Long-term impact of a conditional cash transfer programme on maternal mortality: a nationwide analysis of Brazilian longitudinal data.
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ABSTRACT: Background
Reducing poverty and improving access to health care are two of the most effective actions to decrease maternal mortality, and conditional cash transfer (CCT) programmes act on both. The aim of this study was to evaluate the effects of one of the world's largest CCT (the Brazilian Bolsa Familia Programme (BFP)) on maternal mortality during a period of 11 years.Methods
The study had an ecological longitudinal design and used all 2548 Brazilian municipalities with vital statistics of adequate quality during 2004-2014. BFP municipal coverage was classified into four levels, from low to consolidated, and its duration effects were measured using the average municipal coverage of previous years. We used negative binomial multivariable regression models with fixed-effects specifications, adjusted for all relevant demographic, socioeconomic, and healthcare variables.Results
BFP was significantly associated with reductions of maternal mortality proportionally to its levels of coverage and years of implementation, with a rate ratio (RR) reaching 0.88 (95%CI 0.81-0.95), 0.84 (0.75-0.96) and 0.83 (0.71-0.99) for intermediate, high and consolidated BFP coverage over the previous 11 years. The BFP duration effect was stronger among young mothers (RR 0.77; 95%CI 0.67-0.96). BFP was also associated with reductions in the proportion of pregnant women with no prenatal visits (RR 0.73; 95%CI 0.69-0.77), reductions in hospital case-fatality rate for delivery (RR 0.78; 95%CI 0.66-0.94) and increases in the proportion of deliveries in hospital (RR 1.05; 95%CI 1.04-1.07).Conclusion
Our findings show that a consolidated and durable CCT coverage could decrease maternal mortality, and these long-term effects are stronger among poor mothers exposed to CCT during their childhood and adolescence, suggesting a CCT inter-generational effect. Sustained CCT coverage could reduce health inequalities and contribute to the achievement of the Sustainable Development Goal 3.1, and should be preserved during the current global economic crisis due to the COVID-19 pandemic.
SUBMITTER: Rasella D
PROVIDER: S-EPMC8166529 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundPreterm births increase mortality and morbidity during childhood and later life, which is closely associated with poverty and the quality of prenatal care. Therefore, income redistribution and poverty reduction initiatives may be valuable in preventing this outcome. We assessed whether receipt of the Brazilian conditional cash transfer programme - Bolsa Familia Programme, the largest in the world - reduces the occurrence of preterm births, including their severity categories, and explored how this association differs according to prenatal care and the quality of Bolsa Familia Programme management.MethodsA retrospective cohort study was performed involving the first live singleton births to mothersenrolled in the 100 Million Brazilian Cohort from 2004 to 2015, who had at least one child before cohort enrollment. Only the first birth during the cohort period was included, but born from 2012 onward. A deterministic linkage with the Bolsa Familia Programme payroll dataset and a similarity linkage with the Brazilian Live Birth Information System were performed. The exposed group consisted of newborns to mothers who received Bolsa Familia from conception to delivery. Our outcomes were infants born with a gestational age < 37 weeks: (i) all preterm births, (ii) moderate-to-late (32-36), (iii) severe (28-31), and (iv) extreme (< 28) preterm births compared to at-term newborns. We combined propensity score-based methods and weighted logistic regressions to compare newborns to mothers who did and did not receive Bolsa Familia, controlling for socioeconomic conditions. We also estimated these effects separately, according to the adequacy of prenatal care and the index of quality of Bolsa Familia Programme management.Results1,031,053 infants were analyzed; 65.9% of the mothers were beneficiaries. Bolsa Familia Programme was not associated with all sets of preterm births, moderate-to-late, and severe preterm births, but was associated with a reduction in extreme preterm births (weighted OR: 0.69; 95%CI: 0.63-0.76). This reduction can also be observed among mothers receiving adequate prenatal care (weighted OR: 0.66; 95%CI: 0.59-0.74) and living in better Bolsa Familia management municipalities (weighted OR: 0.56; 95%CI: 0.43-0.74).ConclusionsAn income transfer programme for pregnant women of low-socioeconomic status, conditional to attending prenatal care appointments, has been associated with a reduction in extremely preterm births. These programmes could be essential in achieving Sustainable Development Goals.
| S-EPMC10916064 | biostudies-literature
Project description:ImportanceConditional cash transfers (CCTs) have been consistently associated with improvements to the determinants of maternal health, but there have been insufficient investigations regarding their effects on maternal mortality.ObjectiveTo evaluate the association between being a Bolsa Família program (BFP) beneficiary and maternal mortality and to examine how this association differs by duration of BFP receipt, maternal race, living in rural or urban areas, the Municipal Human Development Index (MHDI), and municipal primary health care coverage.Design, setting, and participantsThis cross-sectional analysis was nested within the 100 Million Brazilian Cohort. Girls and women aged 10 to 49 years (hereinafter referred to as women) who had at least 1 live birth were included, using data from Brazilian national health databases linked to the 100 Million Brazilian Cohort (January 1, 2004, to December 31, 2015). Propensity score kernel weighting was applied to control for sociodemographic and economic confounders in the association between BFP receipt and maternal mortality, overall and stratified by different subgroups (race, urban or rural area, and MHDI), and duration of BFP receipt. Data were analyzed from July 12, 2019, to December 31, 2022.Main outcome(s) and measuresMaternal death.ResultsA total of 6 677 273 women aged 10 to 49 years were included in the analysis, 4056 of whom had died from pregnancy-related causes. The risk of maternal death was 18% lower in women who received BFP (weighted odds ratio [OR], 0.82 [95% CI, 0.71-0.93]). A longer duration receiving BFP was associated with an increased reduction in maternal mortality (OR for 1-4 years, 0.85 [95% CI, 0.75-0.97]; OR for 5-8 years, 0.70 [95% CI, 0.60-0.82]; OR for ≥9 years, 0.69 [95% CI, 0.53-0.88]). Receiving BFP was also associated with substantial increases in the number of prenatal appointments and interbirth intervals. The reduction was more pronounced in the most vulnerable groups.Conclusions and relevanceThis cross-sectional analysis nested within the 100 Million Brazilian Cohort found an association between BFP receipt and maternal mortality. This association was of greater magnitude in women with longer exposure to BFP and in the most vulnerable groups. These findings reinforce evidence that programs such as BFP, which have already proven effective in poverty reduction, have great potential to improve maternal survival.
| S-EPMC9951038 | biostudies-literature
Project description:BackgroundMalaria causes 400 thousand deaths worldwide annually. In 2018, 25% (187,693) of the total malaria cases in the Americas were in Brazil, with nearly all (99%) Brazilian cases in the Amazon region. The Bolsa Família Programme (BFP) is a conditional cash transfer (CCT) programme launched in 2003 to reduce poverty and has led to improvements in health outcomes. CCT programmes may reduce the burden of malaria by alleviating poverty and by promoting access to healthcare, however this relationship is underexplored. This study investigated the association between BFP coverage and malaria incidence in Brazil.MethodsA longitudinal panel study was conducted of 807 municipalities in the Brazilian Amazon between 2004 and 2015. Negative binomial regression models adjusted for demographic and socioeconomic covariates and time trends were employed with fixed effects specifications.ResultsA one percentage point increase in municipal BFP coverage was associated with a 0.3% decrease in the incidence of malaria (RR = 0.997; 95% CI = 0.994-0.998). The average municipal BFP coverage increased 24 percentage points over the period 2004-2015 corresponding to be a reduction of 7.2% in the malaria incidence.ConclusionsHigher coverage of the BFP was associated with a reduction in the incidence of malaria. CCT programmes should be encouraged in endemic regions for malaria in order to mitigate the impact of disease and poverty itself in these settings.
| S-EPMC8243887 | biostudies-literature
Project description:In some countries, conditional cash transfer (CCT) programmes show an impact on maternal and child health. Juntos, the CCT programme in Peru, has been evaluated several times operationally, but seldom for maternal and child health outcomes. The objective of this study is to evaluate the impact of Juntos on children under 6?years, pregnant women and mothers of children under 17?years. Outcomes evaluated included (1) anaemia in women and children; (2) acute malnutrition in children; (3) post-partum complications in mothers; and (4) underweight and overweight in mothers. We identified Juntos eligible respondents from the Demographic and Health Surveys of Peru for years 2007 to 2013. Propensity score matching was used to identify comparable treatment and control groups, including eligible respondents enrolled in Juntos vs. those not enrolled in Juntos (individual-level analysis), as well as eligible respondents living in Juntos districts vs. those not residing in Juntos districts (district-level analysis). We then used generalized linear models to estimate prevalence ratios. Individual level analysis showed that Juntos reduced underweight in women (PR:0.39, 95%CI:0.18 - 0.85) and anaemia in children (PR:0.93, 95%CI:0.86 - 1.00). In the district level analysis, the programme was associated with a reduction of overweight in women (PR:0.94, 95%CI:0.90 - 0.98) and acute malnutrition in children (PR:0.49, 95%CI:0.32 - 0.73), but an increase in the prevalence of anaemia in children (PR:1.09, 95%CI:1.01 - 1.17). We found that Juntos had an effect on maternal and child health indicators, but further studies are required to overcome some limitations encountered here.
| S-EPMC6866111 | biostudies-literature
Project description:BackgroundIndirect financial costs and barriers to health-care access might contribute to leprosy treatment non-adherence. We estimated the association of the Brazilian conditional cash transfer programme, the Programa Bolsa Família (PBF), on leprosy treatment adherence and cure in patients in Brazil.MethodsIn this quasi-experimental study, we linked baseline demographic and socioeconomic information for individuals who entered the 100 Million Brazilian Cohort between Jan 1, 2007, and Dec 31, 2014, with the PBF payroll database and the Information System for Notifiable Diseases, which includes nationwide leprosy registries. Individuals were eligible for inclusion if they had a household member older than 15 years and had not received PBF aid or been diagnosed with leprosy before entering the 100 Million Brazilian Cohort; they were excluded if they were partial receivers of PBF benefits, had missing data, or had a monthly per-capita income greater than BRL200 (US$50). Individuals who were PBF beneficiaries before leprosy diagnosis were matched to those who were not beneficiaries through propensity-score matching (1:1) with replacement on the basis of baseline covariates, including sex, age, race or ethnicity, education, work, income, place of residence, and household characteristics. We used logistic regression to assess the average treatment effect on the treated of receipt of PBF benefits on leprosy treatment adherence (six or more multidrug therapy doses for paucibacillary cases or 12 or more doses for multibacillary cases) and cure in individuals of all ages. We stratified our analysis according to operational disease classification (paucibacillary or multibacillary). We also did a subgroup analysis of paediatric leprosy restricted to children aged up to 15 years.FindingsWe included 11 456 new leprosy cases, of whom 8750 (76·3%) had received PBF before diagnosis and 2706 (23·6%) had not. Overall, 9508 (83·0%) patients adhered to treatment and 10 077 (88·0%) were cured. After propensity score matching, receiving PBF before diagnosis was associated with adherence to treatment (OR 1·22, 95% CI 1·01-1·48) and cure (1·26, 1·01-1·58). PBF receipt did not significantly improve treatment adherence (1·37, 0·98-1·91) or cure (1·12, 0·75-1·67) in patients with paucibacillary leprosy. For patients with multibacillary disease, PBF beneficiaries had better treatment adherence (1·37, 1·08-1·74) and cure (1·43, 1·09-1·90) than non-beneficiaries. In the propensity score-matched analysis in 2654 children younger than 15 years with leprosy, PBF exposure was not associated with leprosy treatment adherence (1·55, 0·89-2·68) or cure (1·57, 0·83-2·97).InterpretationOur results suggest that being a beneficiary of the PBF, which facilitates cash transfers and improved access to health care, is associated with greater leprosy multidrug therapy adherence and cure in multibacillary cases. These results are especially relevant for patients with multibacillary disease, who are treated for a longer period and have lower cure rates than those with paucibacillary disease.FundingCONFAP/ESRC/MRC/BBSRC/CNPq/FAPDF-Doenças Negligenciadas, the UK Medical Research Council, the Wellcome Trust, and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-Brazil (CAPES).
| S-EPMC7191267 | biostudies-literature
Project description:BackgroundBrazil has made great progress in reducing child mortality over the past decades, and a parcel of this achievement has been credited to the Bolsa Família program (BFP). We examined the association between being a BFP beneficiary and child mortality (1-4 years of age), also examining how this association differs by maternal race/skin color, gestational age at birth (term versus preterm), municipality income level, and index of quality of BFP management.Methods and findingsThis is a cross-sectional analysis nested within the 100 Million Brazilian Cohort, a population-based cohort primarily built from Brazil's Unified Registry for Social Programs (Cadastro Único). We analyzed data from 6,309,366 children under 5 years of age whose families enrolled between 2006 and 2015. Through deterministic linkage with the BFP payroll datasets, and similarity linkage with the Brazilian Mortality Information System, 4,858,253 children were identified as beneficiaries (77%) and 1,451,113 (23%) were not. Our analysis consisted of a combination of kernel matching and weighted logistic regressions. After kernel matching, 5,308,989 (84.1%) children were included in the final weighted logistic analysis, with 4,107,920 (77.4%) of those being beneficiaries and 1,201,069 (22.6%) not, with a total of 14,897 linked deaths. Overall, BFP participation was associated with a reduction in child mortality (weighted odds ratio [OR] = 0.83; 95% CI: 0.79 to 0.88; p < 0.001). This association was stronger for preterm children (weighted OR = 0.78; 95% CI: 0.68 to 0.90; p < 0.001), children of Black mothers (weighted OR = 0.74; 95% CI: 0.57 to 0.97; p < 0.001), children living in municipalities in the lowest income quintile (first quintile of municipal income: weighted OR = 0.72; 95% CI: 0.62 to 0.82; p < 0.001), and municipalities with better index of BFP management (5th quintile of the Decentralized Management Index: weighted OR = 0.76; 95% CI: 0.66 to 0.88; p < 0.001). The main limitation of our methodology is that our propensity score approach does not account for possible unmeasured confounders. Furthermore, sensitivity analysis showed that loss of nameless death records before linkage may have resulted in overestimation of the associations between BFP participation and mortality, with loss of statistical significance in municipalities with greater losses of data and change in the direction of the association in municipalities with no losses.ConclusionsIn this study, we observed a significant association between BFP participation and child mortality in children aged 1-4 years and found that this association was stronger for children living in municipalities in the lowest quintile of wealth, in municipalities with better index of program management, and also in preterm children and children of Black mothers. These findings reinforce the evidence that programs like BFP, already proven effective in poverty reduction, have a great potential to improve child health and survival. Subgroup analysis revealed heterogeneous results, useful for policy improvement and better targeting of BFP.
| S-EPMC8478244 | biostudies-literature
Project description:BackgroundConditional Cash Transfer Programs have been developed in Latin America in response to poverty and marked social inequalities on the continent. In Brazil, the Bolsa Familia Program (BFP) was implemented to alleviate poverty and improve living conditions, health, and education for socioeconomically vulnerable populations. However, the effect of this intervention on maternal and child health is not well understood.MethodsWe will evaluate the effect of BFP on maternal and child outcomes: 1. Birth weight; 2. Preterm birth; 3. Maternal mortality; and 4. Child growth. Dynamic retrospective cohort data from the 100 Million Brazilian Cohort (2001 to 2015) will be linked to three different databases: Live Birth Information System (2004 to 2015); Mortality Information System (2011 to 2015); and Food and Nutritional Surveillance System (2008 to 2017). The definition of exposure to the BFP varies according to the outcome studied. Those who never received the benefit until the outcome or until the end of the follow-up will be defined as not exposed. The effects of BFP on maternal and child outcomes will be estimated by a combination of propensity score-based methods and weighted logistic regressions. The analyses will be further stratified to reflect changes in the benefit entitlement before and after 2012.DiscussionHarnessing a large linked administrative cohort allows us to assess the effect of the BFP on maternal and child health, while considering a wide range of explanatory and confounding variables.
| S-EPMC9126365 | biostudies-literature
Project description:BackgroundThe mortality rate in children under 5 years old (U5MR) has decreased considerably in Ecuador in the last decade; however, thousands of children continue to die from causes related to poverty. A social program known as Bono de Desarrollo Humano (BDH) was created to guarantee a minimum level of consumption for families and to reduce chronic malnutrition and preventable childhood diseases. We sought to evaluate the effect of the BDH program on mortality of children younger than 5 years, particularly from malnutrition, diarrheal diseases, and lower respiratory tract infections.MethodsMortality rates and BDH coverage from 2009 to 2014 were evaluated from the 144 (of 222) Ecuadorian counties with intermediate and high quality of vital information. A multivariable regression analyses for panel data was conducted by using a negative binomial regression model with fixed effects, adjusted for all relevant demographic and socioeconomic covariates.ResultsOur research shows that for each 1% increase in BDH county coverage there would be a decrease in U5MR from malnutrition of 3% (RR 0.971, 95% CI 0.953-0.989). An effect of BDH county coverage on mortality resulting from respiratory infections was also observed (RR 0.992, 95% CI 0.984-0.999). The BDH also reduced hospitalization rates in children younger than 5 years, overall and for diarrhea.ConclusionsA conditional cash transfer program such as BDH could contribute to the reduction of mortality due to causes related to poverty, such as malnutrition and respiratory infections. The coverage should be maintained -or increased in a period of economic crisis- and its implementation strengthened.
| S-EPMC6697994 | biostudies-literature
Project description:BackgroundThis study aims to assess the interactive effects of Brazilian public interventions, environmental health programs (access to water, sanitation and solid waste collection) and a Conditional Cash Transfer Program (PBF), on the mortality reduction due to diarrhea and malnutrition among children under 5 years old.MethodsThe study design is ecological, with longitudinal analysis in a balanced panel. The period covered is 2006 to 2016, including 3467 municipalities from all regions of the country, which resulted in 38,137 observations. The generalized linear models were adjusted considering the Negative Binomial (NB) distribution for the number of deaths due to malnutrition and diarrhea, with fixed effects. NB models with and without zero-inflation were assessed. Subsequent interaction models were applied to assess the combined effects of the two public policies.ResultsIn relation to the decline of mortality rates due to diarrhea in the municipalities, positive effect modification were observed in the presence of: high coverage of the target population by the PBF and access to water, 0.54 (0.28-1.04) / 0.55 (0.29-1.04); high coverage by the total population by the PBF and access to water, 0.97 (0.95-1.00) and high coverage by the total population by the PBF and access to sanitation, 0.98 (0.97-1.00). Decline on diarrhea mortality was also observed in the joint presence of high coverage of solid waste collection and access to water, categories 1 (> 60% ≤85%): 0.98 (0.96-1.00), 0.98 (0.97-1, 00) and 2 (> 85% ≤ 100%): 0.97 (0.95-0.98), 0.97 (0.95-0.99). Negative effect modification were observed for mortality due to malnutrition in the presence of simultaneous high coverage of the total population by the PBF and access to sanitation categories 1 (≥ 20 < 50%): 1.0061 (0.9991-1.0132) and 2 (≥ 50 < 100%): 1.0073 (1.0002-1.0145) and high coverage of the total population by the PBF and solid waste collection, 1.0004 (1.0002-1.0005), resulting in malnutrition mortality rates increase.ConclusionImplementation of environmental health services and the coverage expansion by the PBF may enhance the prevention of early deaths in children under 5 years old due to diarrhea, a poverty related disease.
| S-EPMC8011115 | biostudies-literature
Project description:BackgroundHomicide kills more people than war globally and is associated with income inequality. In Brazil, one of the most unequal countries of the world, the homicide rate is four times higher than the world average. Establishing if the Brazilian conditional cash transfer programme [Bolsa Familia Programme (BFP)], the largest in the world, is associated with a reduction in the rate of homicide is relevant for violence prevention programs. We aimed to assess the effect of BFP coverage on homicide and hospitalization rates from violence.MethodsBFP coverage and rates of homicide (overall and disaggregated by sex and age) and hospitalizations from violence from all 5,507 Brazilian municipalities between 2004 and 2012 were explored using multivariable negative binomial regression models with fixed effect for panel data. Robustness of results was explored using sensitivity analyses such as difference-in-difference models.FindingsHomicide rates and hospitalization from violence decreased as BFP coverage in the target population increased. For each percent increase in the uptake of the BFP, the homicide rate decreased by 0.3% (Rate Ratio:0.997; 95%CI:0.996-0.997) and hospitalizations from violence by 0.4% (RR: 0.996;95%CI:0.995-0.996). Rates of homicide and hospitalizations from violence were also negatively associated with the duration of BFP coverage. When, coverage of the target population was at least 70% for one-year, hospitalizations from violence decreased by 8%; two-years 14%, three-years 20%, and four years 25%.InterpretationOur results support the hypothesis that conditional cash transfer programs might have as an additional benefit the prevention of homicides and hospitalizations from violence. Social protection interventions could contribute to decrease levels of violence in low-and-middle-income-countries through reducing poverty and/or socioeconomic inequalities.
| S-EPMC6312285 | biostudies-literature