Maternal depression is a problem due to its effects both on the women who suffer from it and its potential impact on family functioning and children’s physical and cognitive development. There is accumulating evidence that depression is common in lower-income countries, but the majority of research has been conducted in high-income countries. Given the challenges of raising healthy children in contexts of severe poverty, it has been argued that maternal depression is an even greater challenge in the developing world, where children are particularly vulnerable to health and safety risks. For mothers in lower-income countries, attempting to meet economic demands without adequate economic resources may be a source of psychological stress, which is a recognized risk factor for depression. Studies on the relationship between socio-economic status and maternal mental health have primarily relied on cross-sectional designs, which obscure the direction of causation. This study seeks to assess the effects of a large-scale conditional cash transfer (CCT) poverty alleviation program (Oportunidades) on maternal depressive symptoms using a quasi-experimental study design.
Oportunidades is one of the largest and earliest CCT programs implemented in Latin America. The income supplement provided by Oportunidades represented approximately 25% of average rural household income. This fraction was more substantial – and thus perhaps more psychologically impactful – than in previously-studied cash transfer programs in Nicaragua and Ecuador (10-15% of family income), for which there was no evidence of significant program effect on maternal depression. In Mexico, mothers in participating families only received benefits when the family complied with conditions that included pre-natal care, nutrition monitoring and supplementation, and infant checkups and immunization. Prior cross-sectional research on women participating in Oportunidades identified perceived stress and perceived control as the strongest predictors of depressive symptoms. The researchers hypothesized that this program aimed at relieving poverty and improving child health could also affect maternal depression by reducing economic stress for women, reducing stress related to health and development of their children, and increasing their perception of control over their lives. Reductions in perceived stress and increases in perceived control are therefore expected to affect maternal depression.
In 2003, 5,050 women living in rural communities who had participated in Oportunidades since its inception were surveyed using interviews and compared with 1,293 women from matched communities whose families had no exposure to Oportunidades at the time of assessment but were later enrolled. The women in the comparison group were from 152 communities selected using propensity score matching based on socio-demographic and infrastructure characteristics. Because the participating women from matched communities did not enroll in Oportunidades until at least a year after their participation in the study, they represented a stronger comparison group for causal inference than those from observational studies, which are prone to bias from systematic differences between people who participate in social programs and those who don’t.
Mothers’ self-reported depressive symptoms were measured with the validated Center for Epidemiologic Studies Depression Scale (CES-D). The scale ranges from 0 to 60, with scores 26 and higher indicating clinically significant depressive symptoms in the cultural context. Other maternal psychosocial measures were perceived stress, perceived control, and social support. The researchers also measured demographic and other household-level variables, including language, occupation, assets, and housing characteristics. Ordinary least squares regressions were used to evaluate the effect of program participation on depression.
Results and Policy Implications
Although Oportunidades does not target maternal mental health directly, the researchers found modest but clinically meaningful effects on depressive symptoms. Women in the treatment group had CES-D scores that were 1.7 points lower than those in the comparison group, after controlling for maternal age, education and household demographic, ethnicity, and socio-economic variables. The treatment group also had a 26 percent reduced risk for clinically significant depressive symptoms compared with the comparison group, still controlling for the same variables. Reductions in perceived stress accounted for 34 percent of the treatment effect, and increases in perceived control accounted for 12 percent. This suggests that reduction in perceived stress and increase in perceived control may be the channels through which income affects maternal mental health. The results from this study suggest that poverty alleviation programs may enhance the well being of mothers in poor households whose children are the main intended beneficiaries.
Photo Credit: Peter Bate, IDB, 2004