Impact of the Bolsa Família Program on energy, macronutrient, and micronutrient intakes: Study of the Northeast and Southeast

Participation in Conditional Cash Transfer Program During Pregnancy and Birth Weight-Related Outcomes

Importance

There is limited evidence of the association of conditional cash transfers, an important strategy to reduce poverty, with prevention of adverse birth-related outcomes.

Objective

To investigate the association between receiving benefits from the Bolsa Família Program (BFP) and birth weight indicators.

Design, Setting, and Participants

This cohort study used a linked data resource, the Centro de Integracao de Dados e Conhecimentos Para Saude (CIDACS) birth cohort. All live-born singleton infants born to mothers registered in the cohort between January 2012 and December 2015 were included. Each analysis was conducted for the overall population and separately by level of education, self-reported maternal race, and number of prenatal appointments. Data were analyzed from January 3 to April 24, 2023.

Exposure

Live births of mothers who had received BFP until delivery (for a minimum of 9 months) were classified as exposed and compared with live births from mothers who did not receive the benefit prior to delivery.

Main Outcomes and Measures

Low birth weight (LBW), birth weight in grams, and small for gestational age (SGA) were evaluated. Analytical methods used included propensity score estimation, kernel matching, and weighted logistic and linear regressions. Race categories included Parda, which translates from Portuguese as "brown" and is used to denote individuals whose racial background is predominantly Black and those with multiracial or multiethnic ancestry, including European, African, and Indigenous origins.

Results

A total of 4 277 523 live births (2 085 737 females [48.8%]; 15 207 among Asian [0.4%], 334 225 among Black [7.8%], 29 115 among Indigenous [0.7%], 2 588 363 among Parda [60.5%], and 1 310 613 among White [30.6%] mothers) were assessed. BFP was associated with an increase of 17.76 g (95% CI, 16.52-19.01 g) in birth weight. Beneficiaries had an 11% lower chance of LBW (odds ratio [OR], 0.89; 95% CI, 0.88-0.90). BFP was associated with a greater decrease in odds of LBW among subgroups of mothers who attended fewer than 7 appointments (OR, 0.85; 95% CI, 0.84-0.87), were Indigenous (OR, 0.73; 95% CI, 0.61-0.88), and had 3 or less years of education (OR, 0.76; 95% CI, 0.72-0.81). There was no association between BFP and SGA, except among less educated mothers, who had a reduced risk of SGA (OR, 0.83; 95% CI, 0.79-0.88).

Conclusions and Relevance

This study found that BFP was associated with increased birth weight and reduced odds of LBW, with a greater decrease in odds of LBW among higher-risk groups. These findings suggest the importance of maintaining financial support for mothers at increased risk of birth weight-related outcomes.

Association of Conditional Cash Transfers With Maternal Mortality Using the 100 Million Brazilian Cohort

IMPORTANCE

Conditional 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.

OBJECTIVE

To 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 PARTICIPANTS

This 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 MEASURES

Maternal death.

RESULTS

A 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 RELEVANCE

This 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.

Evaluating the effect of Bolsa Familia, Brazil's conditional cash transfer programme, on maternal and child health: A study protocol

BACKGROUND

Conditional 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.

METHODS

We 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.

DISCUSSION

Harnessing 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.

Contribution to the Journal Ciência & Saúde Coletiva on Food and Nutrition in Brazil

A systematic review conducted in January 2020 using SciELO database with the objective of analyzing the scientific production from 1996-2019, of the Journal Ciência & Saúde Coletiva in the area of food and nutrition. We selected 509 out of the 904 articles screened by titles and abstracts. We grouped the articles into ten themes and discussed the most frequent ones: Nutritional Status Assessment (n=142), Food Intake (n=111), Food and Nutrition Policies and Programmes (n=105) and Breastfeeding (n=35). The publications were mostly original articles (75.6%) employing quantitative method (81.6%) and, among these, 18.8% used a probabilistic sampling. We assembled a wide range of topics and subthemes, a relevant production and repository of data and knowledge for health professionals and managers. As gaps, there was a scarcity of publications focused on micronutrient deficiency; the promotion of the Food Guide for the Brazilian Population; supporting the rise of breastfeeding, the impact and analyses of the disruption of the National Food and Nutrition Security Policy and its multi sector interactions with social policies to fight hunger.

Evaluating the impact of the Bolsa Familia conditional cash transfer program on premature cardiovascular and all-cause mortality using the 100 million Brazilian cohort: a natural experiment study protocol

INTRODUCTION

Brazil's Bolsa Familia Program (BFP) is the world's largest conditional cash transfer scheme. We shall use a large cohort of applicants for different social programmes to evaluate the effect of BFP receipt on premature all-cause and cardiovascular mortality.

METHODS AND ANALYSIS

We will identify BFP recipients and non-recipients among new applicants from 2004 to 2015 in the 100 Million Brazilian Cohort, a database of 114 million individuals containing sociodemographic and mortality information of applicants to any Brazilian social programme. For individuals applying from 2011, when we have better recorded income data, we shall compare premature (age 30-69) cardiovascular and all-cause mortality among BFP recipients and non-recipients using regression discontinuity design (RDD) with household monthly per capita income as the forcing variable. Effects will be estimated using survival models accounting for individuals follow-up. To test the sensitivity of our findings, we will estimate models with different bandwidths, include potential confounders as covariates in the survival models, and restrict our data to locations with the most reliable data. In addition, we will estimate the effect of BFP on studied outcomes using propensity score risk-set matching, separately for individuals that applied ≤2010 and >2011, allowing comparability with RDD. Analyses will be stratified by geographical region, gender, race/ethnicity and socioeconomic position. We will investigate differential impacts of BFP and the presence of effect modification for a combination of characteristics, including gender and race/ethnicity.

ETHICS AND DISSEMINATION

The study was approved by the ethics committees of Oswaldo Cruz Foundation and the University of Glasgow College of Medicine and Veterinary Life Sciences. The deidentified dataset will be provided to researchers, and data analysis will be performed in a safe computational environment without internet access. Study findings will be published in high quality peer-reviewed research articles. The published results will be disseminated in the social media and to policy-makers.