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Short-term and long-term distributional consequences of prenatal malnutrition and stress: using Ramadan as a natural experiment
  1. Farhan Majid1,
  2. Jere Behrman2,
  3. Subha Mani3
  1. 1Rice University’s Baker Institute for Public Policy, Houston, Texas, USA
  2. 2Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  3. 3Economics, Fordham University, New York City, New York, USA
  1. Correspondence to Dr Farhan Majid; farhan.majid{at}


Introduction Fetal environments play significant roles in determining adult well-being, particularly as they relate to non-communicable diseases and skill formation. We studied gender-specific distributional consequences of fetal environment (in the form of in-utero exposure to Ramadan, the Islamic holy month of fasting), in Indonesia, on birth weights, performance on Raven’s Colored Progressive Matrices (CPM), math scores, hours worked and earnings.

Methods We used quantile regressions to conduct a quantitative comparison of distributional consequences, by gender, of full month exposures to Ramadan in-utero on outcomes of interest. Our data included Muslim children and adults measured during rounds 1 and 4 of the Indonesian Family Life Survey. Our main outcome measures were: birth weights—559 observations (females) and 624 (males); Raven’s CPM scores—1693 (females) and 1821 (males) for 8–15 year olds; math test scores—1696 (females) and 1825 (males) for 8–15 year olds; hours worked—3181 (females) and 4599 (males) for 18–65 year olds; earnings—2419 (females) and 4019 (males) for 18–65 year olds.

Results Full month of exposure to Ramadan in-utero led to significant reductions at the 5% significance level that were concentrated in the bottom halves of the outcome distributions: among 8–15 years, lower scores on Raven’s CPM tests for females (mean: −9.2%, 10thQ: −19%, 25th Q: −19.4%) and males (mean: −5.6%, 10thQ: −12.5%); lower math scores for females (mean: −8.6%, 25thQ: −15.9%) and males (mean: −8.5%, 10thQ: −13.6%); among females 18–65 years, significant reduction in hours worked (mean: −7.5%, 10thQ: − 26.3%).

Conclusion Events during the fetal period have far-reaching consequences for females and males in the lowest (10th and 25th) quantiles of outcome distributions, affecting the ‘relatively poor’ the most. These results call for caution in interpreting studies on child development that rely on mean comparisons alone.

  • child health
  • health economics
  • nutrition
  • maternal health

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  • Handling editor Seye Abimbola

  • Contributors FM, JB and SM conceived of this study and general research strategy. FM undertook the data preparation and econometric estimates. JB and SM consulted with FM on the estimates and contributed to revisions in the estimates. FM wrote the first draft and JB and SM provided revisions. FM, JB and SM all read the final version and agreed that it was ready for submission. FM is guarantor.

  • Funding This research was supported by Grand Challenges Canada ‘Savings Brains’ grant (Grant 0072-03 to the Grantee, The Trustees of the University of Pennsylvania).

  • Disclaimer The funding agency played no role in the conduct of this research and the decision to submit this manuscript for publication.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No additional data are available. We will be happy to share data used in the anlaysis upon request.