American Economic Review: Papers & Proceedings 2008, 98:2, 511–515
http://www.aeaweb.org/articles.php?doi=10.1257/aer.98.2.511
Stress and Birth Weight: Evidence from Terrorist Attacks
By Adriana Camacho*
While terrorist attacks are relatively infre-
quent, Gary Becker and Yona Rubinstein (2008)
provide evidence that they generate a dispropor-
tionate amount of stress and fear, suggesting that
the indirect effects may be far more reaching
than the direct effects. The international organi-
zation Médecins Sans Frontières (2006) claims
that the physiological effect of civil conflict is
Colombian’s worst public health problem. This
paper is the first attempt to measure the effect of
prenatal psychological stress due to terrorism on
child birth outcomes.
The medical literature indicates that prena-
tal stress increases levels of Corticotrophin-
Releasing Hormone (CRH), which regulates the
duration of pregnancy and fetal maturation and
thus increases the risk of adverse birth outcomes
(Pathik D. Wadhwa et al. 1993, among others).
There is also evidence that birth outcomes are
most sensitive to maternal stress in early stages
of pregnancy (Laura M. Glynn et al. 2001).
This study finds that the intensity of random
landmine explosions during a woman’s first
trimester of pregnancy has a significant nega-
tive impact on child birth weight. This finding
persists when mother fixed effects are included,
suggesting that neither observable nor unob-
servable characteristics of the mothers are driv-
ing the results. I use a large dataset, comprising
approximately 4 million births in Colombia
from 1998 to 2003, which enables me to observe
multiple births by the same mother and gives
strong statistical power to discern patterns. The
data also allow me to link the date of a landmine
explosion with the trimester of the pregnancy,
and thereby to identify the stage of pregnancy
* Department of Economics, Universidad de los Andes,
Bogotá, Colombia (e-mail: adcamach@uniandes.edu.co). I
thank Anna Aizer, Jere Behrman, Emily Conover, Andrew
Foster, Alaka Holla, Daniel Mejia, LACEA 2007, seminar
participants at Brown University, Universidad Javeriana,
Universidad del Rosario, and Universidad de los Andes
for helpful comments and suggestions. I am also grate-
ful to Departamento Nacional de Planeación (DNP) and
Departamento Administrativo Nacional de Estadisticas
(DANE) for providing the data.
511
at which stress most influences birth weight.
Finally, the data show that landmines have been
laid all over the country, and explosions occur
with different levels of intensity across time
and space. This yields a very powerful quasi-
experimental setting design to test the effects
of exogenous stress shocks on birth outcomes,
overcoming both the difficulty of doing an
experiment, and issues of nonrandom residence
during pregnancy.
The results from this paper identify an
important channel through which violence may
increase inequality and have long-lasting inter-
generational effects on human capital accumu-
lation. They could be related to the findings of
Janet Currie and Enrico Moretti (2007), which
show strong intergenerational correlations of low
birth weight (LBW). Moreover, previous work
has established that birth weight is an impor-
tant predictor of aspects of health later in life,
including a higher probability of infant mortal-
ity (Douglas Almond, Kenneth Chay, and David
Lee 2005), lung disease, heart disease, type II
diabetes, lower cognitive abilities, and learning
disorders (Jennifer Couzin 2002). In addition,
it is strongly associated with socioeconomic
outcomes later in life (Sandra Black, Paul J.
Devereux, and Kjell G. Salvanes 2007; and Jere
R. Behrman and Mark R. Rosenzweig 2004).
I.  Data
The Vital Statistics Records, collected by
the Administrative Department of Statistics
(DANE), correspond to 4.3 million birth certifi-
cates filed in hospitals within the 1,120 munici-
palities in Colombia from 1998 to 2003. The
final analysis of this paper will use a panel of
mothers appearing more than once between 1998
and 2003, reducing the sample to 781,000 birth
records. The average birth weight in Colombia

Landmines have been found in 422 out of 1,120 munic-
ipalities (counties) and 31 out of 32 departamentos (states)
in Colombia.
512 AEA PAPERS AND PROCEEDINGS
for the period of study was 3,153 grams, and
7.74 percent of births were LBW.
The working dataset merges Vital Statistics
Records with quarterly data from the National
Planning Department (DNP) on landmine
explosions by municipality of residence.
Municipalities’ showed substantial variation
in violence levels over the 1998–2004 period.
Naively, I could test for associations between
child birth outcomes and any violence indica-
tor, but it is important to use arguably exogenous
indicators of the violence in order to purge the
estimated impact of fetal stress on birth out-
comes of any area-specific unobservable that
may be correlated with both levels of violence
and birth outcomes. Moreover, it is important to
have a measure that mainly captures a shock of
violence rather than persistent levels of violence.
Landmine explosions are used as the most cred-
ible violence exogenous stress shock, since they
generate fear once others in their same area have
suffered from an explosion. Terrorism intends
to instill fear or “terror” in the general popula-
tion by affecting random victims unpredictably.
Using terrorist attacks instead of other violence
measures allows me to assume that people know
the level of violence prevalent in their area of
residence, but they are uncertain about the time,
magnitude, and exact place of an explosion.
II.  Theoretical Framework and   ables (age, education, and marital status of the
Empirical Specifications
In the following health production function:
(1)  bimj 5 G1Yimj , limj , mmj , eimj 2 ,
the subscript i refers to the child, m to the mother,
and j to the area of residence; b corresponds to
birth weight, Y are goods that can affect birth
weight, l are health inputs that require time, m is
a family-specific exogenous health endowment,
and e is an input that can be added to the stan-
dard health production function. Here, e corre-
sponds to an environmental factor that causes
stress. These ­environmental factors can be per-
ceived differently among mothers.
Using cross-sectional samples of births could
lead to biases because of unobserved hetero-
geneity with respect to genetic endowments,

LBW is defined as birth weight less than 2,500 grams.
MAY 2008
parental behavior, and differences in perception
of stress. Since the data permit the construction
of a panel of mothers, comparing siblings is a
better way to deal with unobserved heterogene-
ity, as mother fixed effects will account for all
family-specific heterogeneity.
The reduced form linear relationship of the
health production function estimated is given
by
(2)  bimjt 5 b 0 1 b1vj 1t 2 1 b2vj 1t212 1 b3vj 1t222
1 b4vj 1t232 1 b5 Ximjt
1 gyear 1 gmonth 1 gj 1 mmj 1 eimjt ,
where vj 1t 2 corresponds to a violence shock spe-
cific to place of residence j in quarter of birth
t. Similarly, the lagged vj terms correspond to
shocks in the three previous quarters. The pur-
pose of using the number of landmine explo-
sions and lags for the previous three trimesters
is to identify the stage of pregnancy when stress
has the most impact. As mentioned before, the
medical literature indicates that the strongest
effect should be found in the first trimester of
pregnancy. Thus, the estimated magnitude of b3
should be statistically significant and larger than
the other coefficients on the violence terms. The
matrix Ximjt contains a vector of control vari-
mother, sex of the baby, multiple birth, parity,
urban residence dummy, place of delivery, and
type of insurance). I also include year gyear and
month gmonth dummies to control for unobserv-
ables changing over time, such as seasonal pat-
terns of birth weight. The term gj corresponds
to fixed effects that control for all time invari-
ant unobservables varying at the departmento,
municipality, or mother level, depending on the
specification. The error term eimjt is assumed
to be orthogonal to birth weight, and mmj is the
family-specific health endowment that will be
absorbed only when using a mother fixed-effects
specification. Two assumptions are needed to
identify the impact of terrorist threats on birth
outcomes in a mother fixed-effects specification.
First, mothers’ unobservable characteristics that
affect birth outcomes must not change across
time. Second, siblings must share the same
initial health endowments. Furthermore, cross-
sectional estimations including ­ municipality
or departmento fixed effects yield ­ unbiased
VOL. 98 NO. 2 Stress and Birth Weight: Evidence from Terrorist Attacks 513

Table 1—Effect of Stress on Birth Weight 1in grams2

Section A 1 2 3 4
dmines 24.8240 21.7958
14.92472 12.15212
dmines1 28.5881 23.9416
13.23532*** 12.63552
dmines2 211.5918 27.5301 27.7106
13.10952*** 12.45602*** 12.25692***
dmines3 27.5848 26.1787
13.58692** 14.02432
Observations 2,890,417 2,409,122 2,890,417
R2squared 0.09 0.11 0.10

Section B 1 2 3 4
Mines 21.6061 20.3533
10.84402* 10.40862
Mines1 22.3695 20.8059
10.81092*** 10.61982
Mines2 23.4750 22.0204 22.2124 24.1643
10.83782*** 10.55762*** 10.58262*** 10.89972***
Mines2sq 0.2625
10.09342***
Mines3 22.7684 21.668
10.65042*** 11.02952
Observations 2,890,417 2,409,122 2,890,417 2,890,417
R2squared 0.09 0.11 0.10 0.10
Residence fixed effects Departmento Municipality Municipaliy Municipality

Notes: Robust standard errors 1 in parentheses 2 cluster at the municipal level.

   * Significant at 10 percent.
  ** Significant at 5 percent.
*** Significant at 1percent.
dmines is a dummy variable for having landmines.
mines is the number of landmines.
mines2sq is the number of landmines squared.

estimates only if shocks are equally perceived
or homogenous across all births within a geo-
graphical area. However, given that controls are
included, and given that the variation in land-
mine explosions is by quarter, any confounding
effects would have to vary at the municipality 3
quarter level to bias my results.
III.  Results
Section A in Table 1 presents results from
regressions of birth weight on the incidence of
landmine explosions in a trimester. The vari-
able dmines corresponds to a dummy variable
for having mines in the trimester of birth, while
dmines1, dmines2, and dmines3 correspond to
indicators for mine explosions occurring one,
two, and three trimesters earlier, respectively.
Section B from Table 1 presents results using the
number of landmines exploded in the trimester
of birth and the three previous trimesters. Given
the wide variation in violence data, I also test
for nonlinearities by including a quadratic term
of the number of landmines during early preg-
nancy (mines2sq).
Beginning with a naive approach, I first
assume that the “true” effect of exposure to vio-
lence at a certain time is homogeneous across
infants born within a geographic area. The
different models and empirical specifications
using departmento (column 1 from Table 1) and
municipality fixed effects (columns 2 to 4 from
Table 1) consistently find a negative effect of
landmine explosions during pregnancy on birth
weight. The departmento fixed-effects estimates
overstate the impact of stress on health out-
comes compared to municipality fixed effects.
Children born in a departmento with at least one
landmine explosion in each trimester of preg-
nancy weigh on average 27.76g less than those
born with no explosions. Landmines exploding
during early pregnancy have the strongest effect
514 AEA PAPERS AND PROCEEDINGS MAY 2008

compared to other trimesters, contributing to Table 2—Effect of Stress on Birth Weight

1In Grams2
a reduction of 211.6 grams (column 1). The
municipality fixed-effects regressions may be
Mother fixed effects
more appropriate, given that resources for pub-
lic health investments and health care subsidies Section A 1 2
are administered at the municipal level. dmines 24.958
In these municipal fixed-effects models, the 13.1052
average difference in birth weight for children dmines1 0.602
16.8762
born in a municipality with and without land- dmines2 28.323 28.704
mine explosions during early pregnancy will 13.4222* 13.2822***
be 7.5 grams (in column 2). Interestingly, when dmines3 23.577
municipality fixed effects are included, there is (3.758)
no significant effect of stress in periods other Observations 390,837 390,837
than early pregnancy. Column 3 includes only R2squared 0.740 0.740
landmine explosions lagged by two periods, Section B 1 2
finding a similar effect of 27.7 grams. This mines 22.111
finding supports the stress hypothesis instead of 11.2642
a nutritional channel, since if violence caused mines1 0.599
a reduction in food intake, the strongest effect 11.6802
would be seen in the third trimester, as babies mines2 22.845 22.837
grow most in the third trimester. 11.04882** 11.06862***
When I use the number of landmines as my mines3 20.926
variable of interest (Table 1, section B), the esti- (0.857)
Observations 390,837 390,837
mated effect of each landmine explosion during 0.74 0.74
R2squared
early pregnancy in the municipality of residence
is smaller, 22.2 grams (column 3). The differ- Notes: Robust standard errors 1 parentheses 2 cluster munici-
pal level.
ence in these results could be a sign of nonlin-
ear effects of additional landmine explosions.    * Significant at 10 percent.
To test for these effects, column 4 shows that a   ** Significant at 5 percent.
*** Significant at 1 percent.
quadratic term for landmines during early preg- dmines is a dummy variable for having landmines.
nancy that turns to be statistically significant, mines is the number of landmines.
and thus confirms the existence of nonlineari- mines2sq is the number of landmines squared.
ties in the effect of stress. The value of the qua-
dratic term is positive, indicating that additional
explosions have an accelerating effect on reduc- who weighed 8.7 grams less at birth than their
ing birth weight. siblings who where not exposed to any landmine
The mother fixed-effects regressions reported explosions while in utero (section A, column 2).
in Table 2 compare the birth weight of sibling Estimates of the effect of birth weight on neo-
number 1 to sibling number 2, who lived in the natal and infant mortality from a Norwegian
same municipality but were exposed to different study (Black, Devereux, and Salvanes 2007)
levels of stress shocks during pregnancy. I reduce give a lower bound of the effect of birth weight
the sample to nonmigrant mothers to mitigate on infant mortality. Simple calculations imply
concerns about unobserved lifetime exposure that having no mines will reduce the neonatal
to violence and the endogeneity of migra- mortality by 0.38 percent and infant mortality
tion. I also exclude multiple births, since these by 0.67 percent, which in Colombia represents
births are affected by the same maternal stress. 360 lives per year.
These findings have slightly larger ­coefficients, As a final exercise, I consider the possible
but are qualitatively similar to the ones found sign of the bias for the estimated parameters of
with municipality fixed effects. The stability of interest. It could be argued that the estimates
the coefficients between the municipality and reported represent lower bounds for two main
the mother fixed-effects models attests to the reasons. First, births occurring outside ­medical
randomness of landmines. Pregnant mothers institutions that do not report birth weight
exposed to landmine explosions delivered babies occur mainly in rural areas, and people living
VOL. 98 NO. 2 Stress and Birth Weight: Evidence from Terrorist Attacks
in these areas are the most affected by land-
mine ­ explosions. Second, in the presence of
measurement error in the independent variable
of interest, fixed-effects estimation generates
attenuation bias in the coefficient of interest. It
is therefore reasonable to consider that the pres-
ent study represents a conservative estimate of
the effect of landmines on birth weight.
IV.  Final Remarks
One can argue that landmine explosions are
essentially randomly assigned and act as a con-
vincing exogenous stress shock due to their ter-
rorist nature. This quasi-experimental approach
and the large sample size of the study provide
considerable confidence to the conclusions
derived relative to previous work on the effects
of maternal stress on birth weight.
The study of birth outcomes is currently of par-
ticular interest to economists, due to the strong
link that exists between birth outcomes and cog-
nitive development, socioeconomic, and long-
term health. A significant decrease of 8.7 grams
in weight is found for a baby experiencing stress
in utero due to landmine explosions in the munici-
pality of residence. This paper’s findings about the
negative relationship between stress during early
pregnancy and birth outcomes is consistent with
previous findings in the medical literature.
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