GBPI would like to thank Healthy Mothers, Healthy Babies Coalition of Georgia for their thoughtful review of this paper.
- The wellbeing of Georgia’s children and families starts with healthy mothers and babies. Research is finds that financial stability during the earliest years of a child’s life can lead to positive outcomes in adulthood.
- Many of Georgia’s maternal and infant health indicators have not improved over the past decade and Black birthing people and babies continue to fare the worst.
- Making progress on maternal and infant health, especially for Black birthing people and babies, requires a multifaceted approach. In addition to robust health and social supports, birthing people also need strong economic supports like cash.
- Rigorous research finds that cash programs have a direct impact on birth outcomes, babies’ cognitive development, and maternal mental health. Black mothers and mothers with low levels of education tend to benefit the most from cash supports.
- There are several policy options ranging from modest to ambitious that would strengthen Georgia’s cash programs and provide the financial stability families need for healthy lives.
The wellbeing of Georgia’s children and families starts with healthy mothers and babies. However, Georgia still struggles to improve maternal and infant health overall and specifically for Black birthing people and babies. In a 2019 State of the State report on maternal and infant health, Georgia was still in the “bottom 10 percent for infant mortality, low birthweight, preterm birth and maternal mortality.” Over the past decade, percentages of babies with low birthweight and premature births do not appear to be improving, and Black babies continued to have some of the worst birth outcomes. Research is increasingly clear that health and financial stability during the earliest years of a child’s life can lead to positive outcomes in adulthood.
Outcomes for Black women and birthing people are deplorable as well. Black women are 2.3 times more likely to die due to pregnancy-related causes than white women in Georgia. Black women in Georgia also have some of the highest rates of hypertension during pregnancy, which can contribute to poor birth outcomes. Structural racism within our public and private systems has led to segregated neighborhoods where Black and other people of color are more likely to live in unhealthy environments with low quality housing, have less access to nutritious food and have limited income to maintain stability and build wealth. These and other factors can contribute to poor health before, during and after pregnancy. However, when caregivers have what they need to manage their health and provide for their children, they can create an environment for their babies to thrive. Improving the lives of Black birthing people will help to improve the lives of babies and families.
Recently Georgia lawmakers have taken some modest steps to support birthing people and babies. For example, this year lawmakers passed legislation to extend postpartum Medicaid coverage from six months to a year. Last year, they approved three-weeks of paid parental leave for state and public-school employees, but without funding. As the maternal and infant health crisis continues to worsen, legislators must build on these efforts and consider a wide range of health, social, and economic policy solutions.
Understandably, recommendations for improving maternal/ and infant health are often health care-oriented. Georgia public health experts recommend expanding Medicaid, ending the five-year waiting period for Medicaid for lawful permanent residents, more extensive education for expecting and postpartum parents, home visiting and universal behavioral and mental health screenings. Other policy proposals include addressing social determinants of health or the conditions in which people are born, live, learn, work, play, worship and age—like workplace conditions, housing stability or neighborhood violence—that affect a wide range of health, functioning and quality-of-life outcomes and risks. To address the racial disparity of maternal and infant health outcomes, the federal Black Maternal Momnibus Act, for example, focuses on specific health and social assistance that would improve outcomes for Black birthing people. It promotes funding for culturally responsive community-based health organizations and growing and diversifying the perinatal workforce as well as investments in housing, transportation and nutrition. However, one policy solution is often missed: cash.
Improving maternal and infant health is a goal that requires a multifaceted approach. This paper argues that cash supports can contribute to progress on maternal and infant health, especially for Black birthing people with low income and their babies. Unlike other economic security programs, cash supports provide people the autonomy to prioritize the goods and services they deem important to their health and wellbeing. For birthing people with low and/or unstable income, cash supports should be integrated in the health and social service policy agenda for maternal and infant health.
Policymakers can consider cash programs’ role in the movement to improve maternal and infant health. But there is a lot of work to do as Georgia’s cash policies have significant limitations. Temporary Assistance for Needy Families (TANF), cash benefits for families with children with very low income, has been largely ignored by policymakers and now serves very few families in poverty; Unemployment Insurance denies access to whole categories of workers with low incomes; and lawmakers have yet to take steps to institute a state Earned Income Tax Credit (EITC), which would boost low wages and the benefits from the federal EITC.
This paper presents the research on cash’s relationship to infant and maternal health outcomes and the circumstances contributing to economic insecurity and the lack of adequate cash supports in Georgia today. It concludes with policy recommendations ranging from modest steps to ambitious actions.
Rigorous Evidence that Cash Programs Supports Maternal and Infant Health
Research on the positive health impacts of cash and other income on young children’s near- and long-term outcomes has reached a definitive moment. In 2019, the National Academies of Sciences (NAS) panel on child poverty noted, “The weight of the causal evidence does indeed indicate that income poverty itself causes negative child outcomes, especially when poverty occurs in early childhood or persists throughout a large portion of childhood.” In short, alleviating poverty or increasing income improves health and other outcomes. The studies summarized below use either an experimental or a quasi-experimental design to establish a causal relationship between the cash intervention and the group receiving the intervention.
The research presented in this paper focuses on perinatal health outcomes, infant brain and cognitive development, and parental mental health. The author’s review of the evidence did not find direct connections between cash supports and a reduction in maternal mortality. The research does show evidence of a direct relationship between cash and a reduction in poor birth outcomes. While a reduction in poor birth outcomes may lead to fewer infant deaths, the studies do not explore the direct relationship between cash and infant mortality.
Improving Perinatal Health Outcomes
The perinatal period, which encompasses the time before birth to time after birth (up to a year or more postpartum according to some experts), is a critical time for fetal and infant development as well as bonding between the birthing person and baby. Several studies look at this period to see how income from cash programs affect birthing people’s health behaviors before birth and birth outcomes. Poor diet, missed prenatal appointments and consumption of tobacco or alcohol during pregnancy can contribute to poor birth outcomes like low birthweight (5 pounds 8 ounces, 2,500 grams, or less) and premature birth (birth before 37 gestational weeks, but later than the 20th week). Both birth outcomes are associated with an increased risk of infant morbidity and mortality. Studies show that additional income can help birthing people engage in healthy behaviors, which can extend the gestational period and increase birthweights.
The largest anti-poverty program for the non-elderly is the federal EITC. In addition to the federal EITC, 30 states and the District of Columbia have state EITCs, which are typically a percentage of the federal benefit. EITCs reduce the tax liability for people working for low wages and, depending on the design, offer a cash refund back into workers’ pockets. EITCs also incentivize work by increasing benefits as earnings increase up to a certain point. Because of their large anti-poverty effects, they have been the subject of significant study. In five separate quasi-experimental studies, researchers found the federal and state EITCs support birthing people and are associated with modest increases in birthweight and longer gestational periods.
- In the late 1980s and the 1990s, the federal EITC phased in multiple benefit expansions. Because of the changes in this period, mothers with two or more children received substantially higher payments than similar mothers with only one child. Researchers used these phase-in periods to investigate how increased benefits affected perinatal outcomes.
- Looking at single mothers with a high school education or less, researchers found a $1,000 increase in post-tax income from the expansion of the federal EITC in the 1990s was associated with a 1.6 to 2.9 percent reduction in the low-birthweight rates. Black mothers had stronger improvement in birth outcomes than white mothers. The study shows mothers receiving higher benefits of the EITC accessed more prenatal care and reduced their smoking.
- A similar study found each additional $1000 in federal EITC benefits was associated with a three percent increase in the likelihood of going full term, an increase of birthweight by 65.1 grams and a four percent increase in the likelihood of breastfeeding.
- State-level EITCs are often a percentage of the federal EITC and therefore, are smaller, as are their impacts on birth outcomes.
- A study of state-level EITCs shows the programs increased birthweights by an average of 16 grams and living in a state with an EITC reduced the chances of maternal smoking by five percent.
- Another study found states with more generous EITCs (10 percent of the federal EITC or greater) and refundable credits were associated larger average increases in birthweights (27.3 grams) than states with less generous EITCs and refundable credits (16.8 grams). States with EITCs with no refundability tended to have smaller gains in birthweight.
- The same researchers also found Black mothers have a larger beneficial effect than white mothers from state EITCs. Birthweight gains for Black mothers in states with EITCs ranged from 16 grams to 37 grams while gains for white mothers ranged from nine grams to 28 grams. Again, states with higher value EITCs were associated with higher birthweights.
Between the 1960s and 1980s the federal government funded several evaluations of Negative Income Tax (NIT) pilots. The NIT model, a tax subsidy for people with low income, was proposed as an alternative to other cash assistance programs available at the time but was never adopted as federal policy. Using an experimental design, the pilot in Gary, Indiana, a city with a high proportion of Black mothers with low income, paid families twice a month if their earnings were below a specific income threshold. Researchers found the NIT’s bimonthly payments increased birthweights by 0.3 to 1.2 pounds and mothers with high-risk pregnancies saw the greatest impacts.
Healthy brain and cognitive development for children
Some of the strongest and most recent evidence of cash payments’ impacts on infants comes from the Baby First Years study, which seeks to understand how financial support may affect babies’ brain function and development. Using an experimental design, the study tracks children from birth through early childhood and found that babies of parents with low income who received $300 a month in unrestricted cash were more likely to have high frequency brain waves, which support language and cognitive development, compared to a control group whose parents received $20 a month.
There are other notable non-health outcomes for increasing cash support in the very early years of a child’s life. A recent study finds tax credits to a family soon after the birth of a child leads to higher future earnings for that child by at least one to two percent and boys have larger effects.
Reducing mental health symptoms for birthing people and parents generally
The birth of a child can present many new challenges, stresses and anxieties for parents especially those with low, moderate or unsteady income. For example, affording diapers and formula have been linked to mothers reporting an increase in poor mental health days. GBPI found studies that show cash payments could help address poor mental health for parents with low or moderate income.
- According to a 2022 study, a 10 percentage-point increase in state EITC benefits was associated with a six percent reduction in the prevalence of depressive symptoms after giving birth for mothers with no more than a high school education. There was also a reduction in postpartum depressive symptoms for unmarried mothers with a high school education or less.
- Other research showed the expansion of the federal EITC in the 1990s improved maternal mental health. Among women with a high school degree or less, those with two or more children who received higher federal EITC payments had a 7.5 percent reduction in reported bad mental health days and a 1.35 percent improvement in reported overall health compared to mothers with one child and who received much smaller payments. Additionally, the study found a reduction of biomarkers associated with cardiovascular disease, which are often indicators of high levels of stress, for mothers receiving the EITC.
- Unconditional cash programs also show improvements in mental health and parenting. The study of Canada’s monthly child benefits found that an increase in $1000 of benefits reduced incidents of depression by an average of 11.6 percent. Mothers’ improved mental health persisted over time.
- Finally, relieving some of the financial stress and anxiety that comes with living with low income may positively impact caregivers’ capacity to effectively parent. In the 1990s, the Eastern Band of Cherokee government opened a casino in North Carolina. Adult tribal members received about $4000 a year split between two semi-annual payments. Researchers found that compared to the control group, families receiving the payments showed improved parental supervision and improved parent-child relationships especially for families where children started with more severe emotional disorders. 
The Financial Needs of Birthing People and Families with Infants Are Significant, But Georgia’s Cash Programs Fail to Adequately Support them
Preparing for and having a baby can be a very financially uncertain time. However, many women are already starting from an economic disadvantage. On average, women earn $0.83 for every $1 a man earns. This widens when considering race and ethnicity: Black women make an average of $0.63 and Latina women make an average of $0.58 for every $1 a white man earns. Whether it be through occupational segregation or the caregiving needs that prevent full-time work, many women, and particularly Black and Brown women, are over-represented in jobs that are part-time and/or low quality. Black women in particular have a history of being pushed into caregiving and other service jobs that can be unstable, offer few worker protections and pay low wages. Black women are also more likely than white women to be the primary earner in a household, making their income incredibly important to their families.
There can be many disruptions to a person’s income when they are pregnant. Low-paid jobs are often volatile, leading to a greater likelihood of an income disruption. Expecting persons may have to take time off work for prenatal visits, and many low-wage jobs do not pay for that time off. If a person has a high-risk pregnancy and they work in a physically demanding or a high- stress job, they may be forced to stop working entirely for their health and the health of the baby. Additionally, though illegal, there are still some instances of pregnancy discrimination, where some people are not hired or are dismissed because of their pregnancy. Finally, few jobs paying low wages have paid family leave to support birthing people after delivery, forcing parents to take care of their baby on less income or return to work sooner than is recommended by their health professionals.
Once a child is born, caring for an infant may restrict how much a caregiver can work thus limiting their income. It is unsurprising then that households with children ages 0 to 5 tend to have higher poverty rates than households with older children.
About 46 percent of infants and toddlers (ages 1 to 3) in Georgia are living in a family with income below the federal poverty line or a family with low income but above the federal poverty line. In Georgia, Black babies have the greatest likelihood of living in a family in poverty and a high likelihood of living in families with low income. Furthermore, caring for a baby is expensive. Diapers, formula and other baby essentials can consume a large portion of any family budget but could be nearly impossible to afford for families with very low income.
As the research above describes how cash income improves maternal and infant health, other research explains how insufficient or unsteady income is associated with poor health outcomes. The cash support system in Georgia is not strong enough to provide adequate stability through income disruptions, support people working for low and unsteady wages or reduce poverty for babies.
Temporary Assistance for Needy Families
Many women and birthing people with low income and few other supports may try to turn to a support like Temporary Assistance for Needy Families (TANF) before or after the birth of their child. Yet, there are many limitations that make TANF hard to access and maintain.
- Currently, expecting persons with no other children are not eligible for TANF in Georgia. However, the 11th Circuit Court of Appeals has decided that can move forward with implementing HB 481, which bans abortions at around 6 weeks. State agencies must consider the “personhood provision,” which defines an embryo as a person after cardiac activity is detected, and whether eligibility rules are in accordance with the law.
- The TANF benefit level is extremely low, $280 a month for a family of three. That’s 15 percent of the poverty line and has remained at that level for more than 30 years.
- Many recipients find it hard to comply with TANF’s strict and superficial work reporting requirements and some get cut from the program. While promoted as a way to help support themselves, research shows that work reporting requirements do little to help people get quality jobs and can even push families deeper into poverty.
- Georgia is one of 11 states that still has a family cap policy. For families who are already receiving TANF, the family cap prevents them from receiving higher benefits if they have another child, leaving them without additional support to help buy diapers and other baby essentials. Family caps also extend a legacy of reproductive control policies that were common in Aid to Families with Dependent Children, TANF’s predecessor.
Georgia’s Unemployment Insurance (UI) system is meant to provide economic stability when a worker loses their job. Unfortunately, the state’s UI system is one of the weakest in the country. State lawmakers have chronically underfunded the program for years. It has very low weekly benefits and is only available to workers for a maximum of 14 weeks (most states use the maximum period allowed under federal law—26 weeks). The UI system often fails to reach many eligible workers in times of economic need. One in five Georgians who applied for unemployment insurance in 2020 did not receive benefits. Furthermore, workers like those who are self-employed, work part time or those who work in the “gig” economy are ineligible for UI when they lose employment. As noted earlier, many of the people who work in these types of jobs are Black women. History also shows that the U.S. Congress left out most Black working women when they created the UI system in the 1930s.
State Tax Credits
In recent decades, tax policy decisions at the state level have overwhelmingly contributed to widening disparities in income and wealth between white Georgians and people of color, and more broadly widened the gap between taxpayers with low- to middle-income (who are overrepresented by Black and Brown individuals) and earners with high-income and corporate interests (who are overrepresented by white individuals). Georgia favors the expansion of corporate tax credits while so far largely refusing to create tax credits that would support everyday people. Georgia has no state EITC or a state Child Tax Credit (CTC), which would put cash in the hands of low- to middle-income taxpayers. Over 3.5 million Georgians are currently eligible for the federal EITC, including 1.5 million children. Among this group, 43 percent of dollars invested in a refundable state-level EITC would be directed to Black Georgians, 11 percent to Hispanic Georgians and 41 percent to white Georgians—an opportunity to provide more financial security to Black, Brown and white families who are working low-paid jobs. Furthermore, the enhanced federal CTC passed in the American Rescue Plan Act temporarily provided higher benefits and broadened eligibility beyond the original CTC. If permanently extended, these enhancements could have reduced child poverty in the state by 46 percent for Black children, 52 percent for Latinx children and 41 percent for white children. A state-level CTC with similar policy features would also reduce racial and ethnic disparities in child poverty across Georgia.
Research-Supported Policy Actions Legislators Can Take to Bolster Cash Supports for Pregnant Women, Birthing People and Families with Infants
Georgia’s cash supports for people in poverty and people working for low wages are not enough. For birthing people this creates major stress and worry about how they will care for their growing family. Insufficient economic supports mean children may not be meeting all their basic needs to have a strong and healthy future. The research included in this paper provides evidence that programs that offer regular, periodic or lump sum cash payments are effective at reducing poor maternal and infant health outcomes. This includes state-funded cash programs.
Georgia policymakers can take action to bolster cash supports. There are some modest steps state leaders can take now that would help expecting parents with the lowest levels of poverty (see
green policy proposals). Policymakers can build on those modest steps with major actions that reach a wider group of people with low income (see blue policy proposals). As support for cash policy grows, there are bolder policies to consider that could shift the cash policy landscape in Georgia and nationally (see gold policy proposals).
Expand eligibility to pregnant persons without other children and end the family cap.
- Given that the 11th Circuit Court has allowed for the implementation of HB 481 and its “personhood provision,” the Department of Human Services should allow pregnant persons with no other children to be eligible for TANF. Additional TANF cash payments can help a person cover some of the necessities for a safe pregnancy.
- End the family cap, which will allow families already on TANF who have another child to receive the additional dollars needed for their new baby.
Provide supplemental support for families with young children and increase monthly benefits for all TANF recipients.
- Provide a $50-$80 diaper benefit for TANF families with a child three years old or younger. Other states have implemented similar measures to help cover the additional expenses of caring for very young children.
- In a series of gradual steps, increase the TANF monthly benefit so that it is at minimum tied to 50 percent of the federal poverty line, currently $960 a month for a family of three. This will ensure no child receiving TANF lives in deep poverty.
There are other recommendations around work reporting requirements and work programs that policymakers should consider that would reduce stress and anxiety and help birthing people maintain their access to cash assistance.
- Re-establish the maximum duration of UI benefits to 26 weeks.
- Increase weekly benefits to more closely reflect the state’s median weekly wage of $1,318. The current UI weekly average is $365.
- Establish a comprehensive state UI system that supports self-employed individuals, “gig workers” and part-time workers currently excluded from traditional UI.
- Establish a refundable state EITC like the Georgia Work Credit. This could cut taxes by a few hundred dollars a year for eligible workers, up to around $630 per family. Additionally, an Emory University study estimated a state EITC like the GWC could mean 1,047 fewer low-weight births in Georgia each year.
- Create a state-level CTC to reduce child poverty. The CTC should be available to families with little or no earnings with full refundability, which is a key component to reducing poverty.
- Tax credits should also be structured so that they are delivered every month to improve their utility and meaningfully boost household incomes.
Black activists have promoted Guaranteed Income (GI) since the 1960s as a means to reduce racial inequity and promote economic stability. Those efforts inspired nonprofits and state and local governments to test GI programs in Georgia and other states. Unlike a universal basic income model, GI programs target certain populations, but generally those with low to moderate income. Some are targeting workers with low income or Black women specifically.  While a GI program may need to be largely funded at the federal level, states can support efforts to bolster the concept as effective policy to promote economic security and opportunity.
- Invest state dollars in current and future GI pilot programs to specific populations like birthing people and families with infants.
- Support rigorous evaluation designs to understand causal impacts of monthly benefits on financial stability, economic opportunity, and long-term wellbeing GI participants.
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 The most rigorous research in social sciences includes studies with experimental designs. These studies include procedures that validate or invalidate a causal relationship between an intervention and the group receiving the intervention. One key factor is that the intervention group or groups and the non-intervention group are developed randomly. When the groups are developed randomly, researchers have a high level of confidence that outcomes for the intervention groups are due to the intervention and not some other factor. Experimental studies in the social sciences may not always be possible or ethical so researchers may utilize quasi-experimental studies, which also seek to establish a causal relationship but not with randomly assigned groups. Researchers may use statistical means to control for potential factors that could influence the outcome.
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 Simon, D. (November 2013). Poor and in poor health. Institute for Research on Poverty and Morgridge Center for Public Service at University of Wisconsin Madison. https://www.irp.wisc.edu/publications/factsheets/pdfs/PoorInPoorHealth.pdf
 Pavetti, L. (June 7, 2016). Work requirements don’t cut poverty, evidence shows. Center on Budget and Policy Priorities. https://www.cbpp.org/research/poverty-and-inequality/work-requirements-dont-cut-poverty-evidence-shows.
 Meyer, L., Floyd, I. and Pavetti, L. (February 23, 2022). Ending behavioral requirements and reproductive control measures would move TANF in an antiracist direction. Center on Budget and Policy Priorities. https://www.cbpp.org/research/family-income-support/ending-behavioral-requirements-and-reproductive-control-measures.
 Camardelle, A. (March 24, 2020). It is time to bolster Georgia’s Unemployment Insurance System. Georgia Budget and Policy Institute. https://gbpi.org/it-is-time-to-bolster-georgias-unemployment-insurance-system/.
 Lloyd, S., Ballard, O., Efken Foxx, L., Gideonse, S. Gwiasda, S. (2020). Analysis of black women’s historical labor trends & systemic barriers to economic mobility. Women’s Fund of the Greater Cincinnati Foundation. https://www.womensfundingnetwork.org/wp-content/uploads/2020/10/Final_Hist_Black_Women__Report_Design_reduced.pdf.
 Institute on Taxation and Economic policy, July 2020.
 Finch Floyd, I. (October 13, 2021.) Advancing equity: Ensuring immigrant families can access the expanded child tax credit. Georgia Budget and Policy Institute. https://gbpi.org/advancing-equity-ensuring-immigrant-families-can-access-the-expanded-child-tax-credit/.
 Duncan, G. and Magnuson, K. (Winter 2011). The long reach of early childhood poverty. Pathways. https://www.researchgate.net/publication/281253723_The_Long_Reach_of_Early_Childhood_Poverty
 Research has shown the some of the TANF requirements mitigate the impact of TANF cash on maternal health. The work reporting requirements specifically have been found to reduce breastfeeding. (See Haider S.J., Jacknowitz A., and Schoeni R.F.)
Examples to protect birthing people from these punitive requirements include:
- Exempt pregnant persons and single parents caring for an infant from work reporting requirements for at least the first year of a baby’s life.
- If a parent does want to engage in work programs, ensure the program and services are appropriate for the parents’ circumstances. For example, provide a work subsidy with predictable hours. Also ensure they can child care subsidies and other support
- Protect parents of infants from sanctions if a parent cannot meet other requirements
See more from Lower-Basch, E., Schmit, S., (October 2, 2015). TANF and the First Year of Life: Making a Difference at a Pivotal Moment. CLASP. https://www.clasp.org/sites/default/files/public/resources-and-publications/body/TANF-and-the-First-Year-of-Life_Making-a-Difference-at-a-Pivotal-Moment.pdf
 Harker, L. (August 29, 2018). State earned income tax credits–a proven tool to improve health. Georgia Budge and Policy Institute. https://gbpi.org/state-earned-income-tax-credits-a-proven-tool-to-improve-health/.
 Trisi, D. Cox, K. Neuberger, Z. Lukens, G. Fischer, W. Balmaceda, J. and Jacoby, S. (November 10, 2021.) Build back better legislation would cut poverty, boost opportunity. Center on Budget and Policy Priorities. https://www.cbpp.org/research/poverty-and-inequality/build-back-better-legislation-would-cut-poverty-boost-opportunity.
 Tillmon, J. (Spring 1972). Welfare is a woman’s issue. Ms. Magazine. https://msmagazine.com/2021/03/25/welfare-is-a-womens-issue-ms-magazine-spring-1972/
 National Urban League. (August 25, 2022). Atlanta to work with Urban League to launch citywide guaranteed income program. https://nul.org/news/atlanta-work-urban-league-launch-citywide-guaranteed-income-program.
The Georgia Resilience and Opportunity Fund. https://www.thegrofund.org/.