Elsevier

Journal of Health Economics

Volume 30, Issue 6, December 2011, Pages 1246-1260
Journal of Health Economics

Long-term health effects on the next generation of Ramadan fasting during pregnancy

https://doi.org/10.1016/j.jhealeco.2011.07.014Get rights and content

Abstract

Each year, many pregnant Muslim women fast during Ramadan. Using Indonesian cross-sectional data and building upon work of Almond and Mazumder (2011), I show that people who were prenatally exposed to Ramadan fasting have a poorer general health than others. As predicted by medical theory, this effect is especially pronounced among older people, who also more often report symptoms indicative of coronary heart problems and type 2 diabetes. Among exposed Muslims the share of males is lower, which is most likely caused by death before birth. I show that these effects are unlikely the result of common health shocks correlated to the occurrence of Ramadan, or of fasting mainly occurring among women who would have had unhealthier children anyway.

Introduction

Mothers’ behavior during pregnancy, such as smoking and alcohol and coffee consumption, is known to have long-term effects on their children's health. Medical studies show that fasting during pregnancy in the form of skipping breakfast and other meals is another aspect of mothers’ consumption and behavior that may have a negative effect on the health of their children, which may last into adulthood. Each year, many pregnant women fast during daylight hours during the Islamic holy month of Ramadan. They do this, even though, according to most interpretations of Islam, they are exempted from the religious obligation to fast if they are worrying about their own health, or the health of their fetus. This paper shows that the health of people is negatively affected if their mother fasted during a Ramadan while they themselves were still in utero. This effect gets stronger as these people get older. Although effects on pregnant women and newborn babies with respect to Ramadan fasting have been measured in previous studies, very little research exists on the long-term effects of having a mother who observed Ramadan during pregnancy, and no research has yet examined effects on the serious health problems that are specifically predicted by medical theory, such as coronary heart disease and type 2 diabetes.

Almond and Mazumder (2011) are the first to systematically examine long-term effects of pre-birth Ramadan exposure. Using Michigan data, they first focus on short-term effects and demonstrate that exposure in utero is associated with lower birth weights and a lower share of male births. Next, they show that prenatally exposed Ugandan adults have higher probabilities of having sensory or mental disabilities and less wealth. Iraqi data corroborate these long-run effects. An important implication of their findings is that long-term effects of poor nutrition during pregnancy not only occur for the severe and uncommon types of circumstances that are usually studied (notably famines) but also for milder and more common types of nutritional exposures that are more amenable to intervention.

My paper confirms the finding of Almond and Mazumder that prenatal Ramadan exposure affects later-life health in a different country and context. It moreover goes further in demonstrating the robustness of this general finding to alternative explanations: I not only demonstrate that selection on observables does not drive results by comparing parents of exposed and not exposed children. But I also use a mother fixed effects approach to show that unobservables that are time invariant within mothers do not drive my results. Furthermore, I am able to determine prenatal Ramadan exposure more precisely since I use exact date of birth instead of only month of birth, which reduces noise. Another major contribution of this paper is that, compared to Almond and Mazumder's analyses on long-term health effects which rely on rather crude measures of disabilities, the rich data set I use contains better and more detailed measures of people's general health, and adds indicators for high-prevalence serious health problems, including coronary heart disease, hypertension and type 2 diabetes. My analyses on different symptoms and age groups, moreover, closely follow, and confirm, specific predictions made by medical theory on how poor prenatal circumstances can lead to serious health problems much later in life.

The data I use consist of a cross-sectional sample of the population of Indonesia, which is the country with the largest Muslim population in the world. After showing that general health, especially that of older people, is negatively affected by exposure, I examine which aspects of health are affected. I find evidence that exposure leads to a higher likelihood of developing symptoms that are indicative for coronary heart disease, type 2 diabetes and kidney problems at older age. A point of overlap with Almond and Mazumder is that I also find a lower share of males among the exposed. This fits with medical theory, because in utero, males are more vulnerable to adverse conditions. Importantly, I investigate whether there are alternative explanations for these effects. I show that they are most probably not artifacts of selective timing of pregnancies: perhaps Muslims who care a lot about their offspring's health may avoid pregnancy during Ramadan. Using mother fixed effects and by comparing the characteristics of parents whose child was, vs. was not, in utero during a Ramadan, I refute this alternative explanation. Also, throughout this paper, to rule out that effects of Ramadan during pregnancy are caused by correlated common shocks to birth cohorts, I show that no effects of timing of Ramadan are found on non-Muslims.

The paper is structured as follows: Section 2 gives background information on Ramadan and explores Muslims’ beliefs on observing the Ramadan fast during pregnancy. Section 3 discusses medical theory on how maternal fasting during pregnancy may exert a long-term effect on the health of her offspring. Section 4 describes the data used. Section 5 presents the results. It starts with effects on general health and some checks on the robustness of the results found. It next deals with effects on the sex ratio and then focuses on specific diseases, including coronary heart disease, diabetes, hypertension and anemia. Section 6 discusses the implications of this research. Throughout this paper, I will complement the analyses with information obtained from interviews I held in Indonesia during Ramadan 2008 with doctors, midwifes, health workers and others. These interviews and the observations made in hospitals and health clinics during my visits are not representative for a complete Indonesian population, nor do they serve to replace any quantitative analyses, but they do often shed more light on the local situation and the believes and experiences of Indonesians.

Section snippets

Background

Ramadan is the holiest month of Islam. It is one of the five “pillars” of Islam that Muslims have to fast during this month. No food and drinks are to be taken from dawn to sunset. Smoking, sexual intercourse and, according to some interpretations, the taking of oral medicine are also forbidden during these hours. In the evening, the fast is broken with sweet drinks and snacks. This is a very social happening, in which family and friends come together. If a Muslim misses a day of fasting, (s)he

Medical theory and evidence of the effects of Ramadan fasting during pregnancy on offspring's health

Medical theory on how Ramadan fasting during pregnancy affects the offspring, is highly related to medical theory on fasting, skipping meals, and hunger during pregnancy in general. Long-term effects are mainly expected to arise because a shortage in nutrition hampers fetal growth and causes damage to the fetal body, while at the same time such a nutritional shortage arises relatively quickly in a pregnant woman because the fetus growing inside of her increases her energy demands.

The fasting

The data

The Indonesian Family Life Survey (IFLS) is a broadly set up longitudinal survey carried out by the RAND corporation (Strauss et al., 2004). I use data from the third wave, since, in comparison to the two previous waves, it has the largest sample size, contains the most complete birth date information and contains more information of interest for the purposes of this research. IFLS 3 was carried out in 2000. It collects a great amount of information at individual, household and community level

Effects on general health

The following analyses go into general health. After showing that Indonesian Muslims who were exposed to Ramadan in utero have a worse general health, I look at a few alternative explanations: common shocks in health that happened to be correlated to the occurrence of Ramadan and systematic differences between mothers whose children were vs. were not exposed that can be lead back to selective timing by certain parents of pregnancies to avoid Ramadan. I will show that the finding that fasting

Discussion

Observing the Ramadan fast during pregnancy may cause considerable negative health effects on the offspring, irrespective of the stage of pregnancy in which Ramadan took place. Such effects are not limited to the health outcomes around the moment of birth that were shown in earlier research. Indeed, some effects get stronger, or only show up, when the offspring gets older. Exposure to fasting before birth is associated with a poorer general health. It also increases a person's chances of

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    1

    I would like to thank Douglas Almond, David Barker, Monique de Haan, Bhashkar Mazumder, Sandra McNally, Hessel Oosterbeek, Erik Plug and an anonymous referee for their helpful comments and suggestions. I gratefully acknowledge comments from seminar participants at the National Islamic University (UIN) in Jakarta, Indonesia, the London School of Economics, the Chicago Federal Reserve Bank, the Centre for European Economic Research (ZEW), and the University of Amsterdam Medical Center (AMC). I thank my Indonesian hosts, particularly the people from UIN and Dwi Tyastuti for their great help in organizing the interviews and visits I made during Ramadan 2008. Tessa Roseboom, who leads the “Fetal origins of adult disease” research programme at the University of Amsterdam Medical Center (AMC), I thank for her expert advice on the medical theory described in this paper. Any remaining errors are my own. Part of the research was carried out when the author worked on the Netspar theme “Income, Health and Work and Care Across the Life Cycle”.

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