Universal Unconditional Cash Transfers for Pregnant and Postpartum Women: Necessary but Insufficient

Abstract

[...]pregnancy can both lead to and worsen financial burden among expectant and new parents.1 DISPARITIES IN PERINATAL HEALTH Poverty is highly correlated with multiple conditions that can harm pregnant and postpartum women and their children. Low income is associated with food insecurity, unstable housing, and unhealthy neighborhood conditions, all of which can be detrimental to maternal and infant health. [...]poverty, particularly during the perinatal period, can increase maternal stress, which can lead to mental health disorders and physical chronic disease, thus increasing the risk of maternal morbidity and mortality.2 This is of great concern given that in recent years maternal deaths because of cardiovascular disease and other medical conditions have increased in the United States. [...]BFY was implemented during the height of the COVID-19 pandemic, and it is possible that economic and health hardships outweighed the impact of the program or that other government programs during the pandemic washed out meaningful effects.5 Rx Kids was launched in 2024, after the height of the pandemic, and-unlike BFY-begins cash distribution prenatally, which is when the stress of motherhood starts for many women. [...]while BFY was a meanstested program, Rx Kids is universal within a low-income community, where 59% of children live in poverty and 57% of the community identify as Black or African American. [...]states will likely soon receive fewer dollars to spend on benefits, including Medicaid, Supplemental Nutrition Assistance Program, and TANF.10 Given the medical importance of addressing poverty in the perinatal period and the potential effectiveness of cash-benefit programs in improving maternal health, this is the exact opposite of what should be done.

Economic hardship is often exacerbated during pregnancy, childbirth, and infancy. This period is laden with additional expenses at a time when women might be reducing work hours. Purchasing and eating healthy food is particularly important during pregnancy but can be costly. Once the baby is born, increased expenses include health care and childcare, as well as material goods such as diapers. As a result, pregnancy can both lead to and worsen financial burden among expectant and new parents.1

DISPARITIES IN PERINATAL HEALTH

Poverty is highly correlated with multiple conditions that can harm pregnant and postpartum women and their children. Low income is associated with food insecurity, unstable housing, and unhealthy neighborhood conditions, all of which can be detrimental to maternal and infant health. Moreover, poverty, particularly during the perinatal period, can increase maternal stress, which can lead to mental health disorders and physical chronic disease, thus increasing the risk of maternal morbidity and mortality.2 This is of great concern given that in recent years maternal deaths because of cardiovascular disease and other medical conditions have increased in the United States. Overall, women giving birth in the United States suffer from higher rates of morbidity and mortality than those in similarly large and developed countries, and large racial/ethnic disparities exist.3

The pregnancy-related death rate among Black women is almost three times higher than among White women, and more than three times higher than among Hispanic women.3 Disparities are evident even after controlling for social and economic factors, highlighting the role that racism and discrimination likely play in these differences. 3 In this issue of AJPH, Hanna et al. (p. 2020) describe how Rx Kids, a community-wide, universal, and unconditional prenatal and infant cash transfer program, addresses these disparities by investing in families in Flint, Michigan, a community consisting mostly of Black residents with high rates of poverty.

WHAT WE LEARNED FROM RX KIDS

Women enrolled in Rx Kids receive a one-time sum of $1500 during pregnancy and $500 per month postnatally for 12 months. The authors present evidence of the effectiveness of the Rx Kids program in alleviating economic hardship and improving maternal health and well-being. Specifically, participation in Rx Kids was associated with decreases in not having enough food, owing past due rent or mortgage, and eviction after childbirth. Furthermore, the program was linked to decreases in postpartum depression and increases in mothers' feelings of being valued, respected, and hopeful, as well as trust in health care and government.

The findings of Hanna et al. suggest that in addition to increasing income and reducing hardship, unconditional cash programs during pregnancy and postpartum may be effective at improving maternal health and well-being, which can have an impact on child outcomes in the long term. This is notable, given that a recent large study on an unconditional cash transfer program during the first four years of the baby's life, Baby's First Years (BFY), did not find significant associations with maternal health outcomes.4 There are several important differences between BFY and Rx Kids. BFY distributed a lower amount, $333 per month, but for a longer duration than the Rx Kids program. In addition, BFY was implemented during the height of the COVID-19 pandemic, and it is possible that economic and health hardships outweighed the impact of the program or that other government programs during the pandemic washed out meaningful effects.5 Rx Kids was launched in 2024, after the height of the pandemic, and-unlike BFY-begins cash distribution prenatally, which is when the stress of motherhood starts for many women.

Moreover, while BFY was a meanstested program, Rx Kids is universal within a low-income community, where 59% of children live in poverty and 57% of the community identify as Black or African American. Black women, in particular, experience great economic and health inequalities in the United States; universal programs may be more effective at addressing racial and income inequalities because they are associated with less stigma than means-tested programs. 6 Inequalities are believed to erode trust,7 so the universal nature of Rx Kids could have led to increases in trust, which may have contributed to enhanced civic and social engagement,7 increased social connectedness, and, ultimately, improved maternal mental health outcomes. Furthermore, meanstested benefits can lead to feelings of disempowerment and a lack of autonomy. In contrast, the universal nature of Rx Kids may have been responsible for participants' enhanced feelings of value and respect. As Hanna et al. point out, feelings of love, respect, hope, and trust "capture the underpinning of a reimagined social contract-what it means to be part of a society and community that cares and provides for each other" (p. 2026). The full benefits of such a "reimagined society" may extend beyond the outcomes reported in this article.

INCREASING THE SAFETY NET

Importantly, many other countries have long histories supporting universal programs that guarantee living wages; in fact, the United States is the only developed country that does not guarantee a period of paid and job-protected leave for new mothers.8 In 2021, the United States expanded the Child Tax Credit in what was tantamount to a near-universal, unconditional child cash benefit. The US Census Bureau recorded large drops in poverty, which rose when the tax credit was rescinded at the end of that year.9

In lieu of a national policy, the Rx Kids program is funded through a public- private partnership, leveraging the Temporary Assistance for Needy Families (TANF) block grant dollars to states via a mechanism that does not trigger time limits or work requirements.6 This is a creative use of federal funds, and other states might consider following suit. Unfortunately, the current federal administration is on track to reduce the US safety net. Accordingly, states will likely soon receive fewer dollars to spend on benefits, including Medicaid, Supplemental Nutrition Assistance Program, and TANF.10 Given the medical importance of addressing poverty in the perinatal period and the potential effectiveness of cash-benefit programs in improving maternal health, this is the exact opposite of what should be done. We should identify ways to use universal or near-universal programs to increase the safety net and ensure living wages to entire communities.

NECESSARY BUT NOT SUFFICIENT

Programs like Rx Kids are an important start, but even universal programs are not enough. Cash is necessary but not sufficient to support families in ways that enable them to thrive. Cash does not instantly provide social support, which is critical to mental health and the ability to care for a newborn, or actionable strategies for integrating play, storytelling, and reading into daily routines. Reduced poverty may help women initiate mental health care, but those services need to be available, part of comprehensive primary care, and aligned with language and culture.11 Increased income can give women flexibility and time to attend medical appointments, but mothers need to have insurance to obtain quality care. Universal health insurance that includes mental and physical health care would enable all women to receive necessary medical care and use their income to support their families in other ways. Systems reform must be a part of any comprehensive approach to address perinatal and infant health.

A supportive US system would incorporate all of this-unconditional cash benefits during the perinatal period; effective programming to support pregnancy, postpartum, and early childhood development; and equitable systems able to address the real needs of families. As advocates Aisha Nyandoro and Kathy Spillar write, "By addressing the improvements necessary to our broader economic systems, we can create a society where all women, particularly Black women, have the opportunity to thrive."12

CORRESPONDENCE

Correspondence should be sent to Bonnie D. Kerker, NYU Grossman School of Medicine, 180 Madison Ave, 6th Floor, New York, NY 10016 (e-mail: [email protected]). Reprints can be ordered at https://www.ajph.org by clicking the "Reprints" link.

PUBLICATION INFORMATION

Full Citation: Kerker BD. Universal unconditional cash transfers for pregnant and postpartum women: necessary but insufficient. Am J Public Health. 2025;115(12):1954-1956.

Acceptance Date: September 7, 2005.

DOI: https://doi.org/10.2105/AJPH.2025.308292

ORCID iD:

Bonnie D. Kerker https://orcid.org/0000-0002- 2962-1666

ACKNOWLEDGMENTS

The author is grateful to Laurie Brotman and Peter Ephross for their thoughtful review of this article.

CONFLICTS OF INTEREST

The author has no conflicts of interest to disclose.

References

REFERENCES

1. Doser M. Pregnancy and poverty: forging a path forward for families. American Public Human Services Administration. September 26, 2022. Available at: https://aphsa.org/resources/pregnancyand- poverty-forging-a-path-forward-for-families. Accessed July 15, 2025.

2. Agorastos A, Chrousos GP. The neuroendocrinology of stress: the stress-related continuum of chronic disease development. Mol Psychiatry. 2022;27(1):502-513. https://doi.org/10.1038/ s41380-021-01224-9

3. Ranji U, Diep K, Gomez I, Sobel L, SalganicoffA. Health policy issues in women's health. In: Altman D, ed. Health Policy 101. KFF. July 2024 Available at: https://www.kff.org/health-policy- 101-health-policy-issues-in-womens-health. Accessed July 15, 2025.

4. Duncan GJ, Magnuson K, Kunin-Batson AS, et al. Cash transfers and their effect on maternal and young children's health: a randomized clinical trial. JAMA Pediatr. 2025;179(8):867-875. https://doi. org/10.1001/jamapediatrics.2025.1612

5. DeParle J. 2025, July 30. Study may undercut idea that cash payments to poor families help child development. New York Times. July 28, 2025. Available at: https://www.nytimes.com/2025/07/ 28/us/politics/cash-payments-poor-families-childdevelopment. html. Accessed August 6, 2025.

6. Hanna M, Shaefer HL, Fogle H, et al. 2024, December. Scaling up prenatal and infant cash prescriptions to eradicate deep infant poverty in the United States. Brookings. December 20, 2024. Available at: https://www.brookings.edu/ articles/prenatal-and-infant-cash-prescriptions-toeradicate- deep-infant-poverty-united-states. Accessed July 15, 2025.

7. Onifade E, Shishane K, Elonge F, Glover L. Guaranteed income: experiences of African American mothers in the Magnolia Mother's Trust Project. J Community Pract. 2023;31(1): 105-120. https://doi.org/10.1080/10705422. 2023.2190327

8. Doran EL, Bartel AP, Ruhm CJ, Waldfogel J. California's paid family leave law improves maternal psychological health. Soc Sci Med. 2020;256: 113003. https://doi.org/10.1016/j.socscimed. 2020.113003

9. Sy S, Cuevas K. 2023, September 12. Child poverty increases sharply following expiration of expanded tax credit. PBS News Hour. Available at: https://www.pbs.org/newshour/show/childpoverty- increases-sharply-following-expiration-ofexpanded- tax-credit. Accessed August 7, 2025.

10. Kallins L, Katz E. How proposed changes to federal safety net programs could affect the states. National Conference of State Legislatures. Available at: https://www.ncsl.org/events/details/ how-proposed-changes-to-federal-safety-netprograms- could-affect-the-states. Accessed August 7, 2025.

11. Kerker BD, Barajas-Gonzalez RG, Rojas NM, Norton JM, Brotman LM. Enhancing immigrant families' mental health through the promotion of structural and community-based support. Front Public Health. 2024;12:1382600. https://doi.org/ 10.3389/fpubh.2024.1382600

12. Nyandoro A, Spiller K. 2024 Front & Center's next phase: how we fix systems designed to fail Black women. Ms. August 13, 2024. Available at: https://msmagazine.com/2024/08/13/frontcenter- magnolia-mothers-trust-jackson-mississippiblack- women-poverty-childcare. Accessed July 30, 2025.