RESEARCH

 

Safeguarding maternal and child health in South Africa by starting the Child Support Grant before birth: Design lessons from pregnancy support programmes in 27 countries

 

 

M F Chersich^{I, II}; S Luchters^{III, IV, V}; D Blaauw^VI; F Scorgie^VII; E Kern^VIII; A van den Heever^IX; H Rees^X; E Peach^XI; S Kharadi^XII; S Fonn^XIII

^IMB BCh, PhD; Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^IIMB BCh, PhD; Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^IIIMB BCh, MSc (Public Health), PhD; Burnet Institute, Melbourne, Australia
^IVMB BCh, MSc (Public Health), PhD; Department of Epidemiology and Preventive Medicine, Medicine, Nursing and Health Sciences, Monash University, Australia
^VMB BCh, MSc (Public Health), PhD; International Centre for Reproductive Health, Department of Urogynaecology, Faculty of Medicine and Health Sciences, Ghent University, Belgium
^VIMB BCh, FCPHM (SA); Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^VIIMA, PhD; Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^VIIIBA Hons, Dip Information Science; Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^IXMA (Economics); Wits School of Governance, Faculty of Commerce, Law and Management, University of the Witwatersrand, Johannesburg, South Africa
^XMB BChir, MA, MRCGP; Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
^XIBMBS, MPH, MSES; Burnet Institute, Melbourne, Australia
^XIIBSc Hons; Independent consultant, Toronto, Canada
^XIIIMB BCh, PhD; Gender and Health Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Correspondence

 

 

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ABSTRACT

BACKGROUND. Deprivation during pregnancy and the neonatal period increases maternal morbidity, reduces birth weight and impairs child development, with lifelong consequences. Many poor countries provide grants to mitigate the impact of poverty during pregnancy. South Africa (SA) offers a post-delivery Child Support Grant (CSG), which could encompass support during pregnancy, informed by lessons learnt from similar grants.
OBJECTIVES. To review design and operational features of pregnancy support programmes, highlighting features that promote their effectiveness and efficiency, and implications thereof for SA.
METHODS. Systematic review of programmes providing cash or other support during pregnancy in low- and middle-income countries.
RESULTS. Thirty-two programmes were identified, across 27 countries. Programmes aimed to influence health service utilisation, but also longer-term health and social outcomes. Half included conditionalities around service utilisation. Multifaceted support, such as cash and vouchers, necessitated complex parallel administrative procedures. Five included design features to diminish perverse incentives. These and other complex features were often abandoned over time. Operational barriers and administrative costs were lowest in programmes with simplified procedures and that were integrated within child support.
CONCLUSIONS. Pregnancy support in SA would be feasible and effective if integrated within existing social support programmes and operationally simple. This requires uncomplicated enrolment procedures (e.g. an antenatal card), cash-only support, and few or no conditionalities. To overcome political barriers to implementation, the design might initially need to include features that discourage pregnancy incentives. Support could incentivise service utilisation, without difficult-to-measure conditionalities. Beginning the CSG in pregnancy would be operationally simple and could substantially transform maternal and child health.

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Income poverty and inequality remain pervasive worldwide, leaving many households with insufficient resources to meet their needs. In South Africa (SA), one of the most inequitable countries in the world, the poorest 20% of the population consumes only 4% of the country's goods and services, while the richest 20% takes 61%.^[1] Pregnancy and childbearing further marginalise vulnerable women and children by reducing income-generating potential and introducing a host of new financial needs. Only 14% of pregnant women in the poorest quartile are employed, either in the informal or the formal sector.^[2]

Pregnancy and breastfeeding considerably increase the volume and variety of food a women needs.^[3] Inadequate nutrition during pregnancy results in adverse birth outcomes, suboptimal neonatal growth and development, and impaired cognitive development later in life.^[4] Essentially, the nutritional status of the fetus in utero has a marked effect on subsequent child health and life chances, as well as intergenerational effects.^[5] Also, during pregnancy women incur substantial costs for accessing services, such as transport and childcare for existing children, while seeking healthcare.

A large number of countries, including SA, have recognised the importance of providing support for children living in impoverished households, and the extent and range of benefits accrued are well documented.^[6] The SA Child Support Grant (CSG), which began in 1998, provides ZAR350 (USD26) per month for children from birth up to 18 years. Eligibility is based on a means test, and currently there are over 10 million beneficiaries.^[6] Timing this support to begin only once a child is born, however, limits its effectiveness and cannot undo the harms of maternal deprivation during pregnancy. Conversely, providing support to women during pregnancy would enable an improvement in maternal nutrition and overall wellbeing. The earlier in pregnancy such support begins, the more optimal placental transfer of nutrients will be, with benefits both for the child and for subsequent generations.^[7]

There is compelling empirical evidence that pregnancy support programmes alleviate the vulnerability of pregnant women - and, by extension, of their fetuses - with consequent improvements in maternal and child health outcomes.^[8] Randomised trials in Latin America and South-East Asia have demonstrated that pregnancy grants can promote weight gain during pregnancy, reduce maternal anaemia, raise antenatal care (ANC) and skilled birth attendant (SBA) coverage, reduce maternal mortality, and prevent low-birth-weight births and infant mortality, among other benefits (see Table 1). Similarly, several SA studies have shown that among child beneficiaries of the CSG, the largest gains from this form of support come in the very early nutrition window of childhood. In one modelling study, children who began receiving the CSG within the first year of life had a 0.45 higher height-for-age z-score than other children, and this was expected to translate into an average 5 - 7% higher monthly wage as adults.^[9]

The effect of extending the existing social welfare system in SA to encompass pregnant women would depend on how well it is designed and implemented. Identifying lessons from experiences with pregnancy support programmes in other low- and middle-income countries (LMICs) could help inform the design of and optimise gains from a similar programme in SA, and indicate how best to build upon existing social support programmes. We conducted a systematic review of pregnancy support programmes in LMICs, examining their objectives, types of support provided and factors facilitating implementation, and then considered the implications of these findings for providing an integrated SA maternal and child support programme starting in pregnancy. The health and social impacts of pregnancy support were not reviewed in detail, as these have already been clearly demonstrated in multiple systematic reviews (Table 1).

 

Methods

The systematic review began with a scoping search of Medline (PubMed) using subject headings and thesaurus terms. The full search strategy and terms are provided in Appendix 1. In brief, electronic databases including Academic Search Complete, Psychology and Behavioural Sciences Collection, Educational Resources Information Centre and Global Health Library were searched in August 2012. Reference lists of included articles were examined to identify other eligible articles. We also searched the websites of relevant international organisations (the World Bank, Save the Children and the United Nations Development Programme) for additional 'grey literature' (print and electronic format documents that are not produced by commercial publishers).

To be included in the review, documents had to describe projects implemented in a LMIC that provided cash or vouchers (redeemable for services or commodities) for women or the households in which they lived during pregnancy or childbirth. Projects that only provided postpartum support were excluded. Cash or other support during pregnancy could be the only intervention, or form part of a suite of interventions. We included both state and non-governmental programmes, operational at a national or local level. Excluded were projects that: (i) had pro-natalist objectives (i.e. aimed specifically to increase fertility in the target population); (ii) provided occupational benefits as part of paid maternity leave for women in the formal sector; (iii) entailed only user-fee exemptions at health facilities for pregnant women; and (iv) provided support other than cash or vouchers, such as only nutritional supplements.

A single reviewer extracted data on: (i) the groups targeted and objectives of support; (ii) key design features, including the means of identifying target groups, the type and duration of support, and conditionalities; and (iii) practical experiences with implementation, including administrative challenges faced with eligibility screening, disbursement or verification of conditionalities being met. The outcomes and impact of pregnancy support were also extracted, but are only summarised here (Table 1) as they have been reviewed extensively elsewhere.^[8]

The analysis focused on comparing the objectives and design of projects across settings and identifying the challenges encountered by projects with different design formats and implementation strategies. We also assessed programme changes over time, and what lessons could be derived from these changes. Finally, we discussed the implications of the overall findings for the SA social grant system.

 

Results

The search identified 5 822 documents, from which we located a total of 32 programmes across 27 countries (Table 2). Data were drawn from 57 articles eligible for the review. Only four had started before 2000, with a median onset of 2005. Eight were in sub-Saharan Africa.

Target groups and support objectives

Two main categories of support could be differentiated. The first targeted only pregnant women (n=12). These initiatives were mainly found in South-East Asia (8/12), and primarily aimed to increase utilisation of public sector ANC, SBAs and postpartum care among poor women. Generally, the schemes did not specifically aim to encourage early ANC attendance, although in the Indira Gandhi Matriva Sahyog Yojana (IGMSY) (Table 2, row 5) women had to register their pregnancy before 4 months' gestation to be eligible, and this indirectly incentivised early booking. In some of these programmes assistance was also framed more broadly as a strategy for improving the health and nutrition of pregnant and lactating mothers, for example to enable adequate rest during pregnancy and after delivery (India, row 3), and to encourage optimal infant feeding practices. Finally, a few programmes, mainly in India, conceptualised maternity support as a means of compensating women for their reduced income-earning potential during pregnancy. The Dr Muthulakshmi Maternity Assistance Scheme (DMMAS) programme in India, for example, specifically seeks to 'assist poor women with medical expenses around childbirth and compensate them for loss of wages around this time' (row 3).

The second group of programmes (n=20) targeted pregnant women among other groups, such as children and vulnerable families or households. Most of these programmes were located in Latin America and the Caribbean (12/20), and framed their objectives in much broader terms than the first category. Many were targeted primarily at reducing poverty and food insecurity, or the building of social equity or solidarity, rather than health per se. For some, the focus was mainly on addressing childhood poverty, as in Peru (row 30), where programmes aimed to use pregnancy support as a way to create improved social safety nets for children. In addition, several schemes had more long-term aspirations, such as breaking intergenerational poverty cycles (Brazil, row 15; El Salvador, row 16; Peru, row 30; Mexico, row 25), making investments in human capital (Brazil, row 15; Peru, row 30; Jamaica, row 24; Ethiopia, rows 17 and 18), or building social capital (Paraguay, row 29) and inclusivity (Panama, row 28).

Identifying target groups

Programmes adopted one of two strategies for selecting recipients, either targeting all women in selected poor areas, districts or states, or identifying individual poor women, regardless of where they lived. Two-stage processes were sometimes used, where municipal or district areas were selected first, followed by the identification of vulnerable households (Peru, row 30). Methods used to identify individuals varied widely, including the use of a short interview (India, row 3, Cambodia, row 2); tasking ANC staff with identifying eligible recipients, such as women with anaemia or slow weight gain during pregnancy; and home visits to estimate socioeconomic status, based on the characteristics of households. Countries that opted to target all women in an area cited the costs of screening as the rationale for their choice (Bangladesh, row 1; Nepal, row 8).

Several maternity grants were specifically configured to counter the concerns of politicians and popular opinion that a grant would incentivise pregnancy (especially among young women), or even discourage women from accessing abortion services. Features of such grants included restricting eligibility to a certain number of children (India, rows 4 and 5; Nepal, row 8), to women aged >19 years (India, rows 4 and 5) and to those with birth spacing of >2 years (Bangladesh, row 1), and providing a fixed fee per household rather than payments per child, thereby favouring small families (El Salvador, row 16). Others included a condition that recipients attend family planning services for 2 years after childbirth, or incorporated attending talks on contraception as conditionalities. Three programmes that initially imposed such conditions later dropped them (Bangladesh, row 1; India, row 4; Nepal, row 8).

Types of support

Six projects consisted of cash transfers only, with no conditions or explicit attempts to create linkages with health services. A further 14 of the 32 programmes also involved cash support only, but tied this to conditionalities around ANC attendance, having an SBA or postpartum care visits. The remaining 12 used means other than cash to promote linkages between support and service utilisation. A Cambodian scheme, for example, provided cash and vouchers for attending health services (row 2). Voucher coupons were used for visits to health facilities (including for private sector providers), institutional delivery and transport costs. Other strategies included providing gift hampers for women, nutritional supplementation and education, and cooking or counselling sessions at facilities in addition to cash or vouchers. In many projects, the inclusion of multiple types of support meant that parallel administrative systems were required. Grants in Latin America mainly adopted the conditional cash transfer approach, although in Bolivia (row 14) and a few other instances, families in extreme poverty also received non-conditional payments.

Amount of support and payment mechanisms

The value of cash transfers varied considerably, from relatively small amounts (e.g. USD1 per month in Mozambique, row 26) to USD260 paid to pregnant women in Bolivia, who receive instalments until the child is 2 years old (row 14). In some programmes the amounts given to pregnant women varied, with higher amounts provided in areas that were poorer, more remote, or had lower coverage of services (India, row 4; Brazil, row 15). In several instances, benefits given during pregnancy were a supplement to the support already provided by the state to poor families.

In cash-based programmes, payments were mainly made to debit or savings cards (Argentina, row 13; Brazil, row 15; Mexico, row 25; Peru, row 30; Philippines, row 31; Turkey, row 32). Money was also disbursed through health centres and postal services (Indonesia, row 23; Turkey, row 32), and even from the main square of municipalities (El Salvador, row 16). Cash was even home-delivered in one instance in India. Payments were usually made monthly, but some were bimonthly or even once off. One project gave a once-off payment to parents of twins (Mongolia, row 7).

Practical experience with implementation

Many of the smaller donor-funded projects encountered serious implementation issues, although these problems were also experienced by some of the larger ones. Communication with people eligible for support emerged as a problem in Nepal, for example, where a study showed that only 27% of the eligible population were aware of the grant (row 8). In contrast, in Uganda 90% of women were aware of the scheme, thanks to use of mass media such as radio (row 11). Finally, some reports of corruption were noted. This involved, for example, health workers taking money intended for pregnant women, and giving vouchers to ineligible women in programmes that paid commissions to staff for each voucher distributed (Kenya, row 6).

In many instances, programmes that used complex procedures for determining eligibility struggled to identify individuals requiring support, even ending up with the lowest uptake among the poorest women (India, row 4; Nepal, row 8). Some problems were also noted with cash disbursement processes; for example, women in Mozambique waited on average 7 hours at collection points, and payments were often delayed by several months (row 26). Women in Peru had high transport costs to reach a designated bank for grant collection (row 30).

Rigour in monitoring compliance with conditionalities varied markedly between projects. In some, there was little or no attempt to enforce conditions. For example, in El Salvador instalments were paid without confirming attendance at services, and recipients simply had to sign an agreement that they would use the money for food (row 16). Programmes with more rigorous measures to monitor conditionalities appeared to have higher administrative costs. Administrative costs ranged from 4 - 5% of the overall budget in areas with relatively lax controls (Brazil, row 15; Guatemala, row 20) to an estimated 18% in Mexico (row 25). High costs of monitoring conditionalities and other operational expenses in Nepal meant that only half the money in the programme was used for disbursements (row 8). Some programmes reported that they were able to resolve initial administrative constraints and gradually improve the scheme's performance (Bangladesh, row 1; Nepal, row 8). Not surprisingly, eligibility procedures and payment methods were often simplified over time (Bangladesh, row 1; India, rows 3 and 4), and several programmes dropped some or all conditionalities (India, row 4; Jamaica, row 24).

 

Discussion

This article summarises experiences in LMICs with the design and implementation of grants to support women during pregnancy. Overall, the evidence indicates that feasibility and efficiency were highest where programmes achieved economies of scale through integrating support for women and children within one system, and adopting simplified procedures, including uncomplicated enrolment and disbursement procedures, cash-only support, and few or no conditionalities (Table 3).

Aside from the absence of pregnancy support, the SA social support programmes closely resemble those in Latin American countries. Extending the existing CSG to begin in pregnancy would ensure further alignment with those projects, and move closer to attaining the benefits that women and children have gained there. A pregnancy support grant would also help align women in the formal sector with other women who are more at risk. While the formal sector has long acknowledged the need to alleviate the financial burdens of pregnancy through maternity leave benefits, women in the informal sector are generally excluded from such assistance, as are unemployed women.

Attendance at ANC and facilities for childbirth can be linked to pregnancy support at very low cost through, for example, requiring women to bring an ANC card when enrolling in support. Lack of ANC attendance remains a key cause of maternal deaths and of mother-to-child transmission (MTCT) of HIV in SA.^[78] ANC coverage is about 90%, similar in all socioeconomic quartiles, but far fewer women in the poorest quartile attend ANC before 20 weeks (57% v. 89% in the highest quartile) or have an SBA (92% v. 98% inthe highest quartile).^[2]

To obtain maximum benefit, pregnant women would ideally initiate support as soon as pregnancy is diagnosed. Surprisingly, therefore, in the programmes reviewed, support was seldom configured to incentivise women to initiate support and attend ANC early in pregnancy. Earlier attendance would reduce risk of MTCT of HIV, as the earlier in pregnancy women initiate antiretrovirals, the lower the risk of transmission.^[79] It would also allow for the nutrition benefits described above. Beginning support in pregnancy would mean that the critical neonatal period would be covered, a major deficiency of the present CSG. Processing delays mean that currently support only begins several months, or even years, after birth.

Means testing, based on income, is currently used for determining eligibility for the CSG and pensions in SA, and could be applied similarly during pregnancy. Alternative approaches to means testing may include measurement of things such as type of housing or number of productive assets, which could provide a more multidimensional measurement of poverty. However, these approaches involve significant data collection and transaction costs. Doing away with means testing altogether and providing a universal grant for all women is one option, but this can become politically charged where poverty coincides closely with specific ethnic or political groupings. Similarly, strict implementation of conditions can end up penalising the most vulnerable, and would undermine the central purpose of the grant.

Further issues relating to eligibility include the need to legally verify pregnancy during enrolment in pregnancy support. Pregnancy confirmation could be ascertained through means such as a blood or urine pregnancy test from a certified laboratory, a urine pregnancy test done at the grant processing facility, and the use of antenatal clinic cards. A birth certificate could then be required to continue the grant after delivery.

Possible unintended consequences of maternity support

In addition to ensuring that the programme is designed optimally, the benefits of maternity support need to be weighed against any potential negative consequences. Fears of the potential for maternity and early child support to encourage childbearing, especially among young women, often lead to political and social hesitation to implement pregnancy support. These concerns often reveal underlying gender and class prejudices, and may well account for the absence of pregnancy support in SA to date. Globally, the assertion that social welfare support creates a perverse incentive in the form of encouraging a higher incidence of pregnancy has been tested as far back as the 1970s, and found to be unsupported by research.'^80,811 Moreover, several large studies in SA have demonstrated that providing the CSG clearly does not induce perverse incentives for pregnancy.^[6,82,83] Nevertheless, to assuage the concerns of policy makers, it may be worth framing support around improvements in newborn and child health, rather than women's benefits. Features that explicitly discourage fertility could be included in the initial design of pregnancy support, even though this may initially impact most on vulnerable groups. These features could then be abandoned over time, as has occurred in other programmes.

Politicians and the public may also be concerned that women might spend grant money on non-essential or luxury items. The studies reviewed and evidence of CSG spending, however, show clearly that women use grant money for food and other essential goods. In the Brazil and Mozambique programmes, 60 - 70% of the cash transfer was spent on food, with proportions reaching 80% among families with severe food insecurity.^[28,74] Grants raise both the volume and, even more importantly, the variety of food eaten. ^[20] In India, where health services were not free, women spent the majority of their grant money on accessing services.^[36] No increase in spending on alcohol, tobacco or adult clothes was detected in El Salvador, but purchases of children's clothing and shoes rose.^[57] Having multifaceted support, such as vouchers and cash, was seen as requiring parallel administrative processes, and is hard to justify when clearly monies are spent on food and access to care.

Limitations of this review

There is substantial heterogeneity between the programmes identified, as study settings, interventions and evaluation methods differed markedly. This limits the ability to directly compare studies and to draw overall conclusions. Additional evaluations of maternity support may have been missed, as studies examining the impact of such support are published in a broad range of fora, making it difficult to systematically identify all available evidence. Finally, much of the evidence located was of poor quality, limiting the ability to draw definitive conclusions.

 

Conclusion

A mother's nutritional status during pregnancy is a key determinant of her baby's weight at birth, and thus of childhood survival and life chances, as well as having intergenerational effects. Yet grants to enhance maternal health and wellbeing during pregnancy are not currently provided in SA, and there is much uncertainty about how such a grant would be structured and implemented. Based on lessons learnt elsewhere, we conclude that a programme that provides cash only, has simplified enrolment procedures and is integrated within existing social grant systems would be feasible to implement.

Social assistance has short-term goals of relieving poverty, but also of accumulating human capital and thus reducing intergenerational effects of poverty, among other benefits. Pregnancy support is most uniquely able to achieve both goals, unlike emergency food relief, for example, which only addresses short-term imperatives. More generally, the overall benefits of cash transfers are established beyond doubt; the absence of pregnancy support in SA is a serious design flaw of the otherwise hugely successful CSG, and is long overdue.

 

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Correspondence:
M Chersich
mchersich@wrhi.ac.za

Accepted 19 September 2016.

 

 

Appendix 1. Search strategy

1. Medline (PubMed) 9/7/12 (540 results)

(maternal[TI/AB] OR mothers'MeSH] OR pregnanc*[TI/AB] OR pregnanc*[MeSH]) AND (grant*[TI/AB] OR welfare[TI/AB] OR benefit[TI/AB])

2. Academic search complete (EBSCO Host) 10/7/12 (53 results) ((DE "MOTHER & child") OR (DE "PREGNANCY")) AND ((DE "MATERNAL & infant welfare") OR (DE "PUBLIC welfare policy"))

3. Educational Resources Information Centre (ERIC) 10/7/12 (20 results)

(DE "Pregnancy" OR DE "Mothers") AND (DE "Grants")

4. Psychology and Behavioural Sciences Collection 10/7/12 (5 results)

(DE "PREGNANCY" AND (DE "GRANTS (Money)" OR DE "MATERNAL & infant welfare" OR DE "PUBLIC welfare")

5. Global Health Library 17/7/12

Search 1 (49 results)

S1: ((((DE "pregnancy") OR (DE "mothers")) OR (DE "maternity services")) OR (DE "maternal nutrition")) OR (DE "child nutrition")

AND

S2: (((DE "grants") OR (DE "child welfare" OR DE "nutrition policy" OR DE "program participants" OR DE "social policy" OR DE "social services")) OR (DE "incentives")) AND (S1 and S2)

Search 2 (26 results)

51 ((DE "grants") OR (DE "incentives")) OR (DE "social welfare")

AND

52 ((DE "grants") OR (DE "incentives")) OR (DE "social welfare") Search (32 results)

S1 (((((DE "maternity services" OR DE "health services") AND (DE "food distribution programs" OR DE "development policy" OR DE "emergency relief" OR DE "food security")) OR (DE "Food Stamp Program")) OR (DE "nutrition programmes")) OR (DE "government policy")) OR (DE "social welfare")

AND

S2: (((DE "pregnancy") OR (DE "children")) OR (DE "mothers")) AND (DE "low income groups")