Social Assistance Programs and Birth Outcomes: A Systematic Review and Assessment of Nutrition and Health Pathways

Tenant Right-to-Counsel and Adverse Birth Outcomes in New York, New York

Importance

In 2017, New York, New York, launched the United States' first right-to-counsel program, guaranteeing lawyers to low-income tenants in select zip codes, which was associated with reducing eviction risk by half. Given documented associations between evictions during pregnancy and adverse birth outcomes, the right-to-counsel program may be associated with improved birth outcomes.

Objective

To measure associations between zip code-level right-to-counsel access and risk of adverse birth outcomes, including preterm birth and low birth weight, among infants born to Medicaid-insured birthing parents.

Design, Setting, and Participants

This retrospective cohort study leveraged the staggered rollout of New York's right-to-counsel program from January 2016 to February 2020 as a natural experiment using a population-based sample of live births to Medicaid-insured birthing parents residing in New York, New York. Data were analyzed from February 2022 to September 2024.

Exposure

Zip code right-to-counsel status 9 months prior to birth.

Main Outcomes and Measures

Adverse birth outcomes were measured using individual birth records from the New York Bureau of Vital Statistics. Outcomes included dichotomous indicators of low birth weight (<2500 g), preterm birth (<37 weeks' gestation), and a composite of both. Difference-in-differences linear probability models controlled for year, month, and zip code and included clustered standard errors.

Results

Among 260 493 live births (mean [SD] birthing parent age, 29 [6] years) from January 2016 to February 2020, 43 081 births (17%) were to birthing parents residing in zip codes where right-to-counsel was available during pregnancy. Exposure to right-to-counsel during pregnancy was associated with statistically significant reductions in infants' probability of adverse birth outcomes, with reductions of 0.73 (95% CI, 0.06-1.41) percentage points in low birth weight, 0.91 (95% CI, 0.10-1.71) percentage points in preterm birth, and 0.96 (95% CI, 0.09-1.84) percentage points in the composite outcome in treated vs untreated zip codes.

Conclusions and Relevance

This cohort study found that right-to-counsel was associated with reduced risk of adverse birth outcomes among Medicaid-insured birthing parents. These findings suggest that eviction prevention via right-to-counsel may have benefits that extend beyond the courtroom and across the life-course.

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

Impact of cash transfer programs on birth and child growth outcomes: systematic review

To investigate the impact of cash transfer (CTs) on birth outcomes, including birth weight, low birth weight and prematurity, as well as child physical growth were included, as assessed by anthropometric indices in children under five years of age. Searching was performed using the PubMed/Medline, Embase, LILACS, Cochrane Library, Scopus and Web of Science databases. Quantitative observational, experimental and quasi-experimental. Eleven studies were included in the review. The majority (81.8%) were carried out in low-and middle-income countries and most involved conditional CTs (63.6%). Four were clinical trials and seven were observational studies. Conditional CTs were found to be associated with a reduction in height-for-age (-0.14; 95%CI -0.27, -0.02); (OR 0.85; 95%CI 0.77-0.94); (OR = 0.44; 95%CI 0.19-0.98), a significantly reduced chance of low weight-for-age (OR = 0.16; 95%CI -0.11-0.43), low weight-for-height (OR = -0.68; 95%CI -1.14, -0.21), and low weight-for-age (OR = 0.27; 95%CI 0.10; 0.71). Unconditional CTs were associated with reduced birth weight (RR = 0.71; 95%CI 0.63-0.81; p < 0.0001) and preterm births (RR = 0.76; 95%CI 0.69-0.84; p < 0.0001). Conditional CTs can positively influence birth outcomes and child growth.

The dose-response association between LEAP 1000 and birthweight - no clear mechanisms: a structural equation modeling approach

BACKGROUND

Birthweight is an important indicator of maternal and fetal health globally. The multifactorial origins of birthweight suggest holistic programs that target biological and social risk factors have great potential to improve birthweight. In this study, we examine the dose-response association of exposure to an unconditional cash transfer program before delivery with birthweight and explore the potential mediators of the association.

METHODS

Data for this study come from the Livelihood Empowerment Against Poverty (LEAP) 1000 impact evaluation conducted between 2015 and 2017 among a panel sample of 2,331 pregnant and lactating women living in rural households of Northern Ghana. The LEAP 1000 program provided bi-monthly cash transfers and premium fee waivers to enroll in the National Health Insurance Scheme (NHIS). We used adjusted and unadjusted linear and logistic regression models to estimate the associations of months of LEAP 1000 exposure before delivery with birthweight and low birthweight, respectively. We used covariate-adjusted structural equation models (SEM) to examine mediation of the LEAP 1000 dose-response association with birthweight by household food insecurity and maternal-level (agency, NHIS enrollment, and antenatal care) factors.

RESULTS

Our study included a sample of 1,439 infants with complete information on birthweight and date of birth. Nine percent of infants (N = 129) were exposed to LEAP 1000 before delivery. A 1-month increase in exposure to LEAP 1000 before delivery was associated with a 9-gram increase in birthweight and 7% reduced odds of low birthweight, on average, in adjusted models. We found no mediation effect by household food insecurity, NHIS enrollment, women's agency, or antenatal care visits.

CONCLUSIONS

LEAP 1000 cash transfer exposure before delivery was positively associated with birthweight, though we did not find any mediation by household- or maternal-level factors. The results of our mediation analyses may serve to inform program operations and improve targeting and programming to optimize health and well-being among this population.

TRIAL REGISTRATION

The evaluation is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations (RIDIESTUDY- ID-55942496d53af) and in the Pan African Clinical Trial Registry (PACTR202110669615387).

Association between cash transfer programs and oral health-A scoping review

OBJECTIVES

The aims of this scoping review are to assess the literature investigating the association between cash transfer programs and oral health; and to identify the theoretical frameworks applied to guide this literature.

METHODS

A search strategy to identify studies published until December 2020 was applied to a range of databases. Observational and interventional studies that had cash transfer programs as exposure/intervention and oral health as outcome were considered. Dental health services utilization, as well as access to dental health services, were considered secondary outcomes. Cash transfer programs were considered programs based on conditional or unconditional cash transfer carried out as part of national social protection schemes, and interventional studies on the impact of cash transfer on oral health were also considered eligible. Data charting was performed in two steps and a narrative synthesis was conducted.

RESULTS

Of 6344 articles identified, four articles were included. These articles investigated three different conditional cash transfer programs, Universal Child Allowance (Argentina), Bolsa Família (Brazil) and Family Rewards (USA). Inconsistencies were identified in findings on the effect of conditional cash transfer programs on the prevalence of dental caries and these differences may be due to the comparison group selected for each study. Concerning dental visits, the results point in different directions, which makes these findings still inconclusive. No explicit theoretical framework was reported in the articles to guide the expected association.

CONCLUSION

Although cash transfers play an important role in improving certain health outcomes, there is limited evidence to suggest an association between cash transfers and oral health.

A realist review of interventions targeting maternal health in low- and middle-income countries

Maternal mortality is disproportionately higher in low- and middle-income countries compared to other parts of the world. International research efforts are reflective of the urgency to improve global maternal outcomes. The existing literature of maternal health interventions in low- and middle-income countries targets a variety of populations and intervention types. However, there is a notable lack of systemic reviews that examine the wider contextual and mechanistic factors that have contributed to the outcomes produced by interventions. This article aims to use realist synthesis design to identify and examine the relationships between the contexts, mechanisms and outcomes of maternal health interventions conducted in low- and middle-income countries. This will inform evidence-based practice for future maternal health interventions. In May 2022, we searched four electronic databases for systematic reviews of maternal health interventions in low- and middle-income countries published in the last 5 years. We used open and axial coding of contexts, mechanisms and outcomes to develop an explanatory framework for intervention effectiveness. After eligibility screening and full-text analysis, 44 papers were included. The majority of effective interventions reported good healthcare system contexts, especially the importance of infrastructural capacity to implement and sustain the intervention. Most intervention designs used increasing knowledge and awareness at an individual and healthcare-provider level to produce intended outcomes. The majority of outcomes reported related to uptake of healthcare services by women. All mechanism themes had a relationship with this outcome. Health system infrastructure must be considered in interventions to ensure effective implementation and sustainability. Healthcare-seeking behaviours are embedded within social and cultural norms, environmental conditions, family influences and provider attitudes. Therefore, effective engagement with communities and families is important to create new norms surrounding pregnancy and delivery. Future research should explore community mobilization and involvement to enable tailored interventions with optimal contextual fit.

Ghana's Livelihood Empowerment Against Poverty (1000) Program Seasonally Impacts Birthweight: A Difference-in-Differences Analysis

Objectives: Low birthweight (LBW) prevalence remains high in African countries and evidence of cash transfer impacts on birthweight, particularly by season of infant birth, is limited. This study examines overall and seasonal cash transfer impacts on LBW in rural Ghana. Methods: Data come from a longitudinal, quasi-experimental impact evaluation of the Livelihood Empowerment Against Poverty (LEAP) 1,000 unconditional cash transfer program for impoverished pregnant or lactating women in rural districts of Northern Ghana. LEAP1000 program impacts on average birthweight and LBW were estimated for a multiply imputed sample of 3,258 and a panel sample of 1,567 infants using differences-in-differences models and triple difference models to assess impacts by season. Results: LEAP1000 decreased LBW prevalence by 3.5 and 4.1 percentage points overall and in the dry season, respectively. LEAP1000 increased average birthweight by 94, 109, and 79 g overall, in the dry season, and in the rainy season, respectively. Conclusion: Our findings of positive LEAP1000 impacts on birthweight across seasons and on LBW in the dry season demonstrate the need to take seasonal vulnerabilities into account when designing and implementing programs for rural populations in Africa.

Relationship of cash transfers with risk of overweight and obesity in children and adults: a systematic review

BACKGROUND

Cash transfer (CT) programs are an important type of social protection meant to reduce poverty. Whether CT programs increase the risk of overweight and obesity is unclear. The objective was to characterize the relationship between CT programs and the risk of overweight and obesity in children and adults.

METHODS

We searched articles in PubMed, Embase, Cochrane, EconLit, Global Health, CINAHL Plus, IBSS, Health & Medical Collection, Scopus, Web of Science, and WHO Global Index Medicus in August 2021. Studies involving CT as the intervention, a control group, body mass index, overweight, or obesity as an outcome, and sample size > 300 were included. The Newcastle-Ottawa Scale was used for quality assessment.

RESULTS

Of 2355 articles identified, 20 met the inclusion criteria. Because of marked heterogeneity in methodology, a narrative synthesis was used to present results. Thirteen of the studies reported that CT programs were associated with a significantly lower risk of overweight and obesity, eight studies showed no significant association, and one study reported a significantly increased risk of obesity in women. Quality assessment showed that most studies lacked sample size and power calculations, validation of exposure, descriptions of non-respondents or those lost to follow-up, and blinded outcome assessment.

CONCLUSIONS

Overall, the studies were suggestive that CT programs either have no impact or decrease the risk of overweight and/or obesity in children, adolescents, and adults, but no firm conclusions can be drawn from the available evidence. This review demonstrated limitations in the available studies of CT programs and overweight/obesity.