title: Relationship between Receipt of a Social Protection Grant for a Child and Second Pregnancy Rates among South African Women: A Cohort Study.
abstract: BACKGROUND
  Social protection programs issuing cash grants to caregivers of young children may influence fertility. Grant-related income could foster economic independence and/or increase access to job prospects, education, and health services, resulting in lower pregnancy rates. In the other direction, these programs may motivate family expansion in order to receive larger grants. Here, we estimate the net effect of these countervailing mechanisms among rural South African women.
  
  
  METHODS
  We constructed a retrospective cohort of 4845 women who first became eligible for the Child Support Grant with the birth of their first child between 1998 and 2008, with data originally collected by the Agincourt Health and Socio-Demographic Surveillance System in Mpumalanga province, South Africa. We fit Cox regression models to estimate the hazard of second pregnancy in women who reported grant receipt after birth of first child, relative to non-recipients. As a secondary analysis to explore the potential for grant loss to incentivize second pregnancy, we exploited a natural experiment created by a 2003 expansion of the program's age eligibility criterion from age seven to nine. We compared second pregnancy rates between (i) women with children age seven or eight in 2002 (recently aged out of grant eligibility) to (ii) women with children age seven or eight in 2003 (remained grant-eligible).
  
  
  RESULTS
  The adjusted hazard ratio for the association between grant exposure and second pregnancy was 0.66 (95% CI: 0.58, 0.75). Women with first children who aged out of grant eligibility in 2002 had similar second pregnancy rates to women with first children who remained grant-eligible in 2003 [IRR (95% CI): 0.9 (0.5, 1.4)].
  
  
  CONCLUSIONS
  Across both primary and secondary analyses, we found no evidence that the Child Support Grant incentivizes pregnancy. In harmony with South African population policy, receipt of the Child Support Grant may result in longer spacing between pregnancies.
authors.affiliation: Center for Population and Development Studies, Harvard University, Cambridge, United States of America.
authors.forename: Molly
authors.initials: M
authors.lastname: Rosenberg
authors.affiliation: Department of Epidemiology, University of North Carolina-Chapel Hill, Chapel Hill, United States of America; MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Carolina Population Center, University of North Carolina-Chapel Hill, Chapel Hill, United States of America.
authors.forename: Audrey
authors.initials: A
authors.lastname: Pettifor
authors.affiliation: Department of Epidemiology, University of North Carolina-Chapel Hill, Chapel Hill, United States of America.
authors.forename: Nadia
authors.initials: N
authors.lastname: Nguyen
authors.affiliation: Department of Epidemiology, University of North Carolina-Chapel Hill, Chapel Hill, United States of America.
authors.forename: Daniel
authors.initials: D
authors.lastname: Westreich
authors.affiliation: Department of Global Health, Boston University, Boston, United States of America.
authors.forename: Jacob
authors.initials: J
authors.lastname: Bor
authors.affiliation: Center for Population and Development Studies, Harvard University, Cambridge, United States of America; Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, United States of America; Wellcome Trust Africa Centre for Health and Population Studies, Mtubatuba, KwaZulu-Natal, South Africa.
authors.forename: Till
authors.initials: T
authors.lastname: Bärnighausen
authors.affiliation: MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom; Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
authors.forename: Paul
authors.initials: P
authors.lastname: Mee
authors.affiliation: MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Rhian
authors.initials: R
authors.lastname: Twine
authors.affiliation: MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; INDEPTH Network, Accra, Ghana.
authors.forename: Stephen
authors.initials: S
authors.lastname: Tollman
authors.affiliation: MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; INDEPTH Network, Accra, Ghana.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Kahn
mesh_terms: D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D011159:Population Surveillance; D011247:Pregnancy; D018873:Pregnancy Rate; D016016:Proportional Hazards Models; D011632:Public Assistance; D011640:Public Policy; D012189:Retrospective Studies; D012424:Rural Population; D012946:Social Welfare; D013019:South Africa