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. Author manuscript; available in PMC: 2025 Dec 18.
Published in final edited form as: Ann Intern Med. 2025 May 27;178(7):1000–1011. doi: 10.7326/ANNALS-24-03495

Associations Between Unconditional Cash Transfers and Postpartum Outcomes in the United States: A Systematic Review

Sahar A Choudhry 1, G Saradjha Brédy 2, Cyerra Cruise 3, Qai Hinds 4, Margaret A McConnell 5, Sumit K Agarwal 6, David B Flynn 7, Mara E Murray Horwitz 8
PMCID: PMC12710507  NIHMSID: NIHMS2128384  PMID: 40418809

Abstract

Background:

Unconditional cash transfers (UCTs) through social programs or direct cash transfers (DCTs) may address drivers of pregnancy-related morbidity and mortality.

Purpose:

To summarize evidence on UCTs and postpartum outcomes in the United States.

Data Sources:

PubMed, Embase, Web of Science, Social Science Research Network, and structured internet searches through 28 January 2025.

Study Selection:

Primary research reporting associations between UCTs and postpartum outcomes (0 to 2 years after delivery) in the United States.

Data Extraction:

Dual data extraction with predefined outcomes: infant or child care, reproductive health, substance use, other mental health outcomes, and other outcomes. Study quality was assessed using the Cochrane Risk of Bias 2 and ROBINS-I (Risk Of Bias In Non-randomised Studies – of Interventions) tools. Strength of evidence (SOE) was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

Data Synthesis:

Eleven reports from 6 studies were identified. Four quasi-experimental (QE) studies examined 3 different social programs, 2 of which targeted populations with low incomes. Seven reports from 2 randomized controlled trials (RCTs) examined DCTs to postpartum persons with low incomes. The evidence showed an increase in breastfeeding with UCTs (high SOE [2 RCTs, 2 QE studies]), little or no difference in postpartum mood (high SOE [1 RCT, 2 QE studies]), and low SOE or insufficient evidence for all other associations.

Limitations:

Unpublished studies and those not published in English may have been missed. Nonrandomized studies were subject to reporting or recall bias, reducing SOE. Study heterogeneity prevented meta-analysis.

Conclusion:

Unconditional cash transfers increase breastfeeding in diverse settings and populations and result in little or no difference in postpartum mood specifically in persons with low incomes. No studies examined DCTs given during pregnancy. More evidence is needed on associations between UCTs and key clinical outcomes, such as peripartum and postpartum maternal morbidity and mortality.

Primary Funding Source:

None. (Registered on Open Science Framework [https://osf.io/4c3nx])

The United States is home to numerous financial interventions to reduce poverty, such as tax credits (for example, the Earned Income Tax Credit [EITC]) and direct cash transfers (DCTs) (for example, the Alaska Dividend and guaranteed income pilots [1]). Such programs often focus on households with single parents or young children. Poverty-reducing interventions may be especially critical in the postpartum period, as household incomes decrease and expenditures increase after the birth of a child in the United States (2).

At the same time, the United States is facing a maternal health crisis, with significantly higher rates of maternal mortality (pregnancy-related deaths occurring up to 42 days after delivery) than in other high-income countries (3) and growing inequities by race and ethnicity (4). Two thirds of pregnancy-related deaths (maternal and other pregnancy-related deaths up to 1 year after delivery) in the United States occur in the year after pregnancy, and 80% are believed to be preventable (5). Major contributors to preventable pregnancy-related deaths include mental health, substance use, access to care, social isolation, and other social determinants of health (5, 6). Conceptual frameworks affirm the connections between social determinants of health, including income, and maternal mortality (7, 8).

It stands to reason that increasing income may improve postpartum health and survival in the United States. Cash transfers have reduced pregnancy-related health risks in other countries, such as having a low-birthweight baby in Canada (9) and maternal mortality in Brazil (10). In addition, cash transfers seem to reduce obesity in mothers (but not fathers) of young children in Canada (11). Another study among a low-income community in Chelsea, Massachusetts, found that cash transfers improved health outcomes by reducing emergency department visits, particularly for behavioral health and substance use issues, and increasing access to outpatient subspecialty care, suggesting that financial support can alleviate poverty-related health care barriers​ (12). We posit that cash transfers—by increasing resources, expanding choices and opportunities, and reducing stress—may improve postpartum health-related behaviors and health outcomes, with relevance to key causes of pregnancy-related mortality in the United States (see the Supplement Figure [available at Annals.org] for a conceptual model).

In this article, we review and summarize the evidence on unconditional cash transfers (UCTs; cash transfers with “no strings attached”) and postpartum health outcomes in the United States. Prior systematic literature reviews have focused on pregnancy, birth, or infant outcomes rather than postpartum outcomes (that is, outcomes in the birthing person after delivery) (13); have been based in low- or middle-income countries (10, 14–16); or examined only conditional cash transfers (cash transfers conditioned on a particular behavior or type of spending) (17). We focus on UCTs because they enable recipients to decide how to use the money and thus may be most effective at addressing dynamic and individualized social determinants of health. Furthermore, UCTs are easier to administer than conditional cash transfers (18) and may therefore be more efficient and scalable. Our outcome of interest is any health-related behavior or health outcome assessed in a postpartum person. We maintain an intentionally broad outcome in light of the wide range of factors and conditions implicated in pregnancy-related mortality (5, 6).

Methods

We completed the initial search on 18 August 2023, title and abstract screening in September 2023, full-text review in December 2023, and data extraction in January 2024. We registered our review on Open Science Framework (https://osf.io/4c3nx) on 16 February 2024, before data analysis. We updated the initial search on 13 May 2024 and added a search of the Social Science Research Network (SSRN) on 23 June 2024. We repeated the full search on 28 January 2025.

Data Sources and Searches

We developed a search strategy with an academic medical librarian (D.B.F.) and implemented it in PubMed, Embase, Web of Science, and SSRN, restricting to English-language articles published from 2010 onward (details are provided in Supplement Table 1, available at Annals.org). We adjusted our search process over time. First, we initially planned to restrict outcomes to within 1 year after delivery. During the first full-text review, we expanded this criterion to 2 years due to the small number of articles meeting our criteria and the identification of potentially relevant articles with 2-year postpartum outcomes. We repeated the title and abstract search with the updated criteria to ensure completeness. Second, our initial database search did not include the SSRN database. SSRN was included in subsequent searches before publication. Finally, we initially included postpartum economic outcomes (such as spending and labor participation) but later excluded them due to scope and space considerations.

Study Selection

We systematically searched for primary research articles reporting associations between UCTs and postpartum health in the United States (Figure 1 [19]). Our exposure was any UCT during or after pregnancy. We used a broad definition of UCTs, including tax credits and refunds, Supplemental Security Income (SSI) disability benefits, and DCTs (20).

Figure 1. PRISMA diagram.

Figure 1.

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SSRN = Social Science Research Network.

Our a priori outcome of interest was any health outcome or health-related behavior in a postpartum person, assessed 1 day to 2 years after delivery. Although our search was motivated by high rates of preventable pregnancy-related mortality in the United States, we used a broad outcome definition for several reasons. First, a wide range of social determinants of health, health-related behaviors, and health outcomes have been associated with pregnancy-related deaths (5, 6). Second, maternal and pregnancy-related deaths are rare and are therefore difficult to study. Third, the postpartum period is relatively understudied, so we anticipated a paucity of evidence. We divided postpartum outcomes into 5 categories based on themes observed in the literature and as previously reported (13): infant or child care (including breastfeeding), other reproductive health outcomes (for example, fertility), substance use, other mental health outcomes (for example, depression), and other health outcomes (see the Supplement Figure for the conceptual model).

To identify articles that were eligible for inclusion, 2 researchers (combinations of S.A.C., G.S.B., and C.C.) independently screened titles and abstracts on Rayyan.com and then performed full-text screening. The same researchers conducted a second round of full-text screening of additional potentially eligible articles identified during the search process (for example, from the references in another article) or from manual searches of Google, Google Scholar, and government websites. A third researcher (M.E.M.H.) resolved any conflicts. Missing or unclear information in potentially eligible articles prompted at least 2 contact attempts with the corresponding author.

Data Extraction and Quality Assessment

Two researchers (initially S.A.C. and G.S.B.; later S.A.C. and Q.H.) extracted data using a standardized form with the following prespecified variables: study design, sample characteristics, exposure or intervention details, postpartum outcomes, key findings, and study quality. We categorized postpartum health outcomes as follows: infant or child care, other reproductive health outcome, substance use, other mental health outcome, and all other health outcomes. For each outcome, we summarized findings using absolute terms (when available) or else relative terms (for example, odds ratios). We present confidence intervals when possible or P values or standard errors if they are available.

We assessed study quality using the ROBINS-I (Risk Of Bias In Non-randomised Studies – of Interventions) tool (21) and the Cochrane Risk of Bias 2 tool (22). The same 2 researchers independently categorized study quality as good (low risk of bias), fair (moderate risk of bias), or poor (serious or critical risk of bias) based on the following potential sources of bias: randomization or confounding, sample selection (nonrandomized studies only), intervention classification (nonrandomized studies only), performance bias (unintended effects or deviations from the intervention), completeness of outcome data, validity and reliability of measures, and outcome reporting (details are provided in Supplement Table 2, available at Annals.org). A third researcher (M.E.M.H.) reviewed and resolved conflicts.

Data Synthesis and Analysis

Three researchers (S.A.C., G.S.B., and M.E.M.H.) analyzed themes and inconsistencies across studies and evaluated heterogeneity based on the prespecified characteristics in the data extraction form. We synthesized the results by category of postpartum health outcome, as specified a priori. For each outcome, we assessed the strength of evidence (SOE) using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach (23–26). We considered the following factors in SOE: number of studies, study design, study quality, directness of evidence, consistency of results, and precision of results (details are provided in Supplement Table 3, available at Annals.org).

In addition, we conducted exploratory post hoc analyses by the type of UCT program—social programs (for example, Alaska Dividend, EITC, SSI) versus experimental trials (all DCTs), due to their notable differences in intervention purpose, disbursement amount, timing, frequency, duration, dependability, and method of payment—as well as by study design. We also synthesized results post hoc by level of observation, informed by the socioecological model (27) (postpartum individual, parent–infant dyad, or family or household), after we observed that many of the assessed postpartum outcomes related to infant or child care and many of the included studies were designed around infant or child outcomes or family outcomes rather than the postpartum person.

Role of the Funding Source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Results

Figure 1 summarizes our review process, and Figure 2 details the reports that were included. We identified 11 reports from 6 different studies. Four studies were quasi-experimental (QE) observational (nonrandomized) analyses of UCT social programs in the United States: the Alaska Dividend (28), the EITC (29, 30), and SSI benefits (31). The purpose of all of the social programs was to increase income. None of the social programs were specifically designed for pregnant or postpartum people, so the timing of the UCTs in the nonrandomized studies varied from during to after pregnancy. In contrast, 2 studies were randomized controlled trials (RCTs) of DCT interventions, both intended to improve infant or child outcomes and both administered after delivery. In the Baby’s First Years (BFY) RCT, 1000 postpartum persons were randomly assigned to larger ($333 per month) versus smaller ($20 per month) UCTs for several years after childbirth, with primary outcomes relating to child development (32). Secondary analyses of BFY accounted for a majority of the reports in our review (33–38), with outcomes assessed at 12 or 24 months after delivery. The other RCT randomly assigned 46 Medicaid-eligible postpartum persons with a preterm baby to either $200 per week plus educational materials or educational materials alone for up to 3 weeks while their baby was in the neonatal intensive care unit (NICU) (39). In this RCT, all outcomes were assessed at 1 to 3 weeks after delivery. Although the social programs tended to predate the RCTs (1986 to 2017 vs. 2017 to 2019, respectively), all reports were relatively recent; all but 2 (30, 31) were published in 2020 or later.

Figure 2. Summary of reports included in the review.

Figure 2.

Figure 2.

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DCT = direct cash transfer; ECLS-B = Early Childhood Longitudinal Study, Birth Cohort; EITC = Earned Income Tax Credit; FPL = federal poverty level; LA = Louisiana; MA = Massachusetts; MN = Minnesota; NE = Nebraska; NICU = neonatal intensive care unit; NY = New York; PRAMS = Pregnancy Risk Assessment Monitoring System; QE = quasi-experimental; RCT = randomized controlled trial; SSI = Supplemental Security Income.

* Some outcomes had additional inclusion or exclusion criteria, resulting in a smaller sample size.

Associations Between UCTs and Postpartum Health Outcomes

Findings are detailed in the following sections and are summarized in Figures 3 and 4.

Figure 3. Summary of findings on associations between UCTs and postpartum outcomes, separated by UCT program type.

Figure 3.

Figure 3.

Figure 3.

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Italics denote primary or preregistered outcomes. Underlining is used to organize outcomes by family groups or assessment time points as needed. aRR = adjusted risk ratio; DCT = direct cash transfer; EITC = Earned Income Tax Credit; IUD = intrauterine device; NA = not applicable; NICU = neonatal intensive care unit; PHQ-8 = Patient Health Questionnaire 8; PR = prevalence ratio; QE = quasi-experimental; RCT = randomized controlled trial; SSI = Supplemental Security Income; UCT = unconditional cash transfer.

* UCT comparison varied by study; details are provided in the in-row text and in Figure 2. P values are adjusted when available.

Figure 4.

Figure 4.

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Observed associations between unconditional cash transfers and postpartum outcomes in the United States.

Infant or Child Care

Five of 6 studies reported on infant or child care outcomes: 1 QE analysis of the Alaska Dividend DCT (28), 1 QE analysis of EITC payouts (30), 1 QE analysis of SSI eligibility (31), and 2 RCTs of DCTs (34, 35, 37, 39). Most examined breastfeeding outcomes (28, 30, 37, 39), although 2 examined parenting behaviors (31, 34, 35) and the BFY RCT analyses also examined use of nonparental child care (34, 37). The other RCT of a DCT looked at skin-to-skin contact as its primary outcome (39).

Four studies provided overall high SOE that UCTs increase breastfeeding. Two of 3 good-quality studies found positive associations between UCTs and breastfeeding (28, 39). In a QE, cross-sectional, state-based study of the Alaska Dividend DCT, UCT amount was associated with increases in breastfeeding initiation and continuation at 4 weeks and 3 months (28). In a small RCT evaluating the effect of a short-term DCT in the NICU, in which breastfeeding was a secondary outcome, the UCT increased the number of days of breast milk provision (39). In addition, in a fair-quality QE study of estimated EITC payout, UCT amount was associated with an increased likelihood of any breastfeeding (30). In contrast, a good-quality analysis of the BFY RCT found that UCT amount did not increase breastfeeding initiation or continuation, although it did increase the number of mothers who met their intention to breastfeed (37).

Two studies provided low SOE that UCTs may result in little or no difference in parenting behaviors. Two high-quality analyses of the BFY RCT presented mixed results; specifically, UCT amount was associated with increased parental engagement by self-report but not by observation (34, 35). In addition, in a fair-quality QE nationally representative study of postpartum persons with recent preterm deliveries that used birthweight cutoffs to predict eligibility for SSI benefits (regression discontinuity design), SSI eligibility was associated with increased parent–child interaction at 9 months but not at 2 years (31).

One study provided low SOE that UCTs may result in little or no difference in the use of nonparental child care. In 2 good-quality analyses of the BFY RCT, at 12 months after delivery, UCT amount was not associated with self-reported use of nonparental child care in the past week (34, 37). Results were similar for other measures of nonparental child care (data not shown).

One study provided low SOE that UCTs may increase skin-to-skin contact, particularly in a NICU setting. A good-quality RCT of a short-term DCT to families in the NICU found that the UCT was associated with more days of observed skin-to-skin contact between mother and baby compared with an educational control (39). This study had notable limitations of a small sample size and unknown generalizability.

Reproductive Health

One study provided low SOE that UCTs may result in little or no difference in contraception use and barriers. In a good-quality analysis of the BFY RCT, the primary outcome, preferred contraceptive method use, did not differ by UCT amount (33). Nearly all secondary outcomes, including overall contraceptive method use, method-specific contraceptive use, and barriers to contraceptive use, were also not associated with UCT amount.

Substance Use

One study provided low SOE that UCTs may result in little or no difference in substance use and spending. One good-quality analysis of the BFY RCT found no association between UCT amount and combined self-reported alcohol and tobacco use at 1 year after delivery, which was the presumed primary outcome (38). This and another good-quality analysis of the BFY RCT found no associations between UCT amount and other substance use and spending outcomes, including alcohol use, tobacco use, opioid use (38), substance use spending, and cigarette smoking (34, 38).

Mental Health

Three of the 6 included studies evaluated associations between UCTs and postpartum mental health outcomes: 1 QE analysis of EITC payouts (29), 1 QE analysis of SSI eligibility (31), and the BFY RCT (34, 35). Most examined depressive symptoms (29, 31, 35), while the BFY analyses also examined happiness, hope (34), psychological stress, anxiety, and relationship quality (35).

Three studies provided high SOE that UCTs result in little or no difference in postpartum mood, most often assessed by the prevalence, number, or severity of depressive symptoms. A good-quality analysis of the BFY RCT found that UCT amount was not associated with the number or severity of depressive symptoms, measured using the Patient Health Questionnaire 8 scale (35). Similar results were reported by a fair-quality QE nationally representative analysis of presumed SSI eligibility, using the modified Center for Epidemiologic Studies Depression Scale (31). In another fair-quality QE study, based on estimated EITC payout among 2- to 4-month postpartum respondents in a nationwide survey, UCT amount was not associated with prevalence of depressive symptoms, assessed via self-report using 2 different measures: depressive symptoms (feeling “down, depressed, or hopeless”) and lack of interest (having “little interest or little pleasure in doing things that you used to enjoy”) (29). Finally, a good-quality BFY analysis found no associations between UCT amount and happiness or hope (34).

One study provided low SOE that UCTs may result in little or no difference in psychological stress. A BFY analysis measured psychological stress in 2 different ways: stress via the Perceived Stress Scale, and parenting stress via the Parenting Stress Index (35). The analysis found no associations between UCT amount and either measure of stress.

One study provided insufficient evidence to determine an association between UCTs and postpartum anxiety. A good-quality analysis of the BFY RCT found that persons receiving the larger UCT amount reported significantly higher levels of anxiety at 12 months after delivery, as measured by the 21-point Beck Anxiety Inventory, compared with those receiving the smaller UCT amount (35). The analysis included no other measures of anxiety for comparison.

One study provided low SOE that UCTs may result in little or no difference in adult relationship quality. A good-quality BFY analysis found no associations between UCT amount and several measures of adult relationship quality: co-parental relationship quality, romantic relationship quality, having ever been physically hurt, and frequency of arguing (35).

Other Outcomes

Only 1 study examined postpartum outcomes not fitting into the prior categories—physiologic stress and COVID-19 risk—and for both of these outcomes, there was insufficient SOE to determine an association with UCTs. A good-quality BFY analysis found no association between UCT amount and hair cortisol, an indicator of physiologic stress, at 12 months after delivery (35). Of note, only 36% of the total sample (364 of 1000 persons) provided a hair sample. In a different good-quality BFY analysis, the researchers assessed associations between UCT amount and 2 self-reported measures of COVID-19 risk: having ever been diagnosed with COVID-19, and having changed behavior to prevent COVID-19 (36). Compared with persons receiving the smaller UCT amount, those receiving the larger amount were more likely to have changed their behavior, but they were no more or less likely to have been diagnosed with COVID-19.

Subgroup Analyses by UCT Program Type and Outcome Level of Observation

We compared results by UCT program type (social program vs. experimental trial). We were able to make this comparison for only 2 outcomes: breastfeeding and mood (Figures 3 and 4). The associations between UCTs and postpartum outcomes did not vary by type of UCT program. Although the experimental trials provided higher-quality evidence, nearly all of the evidence originated from a single trial (BFY).

We also synthesized findings by outcome level of observation: postpartum individual, parent–infant dyad, and family or household (Figure 4). Each level contained several outcomes that were assessed. At the individual level and the family or household level, all associations were neutral or inconclusive. The only positive associations were observed at the dyadic level. We did not observe negative associations at any level.

Discussion

In this systematic review of UCTs and postpartum health outcomes in the United States, we identified 6 unique studies in 11 reports. Most reports were published in 2020 or later, and more than half were based on a single RCT. Four QE studies examined 3 different social programs, 2 of which targeted populations with low incomes. Seven reports from 2 RCTs examined DCTs to postpartum persons with low incomes. Many of the analyses focused on infant or child outcomes, resulting in a predominance of postpartum outcomes related to infant or child care, especially breastfeeding. The next most common category of postpartum outcomes was mental health, particularly mood, which was often assessed in terms of depressive symptoms. None of the interventions were designed specifically to improve maternal health, and none of the analyses assessed effects of UCTs on maternal or pregnancy-related mortality.

Our literature search process (Figure 1) highlights missed opportunities for UCT analyses to examine postpartum outcomes alongside other pregnancy, infant, or maternal health outcomes (40–46). For example, an often-cited study on EITC and maternal health outcomes does not specify when outcomes were assessed relative to giving birth (47), so we excluded it from our review. In addition, several recent UCT pilots among single or low-income mothers do not report outcomes in postpartum subgroups (48–50), making them ineligible for our analysis.

Despite limited evidence, we are able to draw some conclusions. First, UCTs result in more breastfeeding (high SOE), based on evidence from 2 QE studies of social programs and 2 RCTs of DCTs to persons with low incomes. Breastfeeding can improve maternal health, as people who breastfeed have lower risks for high blood pressure, diabetes, breast cancer, and ovarian cancer (51, 52). Some have suggested that UCTs facilitate breastfeeding by enabling mothers to have reduced or more flexible work schedules, allowing for more parental child care (37, 53). However, we found no association between UCTs and use of nonparental child care or other parenting behaviors. A better understanding of the mechanisms by which UCTs increase breastfeeding and whether they are mediated by work or child care may inform effective interventions to support breastfeeding.

Second, we found that UCTs result in little or no difference in postpartum mood, namely depressive symptoms (high SOE), based on evidence from an RCT on DCTs for families with low incomes and preterm babies, a QE study on disability benefits for families with low incomes and preterm babies, and a QE study on tax credits for families with low incomes. The authors of 2 contributing analyses suggest that the studied UCTs may not have been of sufficient amount or duration to affect mood, given the chronic nature of depression, especially when entangled with the chronic stressors of poverty (29, 35). In addition, 1 analysis from the BFY RCT found higher levels of anxiety among recipients of larger versus smaller UCT amounts (35). Although we conclude that the BFY evidence is insufficient to determine whether an association between UCTs and anxiety exists, anecdotal data from other UCT programs suggest that UCTs may induce anxiety or stress, perhaps by increasing expectations or demands on recipients (42, 54). Taken together, the evidence suggests that UCTs may have no effect on postpartum mood, or they may have mixed effects—both positive and negative—with a net neutral result. Continued attention to the UCT recipient experience is essential to understand how UCTs affect mental health, who is at risk for adverse effects, and how these risks can be mitigated.

Third, UCTs may increase skin-to-skin contact (low SOE), based on a single RCT in a NICU in Massachusetts. All other associations between UCTs and postpartum outcomes suggest little or no difference with low SOE (for example, substance use, adult relationships) or are inconclusive due to insufficient evidence (for example, physiologic stress). The lack of an association with substance use is notable, given theoretical concerns that UCTs may enable unhealthy substance use (38); we found no evidence to support this.

Our review highlights evidence gaps to guide future research. In terms of interventions, both DCT trials took place after delivery. During-pregnancy DCTs may be better timed to affect early postpartum outcomes, such as delivery complications, and can be studied in future trials. Also, in order to affect postpartum mood, UCTs of longer duration or greater value may be warranted, coupled with investigations into the potentially complex effects of UCTs on mental health. Given that UCT payouts may paradoxically lead to anxiety, financial counseling or mental health support may be a useful adjunct to UCT programs. In terms of outcomes, data are lacking for key postpartum clinical outcomes, such as cardiovascular disease and its related behaviors (for example, healthy eating or physical activity) and risk factors (for example, weight or blood pressure). Only 1 RCT report examined maternal depression as an outcome (35). No studies included postpartum health care use as an outcome. In addition, the results of 2 analyses raise questions about the durability of UCT effects (33–39), which could be explored in extended follow-up. For these and other avenues of research, ongoing poverty-reducing programs in the United States are prime opportunities to expand our understanding of the potential for UCTs to improve postpartum health. Such programs include federal and state Child Tax Credit and EITC programs; city-based guaranteed basic income pilots (12, 49, 50, 55–61); and medical–financial partnerships such as StreetCred, a benefits enrollment and tax preparation program embedded within the Department of Pediatrics at Boston Medical Center (20).

Our study has limitations. As with any literature review, our data are subject to publication and reporting bias. We have taken steps to mitigate these, such as conducting comprehensive searches for both white and gray literature, using standardized tools to assess the quality and strength of evidence, and including and reporting on nonsignificant findings. We may still have missed relevant data, particularly unpublished data or data published in a language other than English. In addition, the risk of bias is higher for the studies of social programs due to their observational, nonrandomized designs (see Supplement Table 2), resulting in reduced SOE. Although their designs are QE, residual confounding from unmeasured differences between groups is always possible. In addition, the EITC, SSI benefits, and similar forms of social assistance may affect maternal health due to their being conditional on employment or disability, separate from the effect of additional income. Furthermore, these programs do not specifically target the postpartum period. In the absence of randomization, robustness checks, heterogeneity analyses, and replication remain critical for understanding the full range of effects of these programs on postpartum outcomes. In addition, we recognize that post hoc analyses are especially prone to type I error (false-positive results) due to overinterpretation, differences by chance, or small sample sizes. Therefore, our subgroup analyses by UCT type and level of observation are merely exploratory. Finally, given the heterogeneity of the included studies, we were unable to conduct a meta-analysis.

Despite the connections between poverty and pregnancy-related deaths—a majority of which occur after delivery—little evidence exists on UCTs and postpartum outcomes in the United States. Based on 6 studies, we conclude that UCTs increase breastfeeding in diverse settings and populations and result in little or no difference in postpartum mood (namely depressive symptoms) in populations with low incomes. Evidence suggests that associations between UCTs and other postpartum outcomes are either neutral or inconclusive. We found no evidence of harm. However, data are lacking on key outcomes along the theoretical pathway from UCTs to postpartum health and survival (Supplement Figure). We recommend that UCT programs collect data on an expanded set of postpartum outcomes, especially those related to the leading causes of pregnancy-related deaths: mental health (for example, clinical depression and anxiety), cardiovascular disease (for example, healthy eating and blood pressure), and delivery complications (for example, access to health care and recovery from childbirth). During-pregnancy DCTs can be studied as a potential means to reduce early postpartum morbidity and mortality (60). Repeated measures in extended follow-up can help determine the durability of UCT effects. Collaboration between social scientists and clinicians is critical for analyses of UCTs and other economic interventions to generate the evidence needed to inform public health policy and practice and ultimately improve maternal health.

Supplementary Material

Supplemental data

Acknowledgment:

The authors thank the Boston Medical Center General Internal Medicine Health Equity Track residents and their instructors, Kelly Schuering and Pablo Buitron de la Vega, for their contributions to the design of Figure 4. We also thank Siddharth Ravinutala for his impeccable design sense, which greatly improved Figure 4 and the conceptual model. Finally, we acknowledge the work of Venkataramani and colleagues (62), which was an invaluable resource as we designed and conducted this study.

Financial Support:

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Dr. Murray Horwitz was supported by the Boston University Chobanian and Avedisian School of Medicine, the Boston University Chobanian and Avedisian School of Medicine Department of Medicine Career Investment Award, American Heart Association Career Development Award 937987, and NIH K23HL165097. Dr. McConnell was supported by grant funding for research from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Duke Endowment, the Blue Cross Blue Shield Foundation, the Gates Foundation, and the Development Innovation Ventures program of the United States Agency for International Development. The other authors received no financial support for the research, authorship, and/or publication of this article.

Footnotes

Disclosures: Disclosure forms are available with the article online.

Reproducible Research Statement: Study protocol: Available at https://osf.io/4c3nx. Statistical code: Not applicable. Data set: Available from Dr. Murray Horwitz (mara.murrayhorwitz@bmc.org).

Contributor Information

Sahar A. Choudhry, Department of Pediatrics, Boston Medical Center, Boston, Massachusetts.

G. Saradjha Brédy, Women’s Health Unit, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.

Cyerra Cruise, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts.

Qai Hinds, Spelman College, Atlanta, Georgia.

Margaret A. McConnell, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Sumit K. Agarwal, Division of General Medicine, University of Michigan Medical School, Ann Arbor, Michigan.

David B. Flynn, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts.

Mara E. Murray Horwitz, Women’s Health Unit, Section of General Internal Medicine, Boston Medical Center, and Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts.

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