
(194)
(463)
*Care prior to most recent delivery within preceding 5 years. Total income is the sum of husband's and wife's earnings plus the amount received as family allowance. Excluded are 495 couples for whom eamings could not be determined or who had not had a baby in past 5 years. "Numbers in parentheses are the cell size.
families. The bulk of evidence, from the days of Malthus, suggests that the small landholders and self-employed would probably adopt family limitations more readily than the agricultural laborers and other wage earners. The generally greater fertility control of couples receiving a family allowance seems to be attributable, at least in part, to the fact that these wives were 50 per cent more likely to have had professional care (Table 5). This in turn reflected the medical coverage the program provided and the incentive effect of the additional stipend payable on confirmation of pregnancy. Along with the economic benefits they sought, many of these women must have gained contraceptive information as well as familiarity with medical personnel and procedures. In this way, the extension of the family allowance to cover the fetus could have acted to promote rather than discourage family planning.
sional care tripled in a step-wise fashion, disregarding eligibility status. The importance of this health care link between income and contraception is evident in Table 4 where, for instance, among those having had professional care an independent effect of income was apparent only above 550 escudos. From Tables 4 and 5 it is inferred that a considerable part of the dependence of contraceptive use on income may be explained by the greater access to medical care that money provided. The allowance provided money, and while perceptions and aspirations relating to health and fertility may have been affected by this added income, the implementation of relevant decisions was certainly aided by it. Whether the money was used for bus fare to the city and hospital or for buying contraceptive pills, money facilitated effective choice.
Money is Money Further contributing to their better prenatal care, parents eligible for family allowances had more money on the average: 63.2 per cent of them had total incomes exceeding 400 escudos compared to 26.0 per cent of non-recipients* (Table 5). As total incomes rose, the utilization of profes-
Conclusions
*In Table 1, with slightly different N's, equal proportions had this much in earnings alone.
The hypothesis that family allowances have pronatalist effects apparently rests on the assumptions that parents perceive the stipend as large enough to leave them some surplus after the child's needs are met and/or that they want and would have more children if they could afford them. Neither assumption seemed to be borne out in rural Chile in the late 1960s. The stipend of less than a dollar a week for 70 per cent of recipients was evidently recognized as inadequate to cov-
TABLE 5-Percentage of Women Having Had Professional Prenatal Care by Total Income* and Family Allowance Status, Rural Chile, 1969-70 Family Allowance
0150
151250
Total Income in Escudos 301401251400 550 300
Recipients
33.3
29.0
33.8
39.0
46.7
(69)
(65)
(136)
(242)
(58)
(46)
(21)
(34)
(389)
34.0
45.5
55.2
61.4
40.6
(194)
(288)
(143)
(145)
(1140)
NonRecipients TOTAL
(6)**
20.4
28.1
21.2
(108)
(89) 28.5 (158)
(33) 29.6 (98)
21.1
(114)
22.4
39.1
551750
751 +
Total
55.7
61.3
46.1
(122)
(111)
52.4
61.8
(751)
30.1
*See legend for table 4. "The numbers in parentheses are the cell sizes.
AJPH October, 1978, Vol. 68, No. 10
993
FAMILY ALLOWANCE SYSTEM IN CHILE
er the costs of an additional child. And that larger families were not wanted was shown by responses to direct questions10 and by the progressive adoption of birth control as financial ability to raise another child improved. Since the recipients differed from non-recipients in type of employment, effective access to health care, pension benefits, and perhaps in other unidentified ways, hard and fast conclusions on the effect of the family allowance per se on reproduction cannot be drawn. The evidence presented suggests, however, that the monetary incentive to seek prenatal care helped to promote contraceptive practice as did the greater family income which the allowance provided. More importantly, the absence of any evidence of a pronatalist effect may be helpful to policymakers apprehensive about the assumed demographic and welfare consequences of family allowance programs.
ACKNOWLEDGMENTS The author gratefully acknowledges the support received from The Rockefeller Foundation and the United States Agency for International Development; the technical assistance of the Department of Public Health and Social Medicine of the University of Chile; the cooperation of the Chilean National Health Service; and the invitation and facilities to work in Chile provided by Dr. Benjamin Viel.
REFERENCES 1. Viel B: Pronatalism in Latin America, News Service (International Planned Parenthood Federation/Western Hemisphere Region) 1:2-3, 1972. 2. Freedman R: The sociology of human fertility: A trend report and bibliography. Current Sociology, 10-11:1-121, 1961-1962. 3. Heer DM and Bryden J: Family allowances and fertility in the Soviet Union. Soviet Studies, 18:153-163, 1966. 4. Moynihan D: The Case for a Family Allowance, New York Times Magazine, February 5, 1967. 5. Whitney WV: Fertility Trends and Childrens' Allowance Programs. In: Childrens' Allowances and the Economic Welfare of Children: The Report of a Conference. EM Burns, editor. Citizens Committee for Children of New York, 1968. 6. Simon JL: The effect of income on fertility. Population Studies, 23:327-341, 1969. 7. Ley No. 7295, Actualizada para 1972. Ediciones Gutenberg, Santiago, Chile, 1972. 8. Cruz-Coke R: The population explosion in Chile, Lancet 2:434435, 1965. 9. United Nations, Demographic Year Books for 1965, 1966, 1971. 10. Plank SJ and Milanesis ML: Fertility in rural Chile. Social Biology, 20:151-159, 1973. 11. CELADE, La Fecundidad Rural en Latino America. Demography 2:97-114, 1965. 12. Plank SJ and Milanesi ML: Infant feeding and infant mortality in rural Chile. Bulletin of the World Health Organization, 48:203210, 1973. 13. A Manual for Surveys on Fertility and Family Planning: Knowledge, Attitudes, and Practice. The Population Council, New York Citv 1970.
In Memory of Doctor Jacob Kittredge Who Died July 28th 1813 Aged 63 B eneath the sacred honors of the tomb In awful silence and majestic gloom The man of mercy here conceals his head Amidst the awful mantions (sic) of the dead No more his liberal hand shall help the poor Relieve distress and scatter joy no more While he from death did others seek to save Death threw a dart and plunged him in the grave.
994
AJPH October, 1978, Vol. 68, No. 10
