In a systematic review of the international literature, we have shown that generous parental leave policies are associated with positive mental health outcomes for both parents (Heshmati et al. 2023). This crucial question about health effects prompted our recent study, published in JAMA Pediatrics, which examined Sweden’s “speed premium” policy, introduced in 1980. The policy was designed to provide income protection for parents who had children in quick succession (less than 24 months apart). However, it inadvertently led to negative health consequences for newborns.
In particular, our research revealed that the introduction of the policy was associated with a 24% increase in preterm (premature) birth rates over the six years it was in force. The relaxation of the policy in 1986, which extended the timeframe to 30 months, was associated with an 11% reduction in preterm birth rates over the following six years. These findings have important societal implications as preterm birth is associated with several adverse health and social outcomes later in life and represents a significant economic and societal burden.
The policy
In Sweden, before the introduction of the policy in 1980 and still today, parents who are eligible for earnings-based parental leave benefits can receive approximately 80% of their pre-childbirth salary. However, if they have a subsequent child soon after a period of parental leave, they may experience a significant reduction in benefits, as it is calculated on the basis of a previous period of parental leave or on a lower salary due to shifts to part-time work.
To avoid this loss of income for parents, especially mothers who have children in quick succession, the Swedish system introduced the 1980 speed premium policy to protect parents against the income loss associated with having children less than 24 months apart. In 1986, this period was extended to 30 months, a duration that has remained unchanged to this day.
Mechanisms
The 1980 reform had the unintended effect of increasing the proportion of parents who had children between 18 to 24 months apart to qualify for income support. This birth interval has been associated in the literature with adverse perinatal outcomes. In fact, the current World Health Organization recommendation is that women should wait at least 24 months after giving birth before becoming pregnant again to avoid adverse health outcomes for both mother child.
However, the study also shows an increase in the proportion of preterm births among first-born children, suggesting that the effect of the policy cannot be attributed solely to shorter birth spacing. In the study, we show that the introduction of the policy was also associated with a higher proportion of women having children at older ages, possibly because the policy benefited parents who were further along in their careers and had higher incomes.
We hypothesise that the policy may have encouraged older women who might not otherwise have children, to start their reproductive journey and aspire to the two-child norm in Sweden. This second consequence may have inadvertently contributed to the increase in preterm births, as advanced maternal age is a known risk factor for several adverse reproductive health outcomes.
In conclusion, despite the economic benefits of the speed premium supplement for parents, its introduction has been associated with unintended negative health consequences for the next generation.
Lessons for policymakers
Despite the economic rationale behind the policy, our research highlights the critical importance of considering its wider impact: The reform had unintended negative health consequences because it did not consider how the eligibility criteria might affect fertility decisions among couples and subsequently the health of their offspring.
To avoid similar outcomes in the future, policymakers need to adopt a multidisciplinary approach and integrate health considerations into policy design. Our study also illustrates the need to adopt the Health in All Policies (HiAP) framework, launched during the Finnish Presidency of the European Union to emphasise the importance of considering health in all policy areas.
Lessons for researchers
Family policies can have many unforeseen consequences. It is therefore imperative to broaden the scope of policy evaluation to include their potential side effects. Collaborative efforts are needed to advance the implementation of Health in All Policies.
References:
Debiasi E., Honkaniemi E., Aradhya S., Hjern A., Duvander A-Z. & Juárez SP (2024). Unintended perinatal health consequences of associated with a Swedish family policy. JAMA Pediatrics, doi:10.100/jamapediatrics.2024.0378
Heshmati, A., Honkaniemi, H & Juárez, SP (2023). The effect of parental leave on parents’ mental health: a systematic review and meta-analysis. The Lancet Public Health, Jan 8 (1): e57-e75. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(22)00311-5/fulltext
Acknowledgement:
The study "Unintended perinatal health consequences associated with a Swedish family policy" is part of the research project "The unintended consequences of Swedish parental leave policy: A health equity perspective" led by Associate Professor Sol Juárez. Its purpose is to contribute much-needed knowledge to ongoing debates on parental leave policy reforms by illustrating the ways in which they can also act as health policies, while providing knowledge that can be used to help achieve Sweden’s public health policy goals of social and health equity for all. The project is funded by The Swedish Research Council (Vetenskapsrådet).