Abstract

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.

Key words:
Infant; Nutritional status; Public policy

Resumo

Investigar o impacto dos programas de tranferência de renda (CTs) nos desfechos ao nascer, incluindo peso ao nascer, baixo peso ao nascer e prematuridade, e crescimento físico infantil, avaliado pelos índices antropométricos de crianças menores de cinco anos. Revisão sistemática realizada nas bases de dados PubMed/Medline, Embase, LILACS, Cochrane Library, Scopus e Web of Science. Foram incluídos estudos quantitativos observacionais, experimentais e quasi-experimentais, com um total de 11 estudos na revisão. A maioria (81,8%) foi realizada em países de baixa e média rendas. Também na modalidade CT condicionais (63,6%). Quatro eram ensaios clínicos, e sete observacionais. Os CT condicionais estiveram associados a uma redução nos índices de altura-para-idade (-0,14; IC95% -0,27, -0,02); (OR 0,85; IC95% 0,77-0,94); (OR = 0,44; IC95% 0,19-0,98), redução significativa na chance de baixo peso-para-idade (OR = 0,16; IC95% -0,11-0,43), baixo peso-para-altura (OR = -0,68; IC95% -1,14, -0,21), e redução de peso para idade (OR = 0,27; IC95% 0,10; 0,71). CTs não condicionais foram associados à redução do baixo peso as nascer (RR = 0,71; IC95% 0,63-0,81; p < 0,0001), e de prematuros (RR = 0,76; IC95% 0,69-0,84; p < 0,0001). Os CTs condicionais podem influenciar positivamente os desfechos ao nascer e o crescimento infantil.

Palavras-chave:
Infância; Estado nutricional; Políticas públicas

Introduction

An estimated 90-117 million children live in poverty worldwide¹1 United Nations (UN). Policy brief: the impact of COVID-19 on food security and nutrition, 2020 [Internet]. [cited 2022 ago 3] Available from: https://www.un.org/sites/un2.un.org/files/sg_policy_brief_on_covid_impact_on_food_security.pdf
https://www.un.org/sites/un2.un.org/file... , a condition which reduces a family’s capability to provide children with the care and attention necessary to ensure adequate growth and development in the first five years of life. Poverty is considered a social determinant of health with multidimensional consequences²2 Tirivayi N, Richardson D, Gavrilovic M, Groppo V, Kajula L, Valli E, Viola F. A rapid review of economic policy and social protection responses to health and economic crises and their effects on children: lessons for the COVID-19 pandemic response. Innocenti Working Paper 2020; 2020-02.^,33 Leroy JL, Koch B, Roy S, Gilligan D, Ruel M. Social assistance programs and birth outcomes: a systematic review and assessment of nutrition and health pathways. J Nutr 2021; 151(12):3841-3855.. Previous studies have highlighted relationships between poverty and increases in infectious and parasitic diseases, protein-calorie malnutrition and micronutrient deficiencies, as well as higher rates of hospitalization and death among children³3 Leroy JL, Koch B, Roy S, Gilligan D, Ruel M. Social assistance programs and birth outcomes: a systematic review and assessment of nutrition and health pathways. J Nutr 2021; 151(12):3841-3855.

4 Assis AM, Costa PR, Silva MC, Santana ML, Pitangueira JC, Fonseca NS, Pinheiro SM, Santos SM. Effectiveness of the Brazilian Conditional Cash Transfer Program - Bolsa Alimentação - on the variation of linear and ponderal increment in children from northeast of Brazil. Nutr Hosp 2015; 31(6):2786-2794.^-55 Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study. PLoS Med 2018; 15(5):e1002570..

Social protection policies are important interventions to reduce poverty and protect nutritional status and health of children and newborns, especially considering the strength of relationships between poverty and negative nutritional outcomes, e.g., low birth weight, premature birth and delayed growth³3 Leroy JL, Koch B, Roy S, Gilligan D, Ruel M. Social assistance programs and birth outcomes: a systematic review and assessment of nutrition and health pathways. J Nutr 2021; 151(12):3841-3855.^,66 Ruel M, Alderman H, The Maternal and Child Nutrition Study Group. Nutritionsensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Lancet 2013; 382(9891):536-351.^,77 Owusu-Addo E, Renzaho AM, Smith BJ. Cash transfers and the social determinants of health: a conceptual framework. Health Promot Int 2019; 34(6):e106-e118..

In this context, cash transfer programs (CT) have been implemented in several countries, especially those considered as low- or middle-income. A form of public policy aimed at reducing poverty and social inequality, cash transfers provide a source of monthly income to previously registered eligible beneficiaries. Among the main advantages of CTs are the improved well-being of families, income redistribution and the promotion of social inclusion⁸8 Resende ACC, Oliveira AMHC. Avaliando resultados de um programa de transferência de renda: o impacto do Bolsa-Escola sobre os gastos das famílias brasileiras. Est Econ 2008; 38(2):235-265.^,99 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388..

Consequently, CTs have been linked to improvements in health indicators, such as increased access to health services¹⁰10 Rasella D, Aquino R, Santos CA, Paes-Sousa R, Barreto ML. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet 2013; 382(9886):57-64., food¹¹11 Sperandio N, Rodigues CT, Franceschini SCC, Priore SE. Impacto do Programa Bolsa Família no consumo de alimentos: estudo comparativo das regiões Sudeste e Nordeste do Brasil. Cien Saude Colet 2017; 22(6):1771-1780., hygiene¹²12 Rivera JA, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study. JAMA 2004; 291(21):2563-2570., community services and education for the most vulnerable families¹³13 Lagarde M, Haines A, Palmer N. The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries. Cochrane Database Syst Rev 2009; 2009(4):CD008137.

14 French SA, Tangney CC, Crane MM, Wang Y, Appelhans BM. Nutrition quality of food purchases varies by household income: the SHoPPER study. BMC Public Health 2019; 19(1):231.^-1515 Sicong S, Huang J, Hudson DL, Sherraden M. Cash transfers and health. Annu Rev Public Health 2021; 42(1):363-380.. Some CTs have also positively impacted infant nutritional outcomes⁴4 Assis AM, Costa PR, Silva MC, Santana ML, Pitangueira JC, Fonseca NS, Pinheiro SM, Santos SM. Effectiveness of the Brazilian Conditional Cash Transfer Program - Bolsa Alimentação - on the variation of linear and ponderal increment in children from northeast of Brazil. Nutr Hosp 2015; 31(6):2786-2794.^,1616 Leroy JL, Ruel M, Verhofstadt E. The impact of conditional cash transfer programmes on child nutrition: a review of evidence using a programme theory framework. J Dev Effect 2009; 1(2):103-129.

17 Fernald LC, Gertler PJ, Neufeld LM. 10-year effect of Oportunidades, Mexico's conditional cash transfer programme, on child growth, cognition, language, and behaviour: a longitudinal follow-up study. Lancet 2009; 374(9706):1997-2005.^-1818 Paes-Sousa R, Santos LM, Miazaki ES. Effects of a conditional cash transfer programme on child nutrition in Brazil. Bull World Health Organ 2011; 89(7):496-503..

CTs can be classified according to the presence or absence of eligibility conditions. In unconditional income transfer programs (UCT), monetary transfer occurs with no action required from beneficiaries¹⁹19 Bastagli F, Hagen-Zanker J, Harman L. Cash transfers: what does the evidence say. A rigorous review of programme impact and the role of design and implementation features. London: ODI Briefing London: Overseas Development Institute; 2016., while in conditional income transfer programs (CCT), monthly benefits are linked to the fulfillment of specific education and/or health stipulations¹³13 Lagarde M, Haines A, Palmer N. The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries. Cochrane Database Syst Rev 2009; 2009(4):CD008137.^,2020 Fiszbein A, Schady N, Ferreira FHG, et al. Conditional cash transfers: reducing present and future poverty. Washington: The World Bank; 2009..

To date, no systematic reviews have attempted to evaluate the effectiveness of these strategies on child health and nutrition in different economic contexts. Thus, in light of the relevance of providing consistent evidence on the impact of CTs on child health and nutrition, while also considering CT type (conditional/unconditional), here we endeavored to systematically analyze studies evaluating the effects of these programs on prematurity, low birth weight and other indicators of physical growth among children aged five years or less. Knowledge on these effects serves as a strategic tool for public policymakers to administer social programs aimed at ensuring the healthy development of babies from birth through infancy.

Methods

The present review was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement²¹21 Page M J, Mckenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372:n71., and has been registered with the International Prospective Register of Systematic Reviews (PROSPERO): CRD42021255570

Search strategy

Searching was performed on the PubMed/Medline, Embase, LILACS (Virtual Health Library), Cochrane Library, Scopus and Web of Science electronic databases. Additionally, grey literature was consulted by an expert on the topic of this review (Figure 1).

No language, geographic or publication date restrictions were applied. Results were obtained through July 2021 and update until November 8th, 2022. The keywords employed when performing searches were identified using Medical Subject Headings (MESH) vocabulary and adapted to each database using the Health Sciences Descriptors (DeCS) thesaurus and Embase Subject Headings (Emtree) (Chart 1).

Participants, exposure, comparisons and outcomes

To answer the guiding question: “What are the impacts of cash transfer programs on birth outcomes and physical growth in children aged under five years?”, the acronym PICO (population/problem, intervention/exposure, comparison, outcome) was developed jointly with specialists in the field, as delineated in Chart 2. The exposure/intervention of interest was conditional and/or unconditional income transfer programs targeting socioeconomically vulnerable families or individuals. Children of families who were not beneficiaries of CTs were considered as controls.

The following outcomes were considered: The nutritional status of children under five years, as assessed by the anthropometric measures weight-for-height (W/H), weight-for-age (W/A), height-for-age (H/A) and body mass-for-age (BMI/A)²²22 World Health Organization (WHO). Physical status: the use and interpretation of antropometry. Geneva: WHO; 1995.; birth weight and low birth weight (< 2,500 g); preterm birth, defined as birth occurring before the 37^th week of pregnancy (< 259 days, or 36 weeks and 6 days)²³23 World Health Organization (WHO). International statistical classification of diseases and related health problems. Geneva: WHO; 1992. (Chart 2).

Due to substantial heterogeneity among the obtained results, a narrative synthesis was adopted to present our findings (Charts 3 and 4).

Eligibility criteria

Quantitative observational and experimental studies, as well as quasi-experimental published articles, were included regardless of country income classification (low, middle or high income).

The present systematic review excluded qualitative research, books or chapters of narrative and scientific books, editorials, opinion articles, literature reviews (narrative, integrative, and systematic, with or without meta-analysis, scoping review/rapid review), studies in which food and/or nutritional supplements were offered, as well as those investigating food vouchers or emergency cash transfers.

Study selection and data extraction

All articles identified in the searched databases were entered into the Rayyan application²⁴24 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid. Rayyan - a web and mobile app for systematic reviews. Systematic Rev 2016; 5(1):210. to assist in screening. Four reviewers determined eligibility through the analysis of titles and abstracts. Discrepancies between reviewers were resolved by discussion and in collaboration with a fifth reviewer. The reasons for exclusion of all full-text articles are detailed in Figure 1.

Full texts were reviewed using a standardized form to determine final inclusion in the present review. A data extraction template enabled the collection of information on first author, year of publication, manuscript title, study location, population (study size and description of groups), design, exposure variables (type of CT, monthly transfer value, presence/absence of conditionalities, duration of transfers) and variable outcomes (anthropometric indices or measures, birthweight or gestational age).

Data from the selected articles were extracted and entered into MS Excel. In cases of incomplete or missing data, the authors of the selected studies were contacted by email and asked to provide the requested information, or offer other clarification regarding the metrics evaluated.

Evaluation of methodological quality

The methodological quality of the selected studies was assessed using the Quality Assessment Tool for the Dictionary of Quantitative Studies²⁵25 Armijo-Olivo S, Stiles CR, Hagen NA, Biondo PD, Cummings GG. Assessment of study quality for systematic reviews: a comparison of the Cochrane Collaboration Risk of Bias Tool and the Effective Public Health Practice Project Quality Assessment Tool: methodological research. J Eval Clin Pract 2012; 18(1):12-18., which classifies study quality according to risk of bias (“Strong”, “Moderate” or “Weak”). Two independent research authors assessed the risk of bias in each selected study. Disagreement was resolved by consensus or by consulting a third researcher (Table 1).

Patient and public involvement

No patient involved.

Results

Searching performed in the literature returned 5,933 published studies. Of these, after removing duplicates, 5,825 articles were selected for title and abstract examination. In all, 42 studies were selected for textual analysis, with seven deemed eligible for inclusion. Additional manual searching involving the reading of other review articles produced two additional studies, resulting in a total of nine included studies (Figure 1). The search was updated on November 8, 2022 in all databases. 615 new titles and abstracts were cheked. Of these, 3 texts were fully evaluated and there 2 studies met the inclusion criteria.

Study characteristics

Chart 3 lists the characteristics of all studies included in the present systematic review. Most articles (63.6%) were published within the past five years⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388.^,2626 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15.

27 Adubra L, Le Port A, Kameli Y, Fortin S, Mahamadou T, Ruel MT, Martin-Prevel Y, Savy M. Conditional cash transfer and/or lipid-based nutrient supplement targeting the first 1000 d of life increased attendance at preventive care services but did not improve linear growth in young children in rural Mali: results of a cluster-randomized controlled trial. Am J Clin Nutr 2019; 110(6):1476-1490.

28 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086.

29 Chakrabarti S, Pan A, Singh P. Maternal and child health benefits of the mamata conditional cash transfer program in Odisha, India. J Nutr 2021; 151(8):2271-2281.

30 Lopez-Arana S, Avendano M, Forde I, van Lenthe FJ, Burdorf A. Conditional cash transfers and the double burden of malnutrition among children in Colombia: a quasi-experimental study. Br J Nutr 2016; 115(10):1780-1789.^-3131 González L, Trommlerová S. Cash transfers before pregnancy and infant health. J Health Econ 2022; 83:102622., conducted primarily in low- and middle-income countries (Colombia, Brazil, India, Spain and the Philippines)²⁶26 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15.^,2929 Chakrabarti S, Pan A, Singh P. Maternal and child health benefits of the mamata conditional cash transfer program in Odisha, India. J Nutr 2021; 151(8):2271-2281.^,3030 Lopez-Arana S, Avendano M, Forde I, van Lenthe FJ, Burdorf A. Conditional cash transfers and the double burden of malnutrition among children in Colombia: a quasi-experimental study. Br J Nutr 2016; 115(10):1780-1789.^,3232 Lucas ADP, de Oliveira Ferreira M, Lucas TDP, Salari P. The intergenerational relationship between conditional cash transfers and newborn health. BMC Public Health 2022; 22(1):201.^,3333 Kandpal E, Alderman H, Friedman J, Filmer D, Onishi J, Avalos J. A conditional cash transfer program in the Philippines reduces severe stunting. J Nutr 2016; 146(9):1793-800., notably countries in Africa (Mali, Togo and Tanzania)⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388.^,2727 Adubra L, Le Port A, Kameli Y, Fortin S, Mahamadou T, Ruel MT, Martin-Prevel Y, Savy M. Conditional cash transfer and/or lipid-based nutrient supplement targeting the first 1000 d of life increased attendance at preventive care services but did not improve linear growth in young children in rural Mali: results of a cluster-randomized controlled trial. Am J Clin Nutr 2019; 110(6):1476-1490.^,2828 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086., with just two originating from high-income countries (United States and Canada)³⁴34 Hamad R, Rehkopf DH. Poverty, pregnancy, and birth outcomes: a study of the earned income tax credit. Paediatr Perinat Epidemiol 2015; 29(5):444-452.^,3535 Brownel MD, Chartier MJ, Nickel NC, Chateau D, Martens PJ, Sarkar J, Burland E, Jutte DP, Taylor C, Santos RG, Katz A, PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes. Pediatrics 2016; 137(6):e20152992..

With regard to study design classification, four were randomized clinical trials (RCT) ^9,27,28,33, while seven were observational; six involved cohorts²⁶26 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15.

27 Adubra L, Le Port A, Kameli Y, Fortin S, Mahamadou T, Ruel MT, Martin-Prevel Y, Savy M. Conditional cash transfer and/or lipid-based nutrient supplement targeting the first 1000 d of life increased attendance at preventive care services but did not improve linear growth in young children in rural Mali: results of a cluster-randomized controlled trial. Am J Clin Nutr 2019; 110(6):1476-1490.

28 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086.

29 Chakrabarti S, Pan A, Singh P. Maternal and child health benefits of the mamata conditional cash transfer program in Odisha, India. J Nutr 2021; 151(8):2271-2281.

30 Lopez-Arana S, Avendano M, Forde I, van Lenthe FJ, Burdorf A. Conditional cash transfers and the double burden of malnutrition among children in Colombia: a quasi-experimental study. Br J Nutr 2016; 115(10):1780-1789.

31 González L, Trommlerová S. Cash transfers before pregnancy and infant health. J Health Econ 2022; 83:102622.

32 Lucas ADP, de Oliveira Ferreira M, Lucas TDP, Salari P. The intergenerational relationship between conditional cash transfers and newborn health. BMC Public Health 2022; 22(1):201.^-3333 Kandpal E, Alderman H, Friedman J, Filmer D, Onishi J, Avalos J. A conditional cash transfer program in the Philippines reduces severe stunting. J Nutr 2016; 146(9):1793-800. and one was quasi-experimental in design³²32 Lucas ADP, de Oliveira Ferreira M, Lucas TDP, Salari P. The intergenerational relationship between conditional cash transfers and newborn health. BMC Public Health 2022; 22(1):201. (Chart 3).

Ten different social protection programs⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388.^,2626 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15.

27 Adubra L, Le Port A, Kameli Y, Fortin S, Mahamadou T, Ruel MT, Martin-Prevel Y, Savy M. Conditional cash transfer and/or lipid-based nutrient supplement targeting the first 1000 d of life increased attendance at preventive care services but did not improve linear growth in young children in rural Mali: results of a cluster-randomized controlled trial. Am J Clin Nutr 2019; 110(6):1476-1490.

28 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086.

29 Chakrabarti S, Pan A, Singh P. Maternal and child health benefits of the mamata conditional cash transfer program in Odisha, India. J Nutr 2021; 151(8):2271-2281.^-3030 Lopez-Arana S, Avendano M, Forde I, van Lenthe FJ, Burdorf A. Conditional cash transfers and the double burden of malnutrition among children in Colombia: a quasi-experimental study. Br J Nutr 2016; 115(10):1780-1789.^,3232 Lucas ADP, de Oliveira Ferreira M, Lucas TDP, Salari P. The intergenerational relationship between conditional cash transfers and newborn health. BMC Public Health 2022; 22(1):201.

33 Kandpal E, Alderman H, Friedman J, Filmer D, Onishi J, Avalos J. A conditional cash transfer program in the Philippines reduces severe stunting. J Nutr 2016; 146(9):1793-800.

34 Hamad R, Rehkopf DH. Poverty, pregnancy, and birth outcomes: a study of the earned income tax credit. Paediatr Perinat Epidemiol 2015; 29(5):444-452.^-3535 Brownel MD, Chartier MJ, Nickel NC, Chateau D, Martens PJ, Sarkar J, Burland E, Jutte DP, Taylor C, Santos RG, Katz A, PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes. Pediatrics 2016; 137(6):e20152992. were evaluated, the majority (n = 7; 63.6%) being CCTs²⁶26 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15.

27 Adubra L, Le Port A, Kameli Y, Fortin S, Mahamadou T, Ruel MT, Martin-Prevel Y, Savy M. Conditional cash transfer and/or lipid-based nutrient supplement targeting the first 1000 d of life increased attendance at preventive care services but did not improve linear growth in young children in rural Mali: results of a cluster-randomized controlled trial. Am J Clin Nutr 2019; 110(6):1476-1490.

28 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086.

29 Chakrabarti S, Pan A, Singh P. Maternal and child health benefits of the mamata conditional cash transfer program in Odisha, India. J Nutr 2021; 151(8):2271-2281.^-3030 Lopez-Arana S, Avendano M, Forde I, van Lenthe FJ, Burdorf A. Conditional cash transfers and the double burden of malnutrition among children in Colombia: a quasi-experimental study. Br J Nutr 2016; 115(10):1780-1789.^,3232 Lucas ADP, de Oliveira Ferreira M, Lucas TDP, Salari P. The intergenerational relationship between conditional cash transfers and newborn health. BMC Public Health 2022; 22(1):201.^,3333 Kandpal E, Alderman H, Friedman J, Filmer D, Onishi J, Avalos J. A conditional cash transfer program in the Philippines reduces severe stunting. J Nutr 2016; 146(9):1793-800.. Of these, six investigated cash transfers²⁶26 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15.^,2929 Chakrabarti S, Pan A, Singh P. Maternal and child health benefits of the mamata conditional cash transfer program in Odisha, India. J Nutr 2021; 151(8):2271-2281.^,3030 Lopez-Arana S, Avendano M, Forde I, van Lenthe FJ, Burdorf A. Conditional cash transfers and the double burden of malnutrition among children in Colombia: a quasi-experimental study. Br J Nutr 2016; 115(10):1780-1789.

31 González L, Trommlerová S. Cash transfers before pregnancy and infant health. J Health Econ 2022; 83:102622.

32 Lucas ADP, de Oliveira Ferreira M, Lucas TDP, Salari P. The intergenerational relationship between conditional cash transfers and newborn health. BMC Public Health 2022; 22(1):201.^-3333 Kandpal E, Alderman H, Friedman J, Filmer D, Onishi J, Avalos J. A conditional cash transfer program in the Philippines reduces severe stunting. J Nutr 2016; 146(9):1793-800.. Another analyzed a benefit paid exclusively in cash, which also provided food and preventive care activities to beneficiaries²⁷27 Adubra L, Le Port A, Kameli Y, Fortin S, Mahamadou T, Ruel MT, Martin-Prevel Y, Savy M. Conditional cash transfer and/or lipid-based nutrient supplement targeting the first 1000 d of life increased attendance at preventive care services but did not improve linear growth in young children in rural Mali: results of a cluster-randomized controlled trial. Am J Clin Nutr 2019; 110(6):1476-1490.; finally, another paid a benefit exclusively in cash kind, and also involved integrated intervention by community health workers²⁸28 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086..

With respect to UCTs (n = 4; 36.3%)⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388.^,3333 Kandpal E, Alderman H, Friedman J, Filmer D, Onishi J, Avalos J. A conditional cash transfer program in the Philippines reduces severe stunting. J Nutr 2016; 146(9):1793-800.

34 Hamad R, Rehkopf DH. Poverty, pregnancy, and birth outcomes: a study of the earned income tax credit. Paediatr Perinat Epidemiol 2015; 29(5):444-452.^-3535 Brownel MD, Chartier MJ, Nickel NC, Chateau D, Martens PJ, Sarkar J, Burland E, Jutte DP, Taylor C, Santos RG, Katz A, PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes. Pediatrics 2016; 137(6):e20152992., while all three evaluated programs implemented direct cash transfers⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388.^,3333 Kandpal E, Alderman H, Friedman J, Filmer D, Onishi J, Avalos J. A conditional cash transfer program in the Philippines reduces severe stunting. J Nutr 2016; 146(9):1793-800.

34 Hamad R, Rehkopf DH. Poverty, pregnancy, and birth outcomes: a study of the earned income tax credit. Paediatr Perinat Epidemiol 2015; 29(5):444-452.^-3535 Brownel MD, Chartier MJ, Nickel NC, Chateau D, Martens PJ, Sarkar J, Burland E, Jutte DP, Taylor C, Santos RG, Katz A, PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes. Pediatrics 2016; 137(6):e20152992., one also provided health-related services⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388. involving awareness activities and home visits targeting child health and nutrition, as well as community surveillance of childhood illness and acute malnutrition of mother-child pairs during each newborn’s first 1,000 days of life.

Sample sizes ranged from 188²⁸28 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086. to 11,558²⁹29 Chakrabarti S, Pan A, Singh P. Maternal and child health benefits of the mamata conditional cash transfer program in Odisha, India. J Nutr 2021; 151(8):2271-2281. children under five years in seven studies focused on child development. As for four studies³⁰30 Lopez-Arana S, Avendano M, Forde I, van Lenthe FJ, Burdorf A. Conditional cash transfers and the double burden of malnutrition among children in Colombia: a quasi-experimental study. Br J Nutr 2016; 115(10):1780-1789.^,3131 González L, Trommlerová S. Cash transfers before pregnancy and infant health. J Health Econ 2022; 83:102622.^,3535 Brownel MD, Chartier MJ, Nickel NC, Chateau D, Martens PJ, Sarkar J, Burland E, Jutte DP, Taylor C, Santos RG, Katz A, PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes. Pediatrics 2016; 137(6):e20152992.^,3434 Hamad R, Rehkopf DH. Poverty, pregnancy, and birth outcomes: a study of the earned income tax credit. Paediatr Perinat Epidemiol 2015; 29(5):444-452. investigating gestational age and birth weight, one³⁰30 Lopez-Arana S, Avendano M, Forde I, van Lenthe FJ, Burdorf A. Conditional cash transfers and the double burden of malnutrition among children in Colombia: a quasi-experimental study. Br J Nutr 2016; 115(10):1780-1789. had a sample size of 55,998, the study³¹31 González L, Trommlerová S. Cash transfers before pregnancy and infant health. J Health Econ 2022; 83:102622. had 5,246,874 births; the study³⁵35 Brownel MD, Chartier MJ, Nickel NC, Chateau D, Martens PJ, Sarkar J, Burland E, Jutte DP, Taylor C, Santos RG, Katz A, PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes. Pediatrics 2016; 137(6):e20152992. had 14,591 births; and the study³⁴34 Hamad R, Rehkopf DH. Poverty, pregnancy, and birth outcomes: a study of the earned income tax credit. Paediatr Perinat Epidemiol 2015; 29(5):444-452. had 19,274 births (Chart 3).

Analytic strategies

The included studies employed diverse methods of analysis. Seven studies (63.6%) used linear regression and logistic regression models⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388.^,2626 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15.

27 Adubra L, Le Port A, Kameli Y, Fortin S, Mahamadou T, Ruel MT, Martin-Prevel Y, Savy M. Conditional cash transfer and/or lipid-based nutrient supplement targeting the first 1000 d of life increased attendance at preventive care services but did not improve linear growth in young children in rural Mali: results of a cluster-randomized controlled trial. Am J Clin Nutr 2019; 110(6):1476-1490.^-2828 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086.^,3131 González L, Trommlerová S. Cash transfers before pregnancy and infant health. J Health Econ 2022; 83:102622.^,3232 Lucas ADP, de Oliveira Ferreira M, Lucas TDP, Salari P. The intergenerational relationship between conditional cash transfers and newborn health. BMC Public Health 2022; 22(1):201.^,3434 Hamad R, Rehkopf DH. Poverty, pregnancy, and birth outcomes: a study of the earned income tax credit. Paediatr Perinat Epidemiol 2015; 29(5):444-452., while three (27.2%) utilized Difference-in-Differences (DiD) estimation⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388.^,2929 Chakrabarti S, Pan A, Singh P. Maternal and child health benefits of the mamata conditional cash transfer program in Odisha, India. J Nutr 2021; 151(8):2271-2281.^,3232 Lucas ADP, de Oliveira Ferreira M, Lucas TDP, Salari P. The intergenerational relationship between conditional cash transfers and newborn health. BMC Public Health 2022; 22(1):201. and one (9.0%) adopted a propensity score matching (PSM) technique²⁶26 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15. and one adopted regression discontinuity design (RDD).

Methodological quality assessment

Both high (n = 3; 27.2%) and low (n = 4; 36,3%) methodological quality were identified in the evaluated studies, which were also categorized according to the following criteria: selection bias, study design, confounders, blinding, data collection method, and withdrawals and drop-outs (Chart 4).

Main results

Of the eleven included articles, seven analyzed CTs in low- and middle-income countries and evaluated child growth via anthropometry⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388.^,2626 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15.

27 Adubra L, Le Port A, Kameli Y, Fortin S, Mahamadou T, Ruel MT, Martin-Prevel Y, Savy M. Conditional cash transfer and/or lipid-based nutrient supplement targeting the first 1000 d of life increased attendance at preventive care services but did not improve linear growth in young children in rural Mali: results of a cluster-randomized controlled trial. Am J Clin Nutr 2019; 110(6):1476-1490.

28 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086.^-2929 Chakrabarti S, Pan A, Singh P. Maternal and child health benefits of the mamata conditional cash transfer program in Odisha, India. J Nutr 2021; 151(8):2271-2281.^,3232 Lucas ADP, de Oliveira Ferreira M, Lucas TDP, Salari P. The intergenerational relationship between conditional cash transfers and newborn health. BMC Public Health 2022; 22(1):201.^,3333 Kandpal E, Alderman H, Friedman J, Filmer D, Onishi J, Avalos J. A conditional cash transfer program in the Philippines reduces severe stunting. J Nutr 2016; 146(9):1793-800.. All of these studies reported H/A ratio; W/H were reported in three²⁶26 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15.^,2828 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086.^,3333 Kandpal E, Alderman H, Friedman J, Filmer D, Onishi J, Avalos J. A conditional cash transfer program in the Philippines reduces severe stunting. J Nutr 2016; 146(9):1793-800., while BMI/A³²32 Lucas ADP, de Oliveira Ferreira M, Lucas TDP, Salari P. The intergenerational relationship between conditional cash transfers and newborn health. BMC Public Health 2022; 22(1):201. and W/A (Sudfeld C. et al. 2021)²⁸28 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086. were evaluated in one each (Figure 2 and 3).

Three studies³³33 Kandpal E, Alderman H, Friedman J, Filmer D, Onishi J, Avalos J. A conditional cash transfer program in the Philippines reduces severe stunting. J Nutr 2016; 146(9):1793-800.

34 Hamad R, Rehkopf DH. Poverty, pregnancy, and birth outcomes: a study of the earned income tax credit. Paediatr Perinat Epidemiol 2015; 29(5):444-452.^-3535 Brownel MD, Chartier MJ, Nickel NC, Chateau D, Martens PJ, Sarkar J, Burland E, Jutte DP, Taylor C, Santos RG, Katz A, PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes. Pediatrics 2016; 137(6):e20152992., both investigating UCTs in high-income countries, investigated the effects of social protection programs on birth weight; two of these also considered prematurity³³33 Kandpal E, Alderman H, Friedman J, Filmer D, Onishi J, Avalos J. A conditional cash transfer program in the Philippines reduces severe stunting. J Nutr 2016; 146(9):1793-800.^,3535 Brownel MD, Chartier MJ, Nickel NC, Chateau D, Martens PJ, Sarkar J, Burland E, Jutte DP, Taylor C, Santos RG, Katz A, PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes. Pediatrics 2016; 137(6):e20152992..

A 16-month intervention cohort study conducted in Brazil on the CCT program denominated Bolsa Família²⁶26 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15. identified differences of β = -0.14 [95%CI -0.27, -0.02] in H/A ratio among children up to two years of age whose mothers received monthly payments less than R$1,000 (1,000 Brazilian reais = US$ 184.86 in July 2022), and β = -0.20 [95%CI -0.33, -0.88] among children whose mothers received more than R$1,000, when compared to non-beneficiaries. Regarding W/A, the respective differences reported were β = -0.04 [95%CI -0.17-0.08] in association with receiving less than R$1,000 and β = -0.18 [95%CI -0.30, -0.05] for more than R$1,000. Although the authors also assessed gestational age and birth weight, these estimates were not reported²⁶26 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15..

Another study in Brazil, conducted by the Center for Data and Knowledge Integration for Health, assessed the benefit of intergenerational transmission of health and poverty, as well as the relationship between PBF received by the mother and health and the health of the newborn. The authors present their findings that children born in a household where the mother received BF were less likely to have low birth weight (OR 0.93, CI; 0.92-0.94), very low birth weight (0.87, CI; 0.84-0.89), as well as to be born after 37 weeks of gestation (OR 0.98, CI; 0.97-0.99) or 28 weeks of gestation (OR 0.93, CI; 0.88-0.97)³¹31 González L, Trommlerová S. Cash transfers before pregnancy and infant health. J Health Econ 2022; 83:102622..

A cohort study carried out in India over an intervention period of 60 months evaluated the odds of stunting, as assessed by H/A among poor children under five years of age. The authors reported a reduction [from OR 0.89 (95%CI 0.81-0.98) to OR 0.85 (95%CI 0.77-0.94)] following the implementation of the Mamata CCT program across all Indian States (except Uttar Pradesh, Bihar, Jharkhand and Uttarakhand), as well as in the neighboring states of Odisha (West Bengal, Chhattisgarh, Jharkhand and Andhra Pradesh).

Among the four RCTs evaluated, one carried out in Togo (intervention time of 24-30 months) observed that the UCT Cash Plus program exerted a protective effect on H/A among children aged 6-29 months (DiD = 0.25; 95%CI 0.01-0.50; p = 0.039). This same study reported that female beneficiaries were also less likely to have children with low birth weight (< 2,500g) (DiD = -11.8; ROR = 0.29; 95%CI 0.10-0.82; p = 0.020). Similar results were reported by a study by Brownell M et al.³⁵35 Brownel MD, Chartier MJ, Nickel NC, Chateau D, Martens PJ, Sarkar J, Burland E, Jutte DP, Taylor C, Santos RG, Katz A, PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes. Pediatrics 2016; 137(6):e20152992., carried out in Canada, in which an 84-month interventional UCT program was associated with reductions in LBW (RR = 0.71; 95%CI 0.63-0.81; p < 0.0001) and premature births (RR = 0.76; 95%CI 0.69-0.84; p < 0.0001).

Research carried out in Tanzania²⁸28 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086. evaluated associations between a CCT program and H/A, W/A, W/H and BMI/A indicators, as well as overweight and LBW. After adjusting for sociodemographic variables (area of residence, income, maternal education, basic sanitation, child age), significant reductions in the odds of stunting (H/A) (OR = 0.44; 95%CI 0.19-0.98), low W/A (OR = 0.16; 95%CI -0.11-0.43), LBW (OR = 0.14; 95%CI 0.04-0.55), low W/H (OR = -0.68; 95%CI -1.14, -0.21) and overweight (OR = 0.27; 95%CI 0.10; 0.71) were identified among beneficiary children.

In a study carried out in Colombia³²32 Lucas ADP, de Oliveira Ferreira M, Lucas TDP, Salari P. The intergenerational relationship between conditional cash transfers and newborn health. BMC Public Health 2022; 22(1):201. among children aged two to five years, the CCT program Familias en Acción was associated with reduced stunting (H/A) (OR = 0.21; 95%CI 0.05-0.82) and increased BMI/A (β = 0.12; 95%CI -0.05-0.29; p < 0.05); however, no associations were observed with respect to short stature (OR = 1.0; 95%CI 0.82-1.23), overweight (OR = 1.39; 95%CI 0.86-2.25) or obesity (OR = 0.31; 95%CI 0.09-1.06).

Discussion

The present systematic review synthesized the available evidence investigating the effects of CTs on child health outcomes in high-, low-, and middle-income countries. Our findings indicate that cash transfers are associated with reduced prematurity, low birth weight and improved nutritional status, as assessed by anthropometric indicators (W/A, H/A, W/H and BMI/A). The influence of CTs on the outcomes studied was mainly derived from CCTs whose effects were more pronounced among low- and middle-income countries.

Despite differences in scope, other reviews have also described positive effects on child health and nutrition outcomes resulting from CTs. Indeed, a recent review carried out by Anne E. Fuller et al.³⁶36 Fuller AE, Zaffar N, Cohen E, Pentland M, Siddiqi A, Vandermorris A, Van Den Heuvel M, Birken CS, Guttmann A, Oliveira C. Cash transfer programs and child health and family economic outcomes: a systematic review. Can J Public Health 2022; 113(3):433-445. reported better child health outcomes in families with children in Canada that received a CT.

Four studies evaluating birth outcomes (preterm birth, birth weight and hospital admissions during the neonatal period) provide evidence of the protective effects of UCTs on these outcomes³⁵35 Brownel MD, Chartier MJ, Nickel NC, Chateau D, Martens PJ, Sarkar J, Burland E, Jutte DP, Taylor C, Santos RG, Katz A, PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes. Pediatrics 2016; 137(6):e20152992.; however, none evaluated the impact of CT on child growth.

A recent meta-analysis estimating the effect of CTs on diverse nutritional outcomes, as well as the proximal determinants of those outcomes, including diet quality and infant morbidity, concluded that after systematizing the results of 74 articles CTs were positively associated with higher H/A z-scores (HAZ) (p < 0.03) and a 2.1% reduction in stunting (p < 0.01). However, a similar effect was not observed for W/H (WHZ) (p < 0.42) and low weight z-scores (p < 0.07)³⁷37 Manley J, Balarajan Y, Malm S, Harman L, Owens J, Murthy S, Stewart D, Winder-Rossi NE, Khurshid A. Cash transfers and child nutritional outcomes: a systematic review and meta-analysis. BMJ Glob Health 2020; 5(12):e003621.. The authors argued that the relatively short durations of the studies analyzed may not have been sufficient to evidence relevant changes in growth. When analyzed by region, significant impacts of CTs on W/A z-scores (WAZ) were only identified in Sub-Saharan Africa³⁷37 Manley J, Balarajan Y, Malm S, Harman L, Owens J, Murthy S, Stewart D, Winder-Rossi NE, Khurshid A. Cash transfers and child nutritional outcomes: a systematic review and meta-analysis. BMJ Glob Health 2020; 5(12):e003621., which is similar to the results of another study by Sudfeld C et al.²⁸28 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086.

Two systematic reviews³⁷37 Manley J, Balarajan Y, Malm S, Harman L, Owens J, Murthy S, Stewart D, Winder-Rossi NE, Khurshid A. Cash transfers and child nutritional outcomes: a systematic review and meta-analysis. BMJ Glob Health 2020; 5(12):e003621.^,3838 Manley J, Alderman H, Gentilini U. More evidence on cash transfers and child nutritional outcomes: a systematic review and meta-analysis. BMJ Glob Health 2022; 7(4):e008233. suggest that UCTs positively impact child weight. The present review found that most studies examining the influence of CTs on child health demonstrated positive associations with birth weight, including a study by Briaux J et al.⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388., an RCT that combined monthly cash transfers with community activities targeting 1,035 mother-infant pairs during the first 1,000 days of life. These authors observed that female beneficiaries were less likely to have children with low birth weight (DiD = -11.8; ROR = 0.29; 95%CI 0.10-0.82; p = 0.02). However, Hamada R and Rehkopf D.H. 34 also evaluated UCTs and found no significant associations between cash transfers and birth weight (β = 18.0; 95%CI -17,8,53,8; p > 0.05). Nonetheless, the UCTs evaluated did appear to be positively associated with reductions in childhood illness, improved child weight and food consumption³⁷37 Manley J, Balarajan Y, Malm S, Harman L, Owens J, Murthy S, Stewart D, Winder-Rossi NE, Khurshid A. Cash transfers and child nutritional outcomes: a systematic review and meta-analysis. BMJ Glob Health 2020; 5(12):e003621..

With regard to assessment of the impact of CCTs on child nutritional outcomes in Latin America, such as linear growth, delayed child growth, and improvements in child health and nutritional status³⁹39 Siddiqi A, Rajaram A, Miller SP. Do cash transfer programmes yield better health in the first year of life? A systematic review linking low-income/middle-income and high-income contexts. Arch Dis Child 2018; 103(10):920-926., these programs were found to alleviate both poverty and food insecurity, in addition to bolstering school attendance and enhancing access to health services for beneficiaries³³33 Kandpal E, Alderman H, Friedman J, Filmer D, Onishi J, Avalos J. A conditional cash transfer program in the Philippines reduces severe stunting. J Nutr 2016; 146(9):1793-800.^,4040 De Groot R, Palermo T, Handa S, Ragno LP, Peterman A. Cash transfers and child nutrition: pathways and impacts. Dev Policy Rev 2017; 35(5):621-643.^,4141 Handa S, Davis B. The experience of conditional cash transfers in Latin America and the Caribbean. Dev Policy Rev 2006; 24(5):513-536..

Among the recipients of CCTs in African countries, discordant results were reported²⁷27 Adubra L, Le Port A, Kameli Y, Fortin S, Mahamadou T, Ruel MT, Martin-Prevel Y, Savy M. Conditional cash transfer and/or lipid-based nutrient supplement targeting the first 1000 d of life increased attendance at preventive care services but did not improve linear growth in young children in rural Mali: results of a cluster-randomized controlled trial. Am J Clin Nutr 2019; 110(6):1476-1490.^,2828 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086., as no significant effects on H/A were observed; however, the data did evidence positive effects on short stature, W/A, W/H and low weight.

A study by Kandpal E et al.³³33 Kandpal E, Alderman H, Friedman J, Filmer D, Onishi J, Avalos J. A conditional cash transfer program in the Philippines reduces severe stunting. J Nutr 2016; 146(9):1793-800. found a significant reduction in severe short stature in 6-36-month-old beneficiaries of the Philippine CT entitled Pantawid Pamilyang. Moreover, a study by Chakrabarti, Pan and Singh²⁹29 Chakrabarti S, Pan A, Singh P. Maternal and child health benefits of the mamata conditional cash transfer program in Odisha, India. J Nutr 2021; 151(8):2271-2281. identified a lower chance of stunting among children under five following the implementation of the Mamata Scheme in India. However, it is important to note that the nutritional findings reported in metanalyses and systematic reviews are not considered decisive, as no definitive evidence has been presented to conclusively document these effects⁴²42 Segura-Pérez S, Grajeda R, Pérez-Escamilla R. Conditional cash transfer programs and the health and nutrition of Latin American children. Rev Panam Salud Publica 2016; 40(2):124-137.^,4343 Manley J, Gitter S, Slavchevska V. How effective are cash transfers at improving nutritional status? World Dev 2013; 48:133-155..

The impacts of CCTs on improved child health have been attributed to interventions related to health, nutrition and education. This has contributed to the success of these programs over time by enhancing beneficiaries’ knowledge of important childcare practices and reinforcing the idea that, in the context of greater vulnerability, the provision of social benefits aims to contribute to improvements in child nutritional indicators¹²12 Rivera JA, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study. JAMA 2004; 291(21):2563-2570.^,2828 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086.^,4141 Handa S, Davis B. The experience of conditional cash transfers in Latin America and the Caribbean. Dev Policy Rev 2006; 24(5):513-536..

We additionally highlight that, despite potential improvements in populational health through the targeting of poor and vulnerable groups, the observed impacts of CCTs on child growth are not conclusive. Thus, it will be necessary to conduct studies examining the mechanisms underlying CCTs, especially in West Africa, where definitive evidence of program impact is lacking; moreover, the success seen in Latin America may not be replicable due to specific differences in CCT characteristics that may influence the effects of the studied results⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388.^,2727 Adubra L, Le Port A, Kameli Y, Fortin S, Mahamadou T, Ruel MT, Martin-Prevel Y, Savy M. Conditional cash transfer and/or lipid-based nutrient supplement targeting the first 1000 d of life increased attendance at preventive care services but did not improve linear growth in young children in rural Mali: results of a cluster-randomized controlled trial. Am J Clin Nutr 2019; 110(6):1476-1490.^,2828 Sudfeld CR, Bliznashka L, Ashery G, Yousafzai AK, Masanja H. Effect of a home-based health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in Tanzania. BMJ Glob Health 2021; 6(4):e005086.^,3535 Brownel MD, Chartier MJ, Nickel NC, Chateau D, Martens PJ, Sarkar J, Burland E, Jutte DP, Taylor C, Santos RG, Katz A, PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes. Pediatrics 2016; 137(6):e20152992..

According to studies, it is not possible to separate the reasons for which the CCTS is associated with better infant health outcomes. Suggestions are made that it is likely that women from families who receive benefits have received more appropriate prenatal care, which is linked to better outcomes³¹31 González L, Trommlerová S. Cash transfers before pregnancy and infant health. J Health Econ 2022; 83:102622.^,3535 Brownel MD, Chartier MJ, Nickel NC, Chateau D, Martens PJ, Sarkar J, Burland E, Jutte DP, Taylor C, Santos RG, Katz A, PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes. Pediatrics 2016; 137(6):e20152992..

Regarding programs without conditionalities, three of the included studies⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388.^,3434 Hamad R, Rehkopf DH. Poverty, pregnancy, and birth outcomes: a study of the earned income tax credit. Paediatr Perinat Epidemiol 2015; 29(5):444-452.^,3535 Brownel MD, Chartier MJ, Nickel NC, Chateau D, Martens PJ, Sarkar J, Burland E, Jutte DP, Taylor C, Santos RG, Katz A, PATHS Equity for Children Team. Unconditional prenatal income supplement and birth outcomes. Pediatrics 2016; 137(6):e20152992. found UCTs to be associated with reduced low birth weight. Importantly, only one RCT by Briaux et al.⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388. demonstrated a protective effect on H/A.

The present findings globally reinforce the impact of CT programs and suggest that attempting to mitigate short stature by means of a single interventional approach may prove difficult in at-risk communities that face a variety of contextual factors⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388.. The positive results observed in H/A⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388. in the Togo study may be explained by the fact that the CT evaluated stunting and other forms of malnutrition in the mother-child binomial during the first 1,000 days of life, which likely maximized impact¹⁶16 Leroy JL, Ruel M, Verhofstadt E. The impact of conditional cash transfer programmes on child nutrition: a review of evidence using a programme theory framework. J Dev Effect 2009; 1(2):103-129.^,4444 Owusu-Addo E, Cross R. The impact of conditional cash transfers on child health in low- and middle-income countries: a systematic review. Int J Public Health 2014; 59(4):609-618..

The present review evidenced that child beneficiaries of the Columbian CT Familias en Acción presented increased BMI and a reduced the chance of being underweight; however, no impacts were observed on H/A, short stature, overweight or obesity among children aged two to five years³²32 Lucas ADP, de Oliveira Ferreira M, Lucas TDP, Salari P. The intergenerational relationship between conditional cash transfers and newborn health. BMC Public Health 2022; 22(1):201.. In families benefiting from the Bolsa Família program in Brazil, this CT was negatively associated with H/A and W/A during the 24-month period studied²⁶26 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15..

The authors argue that their findings can be explained by low participation in Bolsa Família, and probable errors in measurement of family income. Moreover, they maintain that, despite the lack of a direct association, the prevalence of short stature has progressively decreased in Brazil, particularly among poor families²⁶26 Labrecque, JA, Kaufman JS, Balzer LB, Maclehose RF, Strumpf EC, Matijasevich A, Santos IS, Schmidt KH, Barros AJD. Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation. Soc Sci Med 2018; 211:9-15.. Another explanation may be that the relatively short duration of some studies may not have been sufficient to detect changes in linear growth, thus making it difficult to interpret the obtained results⁹9 Briaux J, Martin-Prevel Y, Carles S, Fortin S, Kameli Y, Adubra L, Renk A, Agboka Y, Romedenne M, Mukantambara F, Van Dyck J, Boko J, Becquet R, Savy M. Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial. PLoS Med 2020; 17(11):e1003388.^,3737 Manley J, Balarajan Y, Malm S, Harman L, Owens J, Murthy S, Stewart D, Winder-Rossi NE, Khurshid A. Cash transfers and child nutritional outcomes: a systematic review and meta-analysis. BMJ Glob Health 2020; 5(12):e003621.^,3939 Siddiqi A, Rajaram A, Miller SP. Do cash transfer programmes yield better health in the first year of life? A systematic review linking low-income/middle-income and high-income contexts. Arch Dis Child 2018; 103(10):920-926..

Factors related to poverty, such as economic crises, austerity policies, food and nutrition insecurity and cutbacks in social protection programs, directly affect the health of children under five and impact infant mortality rates. A study carried out in Brazil found that the municipal level coverage of Bolsa Família was associated with significantly decreased mortality due to malnutrition (RR = 0.35; 95%CI 0.24-0.50)⁵5 Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study. PLoS Med 2018; 15(5):e1002570.^,1010 Rasella D, Aquino R, Santos CA, Paes-Sousa R, Barreto ML. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet 2013; 382(9886):57-64..

A strength of the present study was the adoption of a broad search strategy entailing the identification of published studies, reports employing robust methodologies and the absence of any language restrictions. In contrast to the focus of previous systematic reviews, the present work aimed to review the available evidence on the impact of CTs on child health outcomes, including anthropometry and prematurity.

Concomitantly, data in recent studies points to increasing rates of infant mortality in high-income countries⁴⁵45 Alderman H. Can transfer programs be made more nutrition sensitive? [Internet]. 2014. [cited 2022 ago 3]. Available from: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.641.357&rep=rep1&type=pdf
http://citeseerx.ist.psu.edu/viewdoc/dow...

46 Kihal-Talantikite W, Padilla CM, Lalloué B, Gelormini M, Zmirou-Navier D, Deguen S. Green space, social inequalities and neonatal mortality in France. BMC Pregnancy Childbirth. 2013; 13:191.^-4747 Kim D, Saada A. The social determinants of infant mortality and birth outcomes in Western developed nations: a cross-country systematic review. Int J Environ Res Public Health 2013; 10(6):2296-2335.. The authors further speculate that this unusual finding is likely to be generalizable to other high-income nations in Western Europe and the US where associations between income and infant mortality have been evidenced⁴⁶46 Kihal-Talantikite W, Padilla CM, Lalloué B, Gelormini M, Zmirou-Navier D, Deguen S. Green space, social inequalities and neonatal mortality in France. BMC Pregnancy Childbirth. 2013; 13:191.^,4747 Kim D, Saada A. The social determinants of infant mortality and birth outcomes in Western developed nations: a cross-country systematic review. Int J Environ Res Public Health 2013; 10(6):2296-2335..

A study performed in England reported increased infant mortality mainly among socioeconomically disadvantaged children⁴⁷47 Kim D, Saada A. The social determinants of infant mortality and birth outcomes in Western developed nations: a cross-country systematic review. Int J Environ Res Public Health 2013; 10(6):2296-2335.. Academics have postulated that these increases may be due to recent cuts in health services and reductions in social benefits available to families⁴⁸48 Taylor-Robinson D, Lai ETC, Wickham S, Rose T, Norman P, Bambra C, Whitehead M, Barr B. Assessing the impact of rising child poverty on the unprecedented rise in infant mortality in England, 2000-2017: time trend analysis. BMJ Open 2019; 9(10):e029424.^,4949 Bennett JE, Li G, Foreman K, Best N, Kontis V, Pearson C, Hambly P, Ezzati M. The future of life expectancy and life expectancy inequalities in England and Wales: Bayesian spatiotemporal forecasting. Lancet 2015; 386(9989):163-170..

The present systematic review suffers from some limitations. First, a high degree of heterogeneity in eligible populations was observed, mainly in relation to the age of the children studied. Second, the CTs evaluated are highly variable in terms of design and duration, time of implementation and target population, which explains the inconsistencies in the estimated results, thus preventing the performance of a meta-analysis. Lastly, we excluded any studies that did not present results separately from those evaluating the effects of other social programs offering income, food and/or nutritional supplementation.

The results of the present systematic review indicate that cash transfer programs exert a positive effect on child growth as assessed by anthropometry and birth outcomes, thus affirming the use of CTs as a valuable social policy instrument for the promotion of child health. However, due to the small number of included studies herein, the body of evidence on this topic should be considered limited.

Accordingly, further study is needed to obtain additional clarification/confirmation and to allow for comparisons that would enable meta-analysis among studies. It would be interesting to elucidate, for example, whether specific positive findings identified among populations were linked to the effect of direct cash transfers, or whether these improvements resulted from the use of health services and/or by offering food and nutritional supplementation provided by other social programs.

The development of research aimed at analyzing and enhancing our understanding of nutritional dilemmas and the role of social policy interventions is important to protecting maternal and child nutrition and enhancing quality of life for future generations. It is therefore essential for forthcoming investigations to not only fully characterize the populations studied, but also to account for socioeconomic and demographic differences, as well as consider social determinants of health.

We must assume that these factors can impart differences in the magnitude and severity of nutritional status during childhood, and that the findings reported in the studies included herein are relevant, thereby affirming the notion that carrying out impact assessments on the effects of CTs on nutritional outcomes among more vulnerable populations continues to be necessary, further reinforcing the need for additional evidence on the role of social protections to mitigate short- and long-term consequences of malnutrition.

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