In Flint, Michigan, mothers face some of the highest risks of adverse health outcomes in the United States. But a new intervention is changing the outlook of Flint babies for the better.

More than 10 years after the city uncovered devastating lead water contamination, Flint still struggles with the highest child poverty rate in the country – nearly 60%, which is triple the national average.

Dr Mona Hanna, a pediatrician who has spent her career tackling the persistent health disparities in Flint, knew this poverty impacted every aspect of her patients’ health: “Poverty is a pathogen. It is a root cause and social determinant of health. It makes kids and communities sick.”

Hanna now has a new prescription at her disposal: unconditional cash transfers to pregnant women and new mothers in the form of the organization, Rx Kids.

The program is offering a solution to alleviate poor maternal and child health: up to $7,500 in cash for new mothers with no strings attached. They can buy a crib, diapers, nasal spray for their baby’s runny nose. All pregnant mothers are eligible, making it the first community-wide prenatal and infant cash transfer in the US.

While cash transfers have enjoyed success in 140 countries, the US remains an outlier in investing in the most critical window of development during pregnancy and early infancy.

“As a society, we consistently under-invest in this window, which makes it really hard to have a healthy pregnancy and have a healthy newborn,” Hanna said in an interview with Health Policy Watch.

Michigan’s program joins a list of others, like those in Kenya, that show a direct correlation between cash transfers and improved birth outcomes.

“With global health budgets shrinking, we think directing cash to pregnant women is a cost-effective way to stretch those dollars and save more lives,” said Laura Keen, a program director at the non-profit GiveDirectly, which administers cash transfer programs.

Pregnancy and first year shape health for life

Rx Kids and other cash transfer initiatives have lasered in on resources for new and expectant mothers because of the outsized role the first year of life plays in a child’s health and development.

“Babies’ brains double in size in that first year of life,” said Hanna, who is also associate dean of public health at Michigan State University College of Human Medicine.

This means that babies’ exposure to poverty, undernutrition, or environmental chemicals in that critical window disproportionately impacts on their health into adulthood.

Conversely, a caring, low-stress environment, breastfeeding, and stable housing can all boost a person’s health across the life course.

Although this is the most critical window for development, it is also the most financially challenging for families. A 2020 study revealed that American family income drops sharply near the birth of a child, often because the mother leaves work without adequate family leave pay, and because costs rise for a baby’s needs.

Supporting pregnant women and new mothers can also benefit communities struggling with an overburdened healthcare system. A recently published study estimates that Flint could save up to $6.2 million each year based on fewer preterm births, underweight babies, and neonatal ICU (NICU) admissions.

Cash infusion halves child mortality in Kenya

While the US has been struggling with domestic health funding cuts, notably Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), overseas aid has also been crippled. The reverberations are already expected to threaten decades of global health progress, including for child and maternal health.

But a massive experiment in villages in Western Kenya found that cash could be as effective, if not more, than the typical aid interventions of bed-nets and malaria medications.

Starting in 2014, the same non-profit that facilitated Rx Kids gave $1,000 to over 10,000 households in Kenya after the birth of a child. This resulted in a reduction of almost 50% in infant mortality, from about 40 deaths per 1,000 births to 21 deaths.

The researchers tracked mortality in infants born to families who received the money and those born without. They found that access to cash increased the use of healthcare facilities, especially when families lived near clinics or hospitals.

Thus, the benefits of extra cash were most pronounced for families who could already access some form of healthcare. The researchers speculated that, like in Flint, new mothers struggled with having to work right up to or right after the birth of their child, which puts physical and mental strain on the mother.

“Despite not being the main aim of the original program, we show that unconditional cash transfers in this setting may be a cost-effective way to reduce infant and child deaths,” the authors write.

Birth outcomes improve

Extra money for strollers, cribs, diapers, and transport to check-ups all relieves stress on expectant mothers, which can improve birth outcomes.

Flint babies are nearly twice as likely to have a low birth weight as the rest of the state, and have higher rates of preterm births.

However, a study measuring the effects of Rx Kids on preterm births, low birthweight, and NICU admissions in Flint over the past year, since the cash transfer program was implemented, found that it is already saving lives.

Using both Flint statistics and a comparison with matched cities, researchers found that Rx Kids was associated with a 2.7% decrease in the preterm birth rate and a 4.4% reduction in admissions to NICU.

The US struggles with poor birth outcomes and maternal mortality relative to other high-income nations. Cash transfers could help bridge this divide, noted Hanna.

“We don’t have to continuously react to poverty; we can prevent poverty, like in other countries,” she said.

Researchers hope to continue tracking the kids who received money for things like gun violence, poverty, and educational success.

Evidence for success in the US

This is the first community-wide prenatal and infant cash program in the US, partly inspired by the COVID-19 era expanded Child Tax Credit (CTC). The pandemic spurred the federal government to increase eligibility and the amount of cash for families under the American Rescue Plan. With this expanded credit, the US joined the list of some 140 countries that offer child cash-transfer programs, and initiated a historic decline in child poverty.

Although the CTC has since expired, Rx Kids was inspired to give direct transfers of $1,500 to women during pregnancy, and $500 a month for the baby for six months or a year.

“During COVID-19, as a nation, we became like all those other countries in the world, and we gave millions of families unconditional cash allowances, and that dropped child poverty to its lowest level ever,” said Hanna.

“Millions of kids in the United States came out of poverty. All these outcomes improved: housing stability, nutrition security, decreased debt, less abuse and neglect, decreased parental stress. The list went on and on of all these amazing outcomes, and that was not renewed by one vote in the US Senate, and millions of kids went back into poverty.”

Maternal mental health and well-being improve

The cash transfers also reduced postpartum depression rates and boosted mothers’ self-reported feelings of hopefulness. Families also reported better trust in healthcare institutions, something that has taken a hit during the pandemic, especially in poorer communities. The study compared a cohort of Flint mothers and infants to three other Flint cohorts who did not receive the cash transfer.

“This money allowed me to take more time off work,” is a common refrain among the moms, said Hanna. “Or, ‘I could afford to catch up on rent.’”

Because the program is universal, and not just for low-income families, there isn’t the same stigma that is sometimes associated with welfare programs.

“We’re targeting poor places with this intervention, not poor people. And that focus on poor places is easily replicated,” said Keen.

GiveDirectly is launching a similar program in the Democratic Republic of the Congo, and hopes to expand beyond Michigan into neighboring states.

Other metrics also improved. Evictions fell by 91%, being behind on rent or mortgages dropped, and nutritional access improved. These are often key measures of future stability and success in a child’s life, said Hanna.

‘Moms know what they need’

Direct cash transfer programs do run the risk of participants spending the money in ways not intended by the program.

“There are understandable concerns for the unconditionality of these programs,” said Keen. “You may think that people will spend the money on alcohol or cigarettes.”

But Keen points to results that show a reduction in spending on those goods.

Preterm births also may have dropped in Flint because those mothers may have reduced smoking, commonly linked to poor birth outcomes. Flint mothers who received cash transfers saw a 1.7% drop in smoking while pregnant, and a 5.7% increase in seeking adequate prenatal care, compared to their peers.

Spending on harmful products are minor concerns when compared to the overall efficiency of the unconditional cash transfer model, Keen noted. Without work, education, or even income requirements, there aren’t many administrative costs associated with running this kind of program.

Indeed, a Michigan-based economic think tank published a piece in support of the program, saying “spending your own money on yourself” is the most efficient way to spend money, unlike many of the government welfare programs that restrict eligibility.

Public health is often criticized for being paternalistic, notes Hanna. “We think we know what’s best for you. But this uproots that notion and conveys a sense of trust and empowerment.”

“Moms know what they need,” she said. Furthermore, the program’s unconditionality has been a boon in participation. Nearly every eligible newborn has been enrolled, unlike some federal welfare programs, which may only have 50% intake.

The program has bipartisan support, largely because of its efficient model. It’s already expanded to 11 rural and urban communities in Michigan.

Over 3,000 families have since been enrolled in the Rx Kids program, totalling $14.5 million in direct cash transfers.

“Bringing a child onto this earth is hard for everyone, and as a community, we should come together and support people through that process,” said Keen.

Image Credits: Sipho Ngondo/ Unsplash, International Confederation of Midwives, Rx Kids .