A common fear among policymakers is that government-provided benefits for households with young children – including cash transfers – may increase incentives to have children, to gain or maintain program eligibility. This is a topic we’ve had our eyes on for some time through the Transfer Project. By conducting reviews of evidence and in our own impact evaluations, we’ve found little evidence to support this narrative from cash transfer programming in low-and middle income countries (LMICs).
Until recently, however, evidence to support this from the Asia and the Pacific region has been absent from the debate. As fertility rates, norms around childbearing, and poverty levels differ across regions, it is possible cash transfer impacts may differ as well. With support from the Social Protection Approaches to COVID-19: Expert Advice (SPACE) helpline, I recently took a deep dive into evidence from the Asia and the Pacific region. I was curious not only to read new studies, but also to draw out implications for program design, to help inform design of new COVID-19 related cash transfer programs in the region.
How might cash transfers affect pregnancy dynamics?
There are a number of ways cash transfers could potentially increase or decrease incentives to have children, especially among programs targeted explicitly to pregnant women or households with young children. Policymakers may fear benefits will increase pregnancies, in line with pro-family policies in high-income, low-fertility settings. However, in theory, the impacts of cash transfers on pregnancies and births are equally likely in the opposite direction. For example, using increased income from cash transfers, parents are able to invest in the health, nutrition and education of their existing children, potentially leading couples to prefer smaller family sizes. The use of family planning may increase among transfer recipients due to income effects or more frequent interaction with the health sector, reducing unplanned pregnancies and allowing safe birth spacing. In addition, recent evidence demonstrates that cash transfers are some of the most promising interventions to delay early marriage and pregnancy for adolescent girls and young women. Therefore, it is possible that total fertility rates may decrease as a result of cash transfer programs over the longer-term. These dynamics are likely to vary based on underlying poverty rates, fertility rates and access to services in a given setting.
What does the evidence from Asia and the Pacific say?
After reviewing existing published and grey literature, compiled through targeted searches and existing review papers, I found a total of five high-quality studies. These studies evaluated cash transfers targeting households with pregnant women or young children and also measured key pregnancy-related outcomes.
What did the studies find? The evidence shows no increase in pregnancies due to cash transfers, and in several cases showed impacts in the opposite direction (e.g. increased birth spacing, delay in first birth).
- Studies from Indonesia show that the government’s Program Keluarga Harapan (PKH) increased birth spacing among women of reproductive age in the short-term, however had no impact on early fertility of girls and young women aged 16 to 21 exposed to PKH when they were school-aged.
- A study of the government of Myanmar’s maternal cash transfer pilot measured both current pregnancy and total number of pregnancies after 30 months of enrollment—finding no impacts on current pregnancy, fertility desires or use of family planning. However, a small reduction in total number of pregnancies since the start of the program was found in the ‘cash only’ group.
- A study of the government of the Pantawid Pamilyana Pilipino Program (4Ps) in the Philippines showed no impacts on total fertility rates after three years among women of reproductive age. A second study found a delay in age of marriage and first birth among women in their early twenties who lived in recipient households of 4Ps for a short period when they were in their teens.
This evidence showing no link between cash transfers and increased pregnancy is particularly policy relevant, given all programs were government run and often reach the poorest women and households. In addition, evaluations reported a host of beneficial outcomes for children, ranging from child nutrition and dietary diversity, to better schooling outcomes.
Programming practicalities and the way forward
Taken together, evidence suggests a number of practical considerations for programs to both maximize wellbeing impacts for maternal and child health, as well as reduce potential unintended consequences:
- Pregnancy-related conditions: While there has been speculation about program designs enforcing pregnancy-related conditions in program eligibility (i.e. making benefits conditional on limiting additional pregnancies or total number of children per woman), others have noted the ethical dangers of such an approach. Conditions may “undermine women’s and couples’ rights to autonomy and reproductive freedom and may translate into dangerous unintended consequences”, which may include “hiding children, not seeking necessary preventative care and health check-ups for children, or, at the extreme, infanticide.” Assuming a wealth-fertility gradient, conditionalities based on limiting number of children will also exclude the most vulnerable women and households. Therefore, given there is little evidence of pregnancy increases in the first instance–it is recommended programs remain free of these types of explicit pregnancy-related conditions.
- Messaging and labeling: Program design should consider if a labeled cash transfer or messaging campaign could serve program objectives. This could include labeling the cash as funds for maternal and infant health, or providing messages at pay points or via community structures around the importance of children’s education or family planning. For example, a study in Zambia found that giving men messages quantifying risk of maternal mortality and morbidity led them to reduce fertility desires and communicate more about family planning, corresponding with a fall in their wives’ pregnancy rates. Messaging should also clearly lay out criteria for eligibility and programming, to both beneficiaries, as well as other community members to avoid misinformation.
- Transfer value and duration: A meaningful transfer value is a key factor in enabling improvements in poverty and broader welling for children and families. However, there may be subtle ways to defusing potential adverse effects via transfer design. For example, capping benefits to a maximum number of children per household – or calculating benefits at a household level could help delink benefit value to new pregnancies and births. Alternatively, expanding the child age range eligibility to 17 years—so caregivers are not worried about children “aging out”—may support families in the longer-term, defusing the need for them to ‘re-qualify.’
- Health infrastructure investments: Governments should seek to combine investments in cash transfers with improvements to health infrastructure and systems strengthening, including strengthening the quality and accessibility of pre- and post-natal care, family planning and other maternal health services. Studies have hypothesized the key role of these services in influencing positive pregnancy-related outcomes for women and families. If couples desire smaller families over time, but are not able to access family planning, or continue to experience adverse birth outcomes, reducing family size may not be possible.
Rigorous evidence refutes the narrative that cash transfers produce increase pregnancies in LMICs, including from five recent studies of government-run programming in Asia and the Pacific. Building on momentum to date, I’m eager to see continued evolution of programs incorporating gender-responsive designs—focusing on promoting wellbeing of women, children and families—rather than on unintended consequences that are not evidence-informed. Finally, as a researcher, I’d be remiss without recommending the continued study of impacts of cash transfers on pregnancy outcomes, including use of family planning and safe transitions to adulthood, in the Asia and Pacific context and beyond.
Amber Peterman is a Research Associate Professor at UNC Chapel Hill and a consultant to UNICEF Innocenti focusing on gender and social protection.
This work is based on the brief Do Child Grants Lead to Increased Pregnancies? An Evidence View from Asia and the Pacific, developed with support from Social Protection Approaches to COVID-19: Expert Advice (SPACE) – a joint initiative of FCDO’s Better Assistance in Crises (BASIC) and Gender Responsive Social Protection (GSP) programmes (funded by UKAid); GIZ (funded by the German Federal Ministry for Economic Cooperation and Development); and the Australian Government through the Department of Foreign Affairs and Trade (DFAT). Helpful comments were received by Juliet Attenborough, Abigail Bakker, Ric Goodman, Lisa Hannigan, Ginevra Jarmaine, Rachel Payne, Jacqui Powell, Dominic Richardson, John Rook and Kathleen Sullivan. SPACE materials including this blog do not necessarily represent FCDO, or GIZ or DFAT’s own views or policies or commit FCDO, GIZ or DFAT to any particular course of action. The author reports no conflicts of interest.