Causes and consequences of fertility decisions, and mental health

In one of her studies, Zwiers investigated the link between the availability of the birth control pill in the Netherlands and the economic position of women in society. What does this mean for the current generation of young women, which seems to be turning away from hormonal contraception? In another study, which is now forthcoming in the Journal of Human Resources, she researched the relationship between postpartum antidepressant use and health outcomes.

Birth Control

The birth control pill was introduced to the Dutch market in 1963. At that time, the packaging did not indicate that the product could prevent pregnancy, Zwiers explains. 'The Netherlands was characterized by conservative Christian norms before the sexual revolution: advertising contraceptives was forbidden. The pill was marketed as a medication that could regulate the cycle, and temporary infertility was only mentioned as a side-effect. To avoid tempting workers to engage in immoral behavior, packaging the pill was even outsourced to a nunnery when demand increased.'

'Significant improvement in the position of women'

Esmée Zwiers examined how improved availability of the birth control pill from the early '70s influenced the economic position of women in the Netherlands. The effects are substantial, as described in a recent article she co-authored with research fellow Olivier Marie from the Erasmus University Rotterdam.

'Women who had access to the pill at younger ages were more likely to delay marriage and motherhood compared to women who gained access at later ages. They also invested more in their education, performed better on the labor market, and accumulated more wealth in the long run.' The research was recently cited in an ESB article, a Demos article, and a podcast. (all sources in Dutch).

Price of the pill has an impact

Today, obtaining a prescription for the pill is quite straightforward. Not all barriers have been eliminated however, as Zwiers explains: 'Statistics from the Rutgers Foundation show that in 2017, 34% of young sexually active women did not use contraception. Of that group, 2% mentions the costs of contraceptives as the reason for not using contraception. Additionally, a survey executed by Doctors of the World indicates that especially economically vulnerable women would prefer using a different contraceptive method than the one they are currently using if they could afford it.' So, a financial barrier to using the pill continues to exist. For the Bureau Clara Wichmann, an organization dedicated to improving the legal position of women, this has been grounds for legal action to force government to include the birth control pill in the public health insurance package.

But price is not the only factor

Hormonal contraceptives such as the pill are currently under pressure for reasons unrelated to price. A recent article (in Dutch) of the Dutch Broadcasting Foundation NOS highlights that fewer young women use hormonal contraceptives. A fear of hormones – ‘hormone phobia’ – is said to underlie this trend, fueled in part by content from influencers on social media. Doctors indicate though that pregnancy risk is higher for alternative ‘natural’ forms of contraception, such as periodic abstinence.

'Contraception is important for women'

Zwiers’ research shows the important role the pill has played for women: 'Preventing unplanned births using the birth control pill has had significant consequences for women since the 1970s. Today, 50 years later it will be interesting to see if ‘hormone phobia’ will lead to more unplanned births in the coming years and if so, how that might influence women’s educational and labor market opportunities.'

Overprescription of Antidepressants

In the paper  “Medication of Postpartum Depression and Maternal Outcomes: Evidence from Geographic Variation in Dutch Prescribing” that Zwiers co-authored with Janet M. Currie (Princeton University, United States), they found that postpartum patients on antidepressants were consistently more likely to rely on them up to three years after giving birth, but that there was little effect on other outcomes. They also found that low-income and socially disadvantaged mothers were more likely to live in high-prescribing areas. The evidence points to an overprescription of antidepressants in certain regions, the researchers report in a paper that is now forthcoming in the Journal of Human Resources.

The comparisons suggest that anti-depressant prescribing has little causal impact on most outcomes with one important exception: New mothers prescribed antidepressants were more likely to still be taking the medication three years later.

While the study faced some limitations, the researchers believe their findings suggest that doctors in high-prescribing areas may be overprescribing antidepressants to mothers who receive little benefit from their use. This comes with a cost of long-term dependence on antidepressants.

About

Esmée Zwiers is an Assistant Professor at Amsterdam School of Economics since September 2022. Before she was a Postdoctoral Research Associate at Princeton University's Center for Health and Wellbeing, United States. She received her PhD in Economics from Erasmus University Rotterdam and Tinbergen Institute and is also a Tinbergen Institute Research Master alumna. Esmée has research interests in health economics, labor economics, economic history, and economic demography.

Sources: news items previously posted by Amsterdam School of Econonomics and Princeton School of Public and International Affairs.