Born into inequality: How neighborhoods influence birth outcomes in the Netherlands

Vera ScholmerichBy Vera Schölmerich / Reading Time: 7 Minutes


Miriam and Sofia are best friends and enjoyed growing up in the same neighborhood next to the Vondelpark in Amsterdam – one of the richest areas in the city. In her early thirties, Miriam moves to the Bijlmer – one of the poorest neighborhoods of Amsterdam. A while later, Miriam and Sofia meet up for coffee. Miriam excitedly tells Sofia that she is pregnant. Sofia replies: “Me too!”
Miriam and Sofia are both healthy, and lead a healthy lifestyle – they eat enough veggies, go to see their midwife on time, etc. Miriam’s lifestyle has not changed since her move to the Bijlmer, but she lives in a very different neighborhood. Would Miriam’s chances of a healthy baby be any different than Sofia’s, as a result of living in a poor neighborhood?


In other words, do neighborhoods influence birth outcomes, 

above and beyond an individual’s health?

 The answer you will find in an article my colleagues and I recently published in PLOS ONE is: yes.

The Netherlands is home to one of the highest recorded disparities in birth outcomes across neighborhoods in any developed country. In wealthy neighborhoods in Rotterdam, for example, about 3% of babies are born prematurely. In poorer neighborhoods, over 15% of babies are born prematurely, and therefore have a bad start in life, often leading to long-term developmental problems such as reduced IQ.

Previous studies have shown that the inequalities in birth outcomes across neighborhoods are partially the result of so-called ‘compositional effects’: healthier people tend to live in wealthier neighborhoods, and less healthy people cluster in poorer neighborhoods. We suspected, however, that there might also be ‘contextual effects’, meaning that neighborhoods influence birth outcomes.

But how could neighborhoods influence Miriam’s birth outcomes? There are at least two pathways. First, neighborhoods influence behavior via specific norms and social control. Imagine Miriam – who is visibly pregnant – waiting for the bus, sitting next to a man. Whether this man will light up a cigarette right next to her partially depends on the existing norms in this neighborhood, and how other people would react.

Second, neighborhoods might influence birth outcomes via biological pathways. Miriam has moved to a neighborhood with much higher crime rates and lower levels of social cohesion amongst residents. Miriam is therefore more likely to feel more stressed, and stress is a major risk for premature birth.

To find out whether neighborhoods influence birth outcomes, we used data on the characteristics of all inhabited neighborhoods in the Netherlands (more than 3400 neighborhoods), as well as data on individual characteristics and birth outcomes of all pregnant women in the Netherlands during the last 8 years (about 1,6 million cases).

We found that neighborhoods indeed influence birth outcomes. More specifically, between 2-5% of the variation in birth outcomes can be attributed to neighborhood effects. To go back to Miriam and Sofia: this means that Miriam will have higher chances of an unhealthy baby due to her move to the Bijlmer – a poor neighborhood with lower levels of neighborhood social cohesion. Our results show that both of these characteristics were the strongest neighborhood predictors of adverse birth outcomes.

For Miriam, the negative effects of her neighborhood are bad news. For policy makers however, our study is actually good news. Currently, policies to reduce inequalities in birth outcomes focus on educating women to lead healthy lifestyles – with disappointing results. Our study indicates a new way of improving birth outcomes, namely by adopting a contextual approach. We recommend investing in improving neighborhoods, such as allocating more funds to reducing poverty and crime rates and increasing social cohesion (e.g. by increasing the amount of parks and neighborhood initiatives).

Instead of focusing on educating a small amount of pregnant women, improvements to neighborhoods have the advantage that they influence a large number of residents in the neighborhood. A shift in policy might reduce inequalities in birth outcomes across neighborhoods – and lower the amount of babies that are born into inequality.


Vera Schölmerich completed her joint-PhD at the Department of Obstetrics and Gynaecology (Erasmus Medical Center) & the Department of Organization Sciences (VU University Amsterdam).She is currently an assistant professor at Erasmus University College, Rotterdam.

Why the poor remain poor

Vera Scholmerich  by Vera Schölmerich / Reading Time: 5 Minutes /

“Vera, you bought bottled water for €2,50 and you live in a country where tap water is not only free but at least as good as the water in that bottle that you paid for. You obviously have more money than you need.”

My friend was right. It is indeed ridiculous that we are still buying bottled water: see the Story of Stuff’s great video about this here. So, I have decided to stop buying water (and a bunch of other things I buy out of laziness) and donate this money to charity instead. But which of the gazillions of charities should I support? Burdened by to many options, I turned to GiveWell’s top-charity list. GiveWell performs rigorous research to annually select three charities that have demonstrated high cost-effectiveness and are underfunded.

GiveWell’s current nr. 1 charity is GiveDirectly (the similarity in names is a coincidence). This charity gives cash to poor families, no strings attached. In spite of their excellent ranking, I felt hesitant to support them. Would such a simple approach work? Is money all that the poor need? In their recently published book “Scarcity – Why having too little means so much”, Mullainathan and Shafir explain why giving money to the poor might be the way to go. This blog is about the theory of scarcity, and its implications for development aid.

Mullainathan and Shafir define scarcity as “a subjective sense of having more needs than resources”. Next to a lack of money, a sense of scarcity can arise due to other aspects, such as too little time or loneliness. The two scholars explain that a feeling of scarcity changes our fundamental mental capacities. More specifically, it reduces our cognitive capacities (which help us solve problems, think logically, and so on) as well as our executive control (which helps us plan, focus our attention, exert self-control, etc).

The effect of scarcity means that a poor person living in the Netherlands might also make the mistake of buying bottled water – but not because she is lazy (as I am), but because she has less mental capacity to exert self-control, and to analyze how this waste of money will put an even bigger strain on her financial situation.

I assume that most if not all readers will recognize being extremely busy for a longer period of time: back-to-back meetings, deadlines, and daunting to-do lists. Mullainathan and Shafir would predict that your mental capacities would decrease during this phase. During this phase you would be particularly likely to underestimate how long meetings will take, overlook dead-lines, or say yes to a new project without taking a step back to really evaluate if you can commit to it. Sound familiar?

Mullainathan and Shafir used natural and lab experiments to assess the impact of scarcity on mental capacities. In one natural experiment, for example, they studied sugar cane farmers. These farmers receive a large sum of money after the harvest, but then find themselves scrambling to make ends meet about a year later, before the next harvest. This means that these farmers experience scarcity before the time of harvest. With this study and many lab experiments, Mullainathan and Shafir found that the effects of scarcity on our mental capacities are substantial. While most pop science books would leave it at that – Mullainathan and Shafir do a great job at actually indicating effect sizes. They explain that the effect of scarcity on human’s mindsets is comparable to skipping an entire night of sleep. Also, scarcity leads to the IQ to drop by about 13 points. This is enough for someone to go from the category ‘average’ intelligence to ‘borderline deficient’.

This means that people experiencing scarcity – say someone living in poverty – are doubly burdened. They have to deal with not having enough money, combined with reduced mental capacities. Mullainathan and Shafir claim that this explains why the poor remain poor, why the lonely remain lonely, or why the busy remain busy. Moreover, they recommend public policies that relieve people of their sense of scarcity. This is exactly what the above-mentioned charity GiveDirectly is doing by providing cash transfers to poor families. And it seems to be working. A rigorous randomized control study concludes that “poor recipients spent the money on a broad variety of items, including food, shelter, and productive assets, leading to significant improvements in income, food security, and psychological well-being.” If Mullainathan and Shafir’s are right, then this intervention will not only lead to psychological well-being, but an increase in mental capacities. And this, as argued above, is key in order for the poor to be able to become less poor.

So are cash transfers the way to go? They are certainly “in” at the moment. At the same time, critics have claimed that the evidence for cash transfers to the poor is overrated, mainly pointing towards limited cost-effectiveness and a lack of evidence of long-term impact.

Cash transfers are – just like any other development approach – not the silver bullet (for more on this see various posts by the great blogger Chris Blattman). However, Mullainathan and Shafir’s research on scarcity defies the conservative logic that everyone can lead a good life if they just try hard enough. The poor are not poor because they are incapable, but because – amongst other constraints – the experience of scarcity makes them less capable.

So, in spite of the criticism of cash transfers, I have decided to stop buying bottled water, and to GiveDirectly.


Vera Schölmerich MSc is a PhD Candidate at the Department of Obstetrics and Gynecology of Erasmus Medical Center and at the Department of Organization Sciences of the VU University Amsterdam. Vera is also an Assistant Professor at Erasmus University College, where she teaches research design and methods.


3 reasons why we are so bad at predicting our chances of academic success

Vera Scholmerich  by Vera Schölmerich / Reading Time: 5 Minutes /

A question that I asked myself at the beginning and throughout my PhD is: “what are the chances that I will be able to pursue a career in academia after my PhD?”. Conversations with fellow PhD’ers at the coffee machine tell me that I am not alone in asking this question. In the absence of a friendly statistician popping by and informing us on our exact chances of advancing, we have to guesstimate what these might be. Humans use mental shortcuts (also called ‘heuristics’) to solve such problems. These shortcuts intuitively feel accurate, but actually provide us with very bad estimates. Borrowing from Daniel Kahneman’s international bestseller ‘Thinking, Fast and Slow’ (2011), I outline 3 major mental shortcuts that lead us astray.

Mental shortcut nr 1: Humans tend to focus on individual cases and neglect statistics, even if the latter are available (Kahneman, 2011, pp. 166). When I first started pondering on my chances of staying in academia, I did not go online to look for data on how many PhDs actually stay in academia. Rather, my first move was to look for individual examples I knew: which of my colleagues that had recently obtained their PhD continued in academia? Last week I heard a fellow PhD declare that our chances of staying in academia were virtually zero because “All of the six fellow PhD candidates that started together with me had to leave academia, so it must be impossible”.

Consequence of this mental shortcut: depending on the (often unrepresentative) individual cases we focus on, our predictions of success rates in academia are either too high or too low. This means that we might be overly optimistic, or pessimistic.

Illustration by David Parkins via

Mental shortcut nr 2: Human brains are wired to ascribe causal explanations to events (Kahneman, 2011, pp. 169). So when mental shortcut nr 1 leads us to focus on colleagues that managed to stay in academia, we look for reasons as to why this happened. We search for characteristics of these people – intelligence, nr of publications, how hard they worked, etc. “Leah did well because she put in so many long hours and because she is very clever”. The problem, however, is that we are bad at distinguishing between causality (the long hours Leah put in actually contributed to her promotion) and mere association (Leah, like many academics, is a workaholic, but this did not contribute to her promotion). In fact, the finding that most people who do well in academia tend to work long hours might say more about the type of people that work in this profession rather than a necessary attribute for success.

Consequence of this mental shortcut: we are bad at assessing what we need to do in order to advance in academia.

Mental shortcut nr 3: People underestimate the role of luck (Kahneman, 2011, pp. 177). Due to the mental shortcut nr 2, we prefer causal explanations. Causality leaves little to no room for the role of ‘luck’. Especially if you put in a lot of tears and sweat to achieve something, it is difficult to entertain the idea that part of your success was due to pure luck – the mood that a reviewer was in or whether that hotshot researcher from Oxford also decided to apply to the job that you want. When asked by’s John Brockman what his favorite equation was, Kahneman replied:

Success = talent + luck

Great success = a little more talent + a lot of luck

Consequence of this mistake: we do not account for the unpredictability of success in academia and incorrectly entirely attribute success (or lack thereof) to the actions of individuals.

Fortunately, there is a way out:

Kahneman provided some tricks for making better predictions, which I have adapted to fit our particular question at hand:

Step 1: Start with the base rate of advancing in academia. This is what I should have done when I first starting thinking about this question (but never did until I started writing this blog…). In the Netherlands about 20% of PhD candidates stay in academia upon completion of their PhD (WOPI 2011). In other words, there is a 1 in 5 chance of advancing in academia.

Step 2: To determine your personal chances of staying in academia, adjust this rate up or down based on individual variables that influence the success rate.

This step is much more difficult in the Netherlands due to lack of accessible data and analyses. One crucial piece of information that we do have is the distribution of women/men in post-PhD positions. Not surprisingly, the percentages of women drop with each jump up the career ladder (women as assistant professors: 33%, associate professors: 21%, professors: 14%, see WOPI 2011). Hence, if you are a woman, your chances are much lower than 1 in 5.

(WOPI, 2011)

A crucial variable is missing, however: we don’t know how many of the 80% of PhDs leaving academia would have preferred to stay. For example, if almost all of the PhDs that left academia did not want to stay anyway, then the future looks quite bright for those eyeballing an academic career!

What are other important variables we need to take into account? My intuition tells me that the characteristics usually proclaimed as important for an academic career – namely being very clever and working long hours – are outdated. Academia is changing, and perhaps other skills are becoming more and more important, such as social skills, cooperation with others, productivity and being able to spot opportunities. However – I’ll leave it up to future research to figure this out – as these answers are also just the product of my mental shortcuts. Have any of the readers come across interesting research that tells us which characteristics we need to include in our guesstimation? I would be enchanted to hear from you.  


Vera Schölmerich MSc is a PhD Candidate at the Department of Obstetrics and Gynecology of Erasmus Medical Center and at the Department of Organization Sciences of the VU University Amsterdam. Wedged in between a medical and a social science faculty, Vera looks at how ‘social factors’ influence prenatal health and the organization of maternal health care.

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