Escaping The Inequality Trap: The Case For Supporting Pregnant Women

ESCAPING THE INEQUALITY TRAP: THE CASE FOR SUPPORTING PREGNANT WOMEN _

South Africa is stuck in an inequality trap with too few people able to build the knowledge and skills needed to fully participate in society and the economy. Our human capital pipeline is throttled at source, as high rates of low birth weight, stunting and inadequate access to early learning opportunities mean many children enter school with enduring learning deficits. They are likely to join the 300 0001 learners that drop out of school annually; perpetuating inter generational cycles of social and economic exclusion. Stop and think about it: we already know that, without a major change in the way we treat our children, many of the babies born in South Africa today have no chance of fulfilling their human potential!

This learning brief will show how, and why, improved support for pregnant women can help address malnutrition and stunting in the critical first 1 000 days of a child’s life, thereby changing a child’s development trajectory.

1 Van der Berg S., Wills G., Selkirk R., Adams C., Van Wyk C. 2019. The cost of repetition in South Africa. Stellenbosch Working Paper Series No. WP13/2019. https://www.ekon. sun.ac.za/wpapers/2019/wp132019

South Africa is the most unequal country in the world –80% of wealth is in the hands of 10% of the population and women earn 30% less than men with the same level of education.2 According to South Africa’s Living Conditions Survey, 52.2% of women fall below the upper-bound poverty line, compared with 46.1% of men.3 Additionally, research shows that 74.8% of women-led households fall below the upper-bound poverty line. Grow Great, a national campaign that seeks to galvanise South Africa towards a national commitment to zero stunting by 2030, says only a quarter of the approximately 1.2 million women who become pregnant annually have any source of income.

Stunting is a (largely preventable) condition where young children are short for their age and do not reach their full growth potential due to chronic nutritional deprivation, repeated infections and poor psycho-social stimulation. Stunting is associated with lifelong cognitive defects, educational and employment challenges, increased risk of chronic diseases in adulthood and cycles of inter-generational poverty.

2 Africanews with AFP. 2022. South Africa: The most unequal country in the world. Africanews, 10 March. https://www.africanews.com/2022/03/10/world-bank-southafrica-is-the-most-unequal-country-in-the-world//

3 Stats SA.2018. Men, Women and Children: Findings of the Living Conditions Survey 2014/15. Report 03-10-02. https://www.statssa.gov.za/?page_id=1854& PPN=Report-03-10-02

"Lack of access to socio-economic rights provides the clearest reflection of the levels of systemic poverty, unemploxyment, and inequality in South Africa and demonstrates the persistent recurrence of the cycle of poverty..."

South African Human Rights Commission, December 2018

As the cost of food continues to rise, poor households are paying more for less. This deepens food insecurity and places millions of children at risk of stunting. In order to reduce the cost of a carefully chosen basket of commodities by 30% and improve the diet of South Africa’s most underprivileged children, DGMT and its allies in a burgeoning nutrition coalition (including Grow Great) are urging the national government to join manufacturers and retailers, who waive their mark-ups on the 10 “best buy” foods for cash-constrained families, by matching the waivers.4

WHY DO PREGNANT WOMEN NEED SUPPORT?

A review published in The Lancet in 2013 found that maternal undernutrition accounts for about a fifth of all stunting.5 The 2022 provincial survey of child growth and stunting in the Western Cape found that babies who are born with a low birthweight are 2½ times more likely to have stunted growth.6 Typically, low birthweight is associated with undernutrition, maternal stress and other factors such as smoking and drinking alcohol. These interlocking factors are more prevalent in poorer communities, and threaten the well-being of pregnant women living in depressed socio-economic circumstances.

Poverty affects the nutritional status and mental well-being of pregnant women. These are factors that mutually reinforce each other7 and have a knock-on effect on foetal development, which in turn has a knock-on effect on early childhood outcomes (physical, cognitive and psychological).

Decades of structural inequality have concentrated disadvantage among poor, black women, reproducing cycles of racialised, gendered and class inequity. Despite policy and legislation aimed at expanding women’s economic participation, women remain less likely to be employed than men. When women do work, they are concentrated in low-skilled and less secure positions; earning lower wages for work of equal value (about 75% of what their male peers earn).8

According to the National Income Dynamics Study — Coronavirus Rapid Mobile Survey (NIDS-CRAM), women experienced slower financial recovery than men as the economy reopened after the national lockdown. Of the women who were employed pre-Covid, only 47% stayed employed across cycles of the pandemic.9 Women were also more likely than men to increase the hours they spent on childcare with the closing of schools and early childhood development centres, which showed that women tend to take on a bigger share of the responsibility of looking after children in the home. This also meant that many were prevented from working the same hours they were able to work before the Covid-19 lockdown, and were delayed or prevented from returning to their jobs or finding employment.

Pregnancy simultaneously reduces women’s income-generating potential and brings with it several financial responsibilities. Julie Mentor, project lead of Embrace, a national movement for supported and celebrated motherhood, points out that a lack of affordable childcare creates significant barriers to looking for work and continuing to work.

4 Harrison, D. 2023. Why Supermarkets should slash the price of these 10 foods. Financial Mail, 2 March. https://www.businesslive.co.za/fm/fm-fox/2023-03-02-whysupermarkets-should-slash-the-price-of-these-10-foods/

5 Black R.E., Victora C.G., Walker S.P., Bhutta Z.A, Christian P. de Onis M., et al.; the Maternal and Child Nutrition Study Group. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013: 371:243–60. doi:10.1016/S0140-6736(13)60937-X.

6 Western Cape Dept of Health and DG Murray Trust (2023). Western Cape Stunting Baseline Survey on under-5-yr-old children.

7 Field, S., Honikman, S. and Laurenzi, C.2020. Food Insecurity, Maternal Mental Health, and Domestic Violence: A Call for a Syndemic Approach to Research and Interventions. Maternal and Child Health Journal 24, p 401–404 https://doi.org/10.1007/s10995-01902872-8

8 Realising women’s rights for an equal future on Women’s Day. StatsSA. 9 August 2021. https://www.statssa.gov.za/?p=14559

9 Casale, D. and Shepherd, D. 2021. Gendered employment dynamics during the Covid-19 pandemic. National Income Dynamics Study (NIDS) – Coronavirus Rapid Mobile Survey (CRAM) https://cramsurvey.org/wp-content/uploads/2021/05/4.-CasaleD.-_-Shepherd-D.-2021-Gendered-employment-dynamics-during-the-Covid-19pandemic-Evidence-from-four-waves-of-a-South-African-longitudinal-survey.pdf

1PREGNANT WOMEN ARE FINANCIALLY VULNERABLE

WHAT DO EXISTING SOCIAL SAFETY NETS LOOK LIKE?

South Africa offers a child support grant to poor and vulnerable families, but this grant is only available once the infant is born, missing a critical window of opportunity in pregnancy when brain development is happening and when pregnant women are especially vulnerable to unemployment. At the moment employed female contributors can apply to the Unemployment Insurance Fund to receive maternity benefits when they go on maternity leave. To qualify for the benefits, they must receive less than their normal wages while on maternity leave.10

There is also the Social Relief of Distress (SRD) grant of R350 per month for six months to be paid to individuals who are currently unemployed, and do not receive any form of income, social grant or UIF payment etc. In his State of the Nation speech in February 2023, President Cyril Ramaphosa said that work was under way to develop “targeted basic income support” known as the Basic Income Grant (BIG) in South Africa – separate from the temporary SRD grant, which would be extended. At R350, the cost of the grant would range from R27 billion (if offered to original SRD recipients) to R252 billion if offered to everyone in the country (universal grant).11

Mentor believes South Africa needs a comprehensive and efficient social security system that caters to women who are self-employed and employed in the informal economy.

2THEIR CHILD IS AT RISK OF STUNTING

The World Bank considers stunting to be one of the most serious, but least-addressed, problems in the world.12 It affects the development of more than a quarter of South African children under five years old.13 The impact of the Covid-19 pandemic and resulting hunger crisis is expected to exacerbate stunting globally, increasing the need for critical nutritional services among children by 15% and placing an additional 1.7 million South African children at risk for stunting by 2025.14

Dr Edzani Mphaphuli, Grow Great executive director, says the time of greatest vulnerability to stunting is the first 1 000 days of a child’s life. “It’s a time when brain development is happening, so [it offers] an opportunity to establish a foundation for children’s academic success, health, and general well-being but it is also a time when the brain is most sensitive to poor nutrition and toxic stress.” How well or how poorly mothers and children are nourished and cared for during the first 1 000 days has a profound impact on a child’s ability to grow, learn and thrive. But sadly, in our context, the first 1 000 days is a time of great vulnerability for many of South Africa’s women and children.

10 https://www.gov.za/services/uif/maternity-benefits-uif#:~:text=As%20an%20 employed%20female%20contributor,you%20are%20on%20maternity%20leave.

11 Basic income grant for South Africa is coming. Business Tech. 9 February 2023. https://businesstech.co.za/news/government/663607/ramaphosa-confirms-basicincome-grant-for-south-africa-is-coming/#:~:text=Most%20proposals%2C%20 however%2C%20fall%20into,month%20for%20all%20unemployed%20adults).

12 The World Bank. 2021. Investing in Nutrition Can Eradicate the “Silent Pandemic” Affecting Millions of Poor Families in the Philippines. Press Release No: 2021/10/PH. https://www.worldbank.org/en/news/press-release/2021/06/15/investing-innutrition-can-eradicate-the-silent-pandemic-affecting-millions-of-poor-families-inthe-philippines-world-ba

13 Stats SA. 2017. South Africa Demographic and Health Survey 2016: Key Indicator Report https://www.statssa.gov.za/publications/Report%2003-00-09/Report%200300-092016.pdf

14 Reddy, S.2021. The 'slow violence' of malnutrition in South Africa. United Nations South Africa. https://southafrica.un.org/en/123531-slow-violence-malnutrition-south-africa

3 VULNERABILITY TAKES ITS TOLL ON MENTAL HEALTH

Maternal stresses were greatly increased by the Covid-19 pandemic, lockdown and the economic recession. Dr Simone Honikman, founder and director of the Perinatal Mental Health Project (PMHP) in Cape Town, says that for women already living in poverty, becoming pregnant can often catalyse a scenario of psychological distress, hunger in the household and impaired capacity to take up health or social services. According to the PMHP, studies have found that about one in three women living in adversity in South Africa will experience a common mental illness (depression and/or anxiety) during or after pregnancy.

Honikman explains that when caregivers (mothers, fathers, grandparents and child minders) of young children are psychologically in good shape, they are able to manage the challenges associated with childcare and socio-economic adversity. A caregiver who is mentally well has agency, a sense of purpose, and is best able to plan, problem solve, and access public health and welfare resources.

Healthy engagement with children – whether it relates to communication, stimulation, play or discipline – requires a caregiver who has the capacity to connect at an emotional level with their child. A person who is depressed or anxious usually finds it hard to read the cues of others, especially infants or children who are still learning to communicate their needs and responses. Caregivers with these common mental disorders may respond to infants harshly, withdraw from them, or engage in an intrusive manner.

Thus, PMHP strongly advocates that pregnant women in South Africa have access to financial assistance through a government grant. Global evidence has demonstrated the benefit of a Maternal Support Grant (also called the Maternity Support Grant or MSG) for both mother and infant. Grow Great, Embrace and their partners in the Western Cape have shown that providing digital food vouchers to pregnant women mitigates food insecurity and symptoms of mental distress in mothers (See case study).

“A Maternal Support Grant has significant long-term physical and mental health benefits for mother and baby. It is timebound, ringfenced and essentially easier to budget for and thus could actually be a cost-saver to government in the long term,” argues Embrace’s Mentor.

"Promotion of maternal mental health, which could take the form of social, economic and psychological support as well as access to basic human rights such as shelter and safety, is likely to yield enormous benefit for early childhood development."

Dr Simone Honikman, PMHP director

Case Study: MATERNAL SUPPORT

In 2020/21 the CoCare Maternal Support Study conducted by Grow Great, Embrace and partners in the Western Cape found that vulnerable pregnant women who received digital food vouchers reported improvements in maternal hunger, mental health and dietary diversity between baseline and endline results.

INTERVENTION:

› 584 pregnant women in the Western Cape participated in the baseline telephonic survey and received R300 digital food vouchers every two weeks between November 2020 and April 2021.

RESULTS:

› At baseline, 39% of respondents indicated that they had gone to bed hungry in the past seven days. Pregnant women who had experienced hunger in the past week were almost twice as likely to report feeling down, depressed or hopeless. These odds increased when pregnant women reported that a child in their household had gone to bed hungry.

› Respondents who reported receiving no direct social grant income were 63% more likely to report mental health symptoms, such as “having little interest or pleasure in doing things”.

› In order to determine the potential impact of receiving digital food vouchers during pregnancy, participants were contacted in March/April 2021 and again in October/ November 2021. Maternal hunger had significantly decreased at follow-up by 14% versus 39% at baseline. Child hunger also decreased by 9% compared with 22% at baseline.

LEARNINGS:

› These findings supported the evidence base that cash transfers provided to poor and economically vulnerable pregnant women and new mothers can have a significantly positive impact on their food security and that of their children, as well as on maternal mental health.

› The study helped to dispel some of the harmful myths around mothers’ misuse of grants and cash transfers. Follow-up reports documented how vouchers were utilised and showed that recipients had redeemed the vouchers to purchase food, baby items and electricity. This negated popular myths that women use grants irresponsibly and demonstrated that, when given the chance, mothers would most likely act in the best interests of their children.

› The study makes a case for why unconditional cash transfers, and not just food parcels, are a better option for pregnant women to meet their needs and the needs of their unborn children, and why we need to ensure that our social security system recognises, respects and protects the dignity, autonomy and agency of mothers.

Extending the child support grant into pregnancy is one way to support pregnant women living in low-resource communities. As Mentor notes, it is important to change public perception that “because such a grant is timebound (a few months while a woman is pregnant), it can’t possibly be an effective intervention.” She concludes: “Of course, it can't be a standalone intervention. Pregnant women need wrap-around support, but the financial assistance through a Maternal Support Grant signifies that pregnancy has financial implications requiring financial support.”

The MSG should not be seen as a competition for a BIG; rather it is an acutely targeted intervention likely to have significant impact on the core drivers of stunting.

COSTING STUDY OF MSG CONDUCTED IN 2021

To arrive at an estimate of the approximate financial cost of implementing a maternal grant, we need estimates of the annual number of eligible pregnant women.

In a 2021 study conducted by Debbie Budlender, commissioned by the Soul City Institute15 , an estimate of 1.1 million pregnancies per year was used, and it was assumed that 75% would qualify in terms of the child support grant means test. According to the Budlender study, the 75% was based on previous estimates and research16. In practice, not all women who are eligible will apply for the grant, especially in the first few years. The use of 75% will thus produce a worst-case scenario in terms of the size of the cost to government.

It is assumed that all women apply for the grant in time to receive it for the full six months of the second and third trimester. Again this produces an over-estimate because not all women will apply so early.

For the value of the grant, the 2021 study used the value of R460 per month.17

These estimates produce a maximum annual budget of R2.23 billion for the maternal grant. This constitutes only 1.2% of the total grant budget for 2021/22.

R460

15 https://www.soulcity.org.za/projects/previous-projects/re-engineering-primaryhealth-care/campaign-for-the-accelerated-reduction-of-maternal-mortality-inafrica-carmma

16 Delany A, Jehoma S & Lake L (eds) (2016) South African Child Gauge 2016. Cape Town: Children’s Institute, University of Cape Town. ISBN: 978-0-7992-2531-0.

17 The Child Support Grant increased to R500 on 1 April 2023 (an increase of R20 since the last adjustment to the grant).

2.2bn

1.2%

grant per month annual budget of total grant budget

OTHER FORMS OF SUPPORT FOR PREGNANT WOMEN

Other forms of support for pregnant women that can help address stunting include Flourish mom and baby classes, Grow Great Champions and the PMHP maternal support service.

Flourish

Flourish, a Grow Great initiative, helps parents provide responsive caregiving to their children through a rapidly growing national network of affordable and evidence-based mom and baby classes. It is a social franchise that offers a community of support for new and expectant mothers. It empowers and equips them with the skills and information they need to care for themselves and provide nurturing care to their child in the critical first 1 000 days. Since its inception more than 26 000 moms have been reached.

Grow Great Champions

Grow Great Champions (GGCs) is an initiative that catalyses Community Health Workers (CHWs) to be “Grow Great Champions” who support parents and children. They focus on maternal and child health, growth and early childhood development in the first 1 000 days of a child’s life. In several developing countries, where significant reductions in stunting have been achieved, CHWs have been central to these countries’ stunting reduction strategies. If one considers that a healthy child typically only interacts with the health system for 20 of the first 1 000 days, a strategy that includes interacting with the child and primary caregiver in the home is critical to the prevention of stunting. There are currently more than 2 000 GGC-trained CHWs operating in four provinces who have supported more than 125 000 children.

Maternal support service

For 12 years, PMHP has provided a maternal support service at the Hanover Park Midwife Obstetric Unit. Women visiting this unit come from Hanover Park and surrounding areas and face extremely high levels of social and economic hardship. The service design has recently changed to increase efficiency; shifting from a universal screening approach to providing targeted screening to adolescents, women with HIV, women experiencing violence and women deemed at-risk by the unit’s staff.

WHAT’S NEXT?

Pregnant women are excluded from South Africa’s current social security system. Because women make up a significant proportion of vulnerable workers in the formal and informal economies, many mothers lack basic rights to care and provide for their families. In order for them to break out of the inequality trap, we must provide better systems of support for pregnant women. Mentor believes that changes to the Basic Conditions of Employment Act and the introduction of an improved paid maternity leave policy would help ensure women are not forced to drop out of the economy to care for their young children.

Honikman is of the opinion that a Maternal Support Grant (MSG) would incentivise pregnant women to visit health facilities early in pregnancy and get greater benefits of preventive and promotive maternal health services and monitoring. “Further, a maternal support grant that converts into a child support grant when the child is born would likely promote early birth registration, which has many documented benefits for infants’ health and development. From the evidence available, it is highly likely that the societal benefits of such a grant would significantly outweigh the costs.”

Dr Edzani Mphaphuli of Grow Great says that although mothers are vulnerable, they are – and have historically been – key agents of social change. She urges government to invest in the MSG, rather than “pay the price of stunting in the form of high unemployment, continued poverty and poor health outcomes”. She believes children whose brains and bodies “grow great” in the first 1 000 days grow up to be adults with great ideas that grow great economies!

Learning brief developed by Daniella Horwitz, with contributions from Embrace, Grow Great and the Perinatal Mental Health Project, and edited by Rahima Essop.

This is the learning experience of:

"Pregnant women need wrap-around support."

Julie Mentor, Embrace Project Lead