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Rx Kids Research Brief

Results from the Rx Kids Participant Survey

& Maternal Wellbeing Research Study

A research brief from Rx Kids Directors, Dr. Mona Hanna & Professor Luke Shaefer

High Level Summary

A public-private partnership, Rx Kids launched in Flint, Michigan, in January 2024. Early findings from the nation’s first community-wide universal and unconditional maternal and infant cash prescription program reveal the following positive outcomes consistent with existing extensive evidence on child cash benefits:

  • Strengthened family financial security
  • Improved maternal mental health and wellbeing

Rx Kids Background

Built on global evidence and the success of the 2021 expanded Child Tax Credit (COVID-era unconditional cash transfers for families with children), Rx Kids launched in Flint, Michigan as a prescription for health, hope, and opportunity. Flint is the poorest city in the state, with the worst child poverty rate (59%) in the country.1 As the nation’s first community-wide maternal and infant cash prescription program, Rx Kids provides $1,500 to every pregnant person in mid-pregnancy and then $500/month for the first twelve months of life ($6,000 for newborns). Since the program launched in January 2024, Rx Kids has achieved a near 100% uptake rate of City of Flint newborns and is on track to effectively eliminating deep infant poverty with over $3 million successfully prescribed to over 1,000 Flint mothers.

Consistent with best practices as outlined by U.N. agencies,2 Rx Kids is a universal and unconditional cash prescription program (targeting low-income communities). This design allows for easy-tounderstand messaging, fosters dignity and trust, and decreases administrative burden. Laser-focused on the poorest and most neurodevelopmentally critical maternal-infant period, Rx Kids seeks to upend historic and systemic place-based inequities, eliminate infant poverty and bolster financial family security, reduce disparities and improve health equity, and lower costs for families while revitalizing local economies.

Rx Kids Research

Informed by community partners and multidisciplinary experts, the Rx Kids research and evaluation team is led by Dr. Mona Hanna (Rx Kids Director, Michigan State University) and Professor Luke Shaefer (Rx Kids Co-Director, University of Michigan). The tiered and robust research plan includes a mixed methods design utilizing multiple data sources (quantitative, qualitative, self-report, and administrative) to determine the impact of the program on several individual and community-level outcomes. Because maternal and infant poverty impacts so many health and opportunity outcomes across the life-course, we expect to see both short-term (i.e.: decreased hardship) and long-term (i.e.: kindergarten readiness) impacts from this community-wide intervention. Based on the extensive evidence of the benefits of maternal and infant cash benefits, improved outcomes may include but are not limited to: increased breastfeeding and health care services utilization, kindergarten readiness,3 educational attainment,4 health,5 expenditures on children,6 improved cognitive development,7 healthy food access8 and consumption9, smoking cessation,10 and economic productivity11. Child cash transfers have also been linked to a reduction in low birth weights12 and prematurity,13 child welfare involvement,14 and improved parent mental health.15

We are thrilled to share results from two different evaluations: the Rx Kids Participant Survey and the Maternal Wellbeing Research Study. Results from the Rx Kids Participant Survey were previously released (see here at RxKids.org) and are summarized below. The results from the Maternal Wellbeing Research Study presented below should be considered preliminary; further analysis and peer-reviewed publication are forthcoming.

1. Rx Kids Participant Survey

Administered by Rx Kids partner, GiveDirectly, the Rx Kids Participant Survey was conducted in May 2024 and gathered responses from over 112 participants (50% response rate). The voluntary survey was the first opportunity to collect impact data and was designed to assess participant experience and provide real-time feedback to inform program improvements.

Key survey findings from Rx Kids beneficiaries:  

  • 70% report an annual income of less than $10,000
  • 80% report Rx Kids helped them make ends meet and feel more secure in their finances
  • 59% report Rx Kids made it easier to get the health care that their household needs
  • 72% report Rx Kids helped improve the health of themselves and their infants
  • 80% report the money from Rx Kids has helped them become more confident as parents
  • Per respondents, the top five items cash prescriptions are spent on include: 88% baby supplies, 78% food, 57% rent, 48% utility bills, 36% transportation

Select Qualitative Responses from Rx Kids Participant Survey

  • “[Rx Kids] has given us more financial stability. It has helped us with a home, a car, food, and more. It has made me feel like a parent that can provide, [and] the things that I’ve done with it will reflect in my life.” – Savannah
  • “Because I am spending the money only on things me and the baby need, so everything I’ve gotten with the money will be able to help me long term. I’ve been saving half of the money, so when she gets here, we will be financially prepared.” – Angel
  • “I know I can get what my baby needs and my bills paid, so I won’t be homeless again” – Saysha
  • “[Rx Kids has given me] reduced stress with the knowledge of some sort of financial cushion that can make sure I at least have a roof over my and my children’s head.” – Joan
  • “[Rx Kids] helps me be able to spend present moments loving and nurturing my new baby… [it] has been able to help me neutralize health issues because of the lack of stress I have in all departments.” – Mary
  • “I’m now able to get back and forth to the NICU until my daughter is home without hesitation. I can go when I need to because the initial Rx Kids payment helped me get another running vehicle.” – Lexie
  • “[Rx Kids] gives me financial freedom and peace of mind to be able to care for my children and not have to workday and night to get by.” – Shianna

Summary: Critical insights from this voluntary and early survey of 112 participants indicate that participating families report Rx Kids helps them to access health care services, be more secure in their finances, feel more confident in their parenting, and that respondents report that they spend cash prescriptions on items for their babies, and to secure stable housing and transportation to medical appointments. These findings are consistent with other evidence on maternal and infant cash benefits.

2. Maternal Wellbeing Research Survey

The participant survey described above offers important insights into how recipients view Rx Kids. A more robust analysis of the effects of Rx Kids, though, would compare outcomes for birthing families in Flint before and after implementation of the program. Even better is to compare the differences in outcomes for Flint families to outcomes before and after the program for birthing families in the surrounding geographic area who are not eligible for Rx Kids.

With such an analysis in mind, a maternal wellbeing study was developed by the Rx Kids research team in collaboration with community partners. The goal of this study was to examine outcomes that could only be assessed by maternal self-report, such as economic hardship, maternal mental health, and wellbeing. Survey questions were based on previous literature and/or validated survey instruments. After necessary IRB approvals, the survey was administered during the months of July and August 2024. Every mother 18 years or older who gave birth at Hurley Medical Center (HMC) between July 2023 through June 2024 was invited to complete the survey. HMC is the largest birthing hospital in Flint and also serves the surrounding geographic region. All mothers received a letter in the mail inviting them to complete the survey with follow-up text messages and phone calls if needed. Survey participants received a $50 gift card after survey completion.

The survey included four cohorts of mothers who gave birth at HMC:

  • 2023 non-Flint mothers (Not eligible for Rx Kids)
  • 2024 non-Flint mothers (Not eligible for Rx Kids)
  • 2023 City of Flint mothers (Not eligible for Rx Kids)
  • 2024 City of Flint mothers (Eligible for Rx Kids)

Residential status was determined by geocoding eligible participants’ address to determine if they lived inside or outside the boundaries of the City of Flint. Considering the near 100% uptake rate of Rx Kids among Flint mothers with 2024 newborns, the 2024 City of Flint cohort is the Rx Kids intervention group, which can be compared to three control cohorts who did not receive Rx Kids from before and after the launch of the program.

Outcomes for respondents with annual income below $40,000 were descriptively analyzed and are presented in the tables below. Additionally, a differences-in-differences statistical design was utilized, which accounts for differences across time and populations inside and outside of Flint to better assess the impact of Rx Kids on surveyed outcomes. Difference-in-differences models included the full survey sample (including higher income respondents), and control for age of respondent, number of children in the household, race, educational attainment, marital status, and income. For this report on preliminary findings, the statistical significance in the difference-in-differences estimator was evaluated at p<0.05.

Preliminary Results

Over 2,000 mothers were invited to take the survey, and over 1,000 (51%) completed the survey. The response rate exceeded typical response rates for voluntary surveys; of note, the response rate was the greatest for the 2024 Flint Rx Kids cohort (54%). The demographics (race, age, education) of the Flint cohorts were similar to each other, and the non-Flint cohorts were similar to each other.

Economic Hardship

Based on the recently released 2023 U.S. Census American Community Sruvey data, the child poverty rate for the city of Flint is the highest in the nation at 59%; the poverty rate for families with young children (under 5 years) is even greater at 62%.1 Moreover, childbirth can be considered an economic shock, as there are substantial costs to bringing home a newborn during a period when income plunges.16 From baby supplies to out of pocket medical expenses to childcare, the first year of life has many expenses, and families are the poorest around childbirth. However, evidence demonstrates that birth grants and monthly cash allowances have the potential to reduce poverty after birth.15,17 In addition, cash transfers have been proven to improve food security,8 nutrition quality, and food satisfaction,9 while reducing child poverty,16 housing hardship,18 and the likelihood of facing multiple hardships.19

Moreover, parents often reinvest these cash transfers into their children, positively impacting them across the lifespan. Research shows that recipients of cash transfers invest the cash into child-specific purchases like baby essentials (i.e.: cribs, car seats, clothes, etc).20 In addition, child cash benefits are very often spent on core household expenses such as rent, utilities, food, household supplies, etc.20,21 This spending is largely local, thus a stimulus to local economies.22 Qualitatively, cash transfer recipients report using the funds to invest in entrepreneurial activities, using the agency granted by the cash transfers to create financial stability for themselves and their families.23 While these purchases aren’t necessarily childspecific, they often improve the safety, stability, and quality of the child’s life, and parents consider these purchases as important for their children’s wellbeing.20 

In eight out of nine hardship key questions asked, Flint 2024 families improved compared to Flint 2023 families (with no change in just one outcome.) Flint families also improved their relative position compared to non-Flint families on eight of nine outcomes (with no relative change in one). The difference-in-differences comparison is statistically significant for four outcomes examined. Flint Families exposed to Rx Kids (2024 Flint) saw improvements on two of three food hardship outcomes, including an 8.2 percentage point increase in reporting they have “Enough of the kinds of foods we want” as compared to Flint families in 2023, an improvement consistent with impacts from the Chelsea Eats cash transfer study.9

In terms of housing security, Rx Kids families saw a marked improvement in the likelihood that they were paid in full (not behind) on their rent or mortgage – and a large reduction in how much they owed if they were behind, consistent with research on the expanded Child Tax Credit.24 In contrast, both of these housing stability outcomes worsened for non-Flint families between 2023 and 2024. We are particularly pleased with the fact that not a single low-income Flint 2024 Rx Kids family reports that they have been evicted since childbirth, which is not true of non-Flint, low-income families. In contrast, in 2023, lowincome Flint families were more likely to report being evicted than non-Flint families. Rx Kids families were more likely to report that they had enough diapers than Flint families in 2023 who did not receive Rx Kids. They were more likely to report that they had “enough cash on hand for an emergency,” and they were far more likely to say they had “freedom to choose how they use their cash.”

Economic Hardship, Maternal Wellbeing Research Study, Low-Income Respondents
  2023
non-Flint 		2024
non-Flint 		2023
Flint 		2024
Flint
Rx Kids 		  DID Stat Sig p<0.05
“Within the past 30 days, the food we bought just didn’t last and we didn’t have the money to get more.” Never true 63.2% 65.8% 65.9% 70.4% ↑

 

 
 “Within the past 30 days, we worried whether our food would run out before we got money to buy more.”  Never true 58.3% 60.0% 60.0% 59.7% ≈
“Which of these statements best describes the food eaten in your household in the last 30 days?”  Enough of the kinds of foods we want 50.4% 50.0% 54.3% 62.5% ↑ *
“Do you owe any back rent or mortgage (rent or mortgage you owe but have not paid) at your current home?”  No 83.3% 77.3% 69.2% 82.6% ↑ *
“How much do you owe in back rent or mortgage in your current home?” $168.66 $320.45 $376.20 $169.42 ↓ *
Since giving birth: “You were evicted or your landlord forced you to leave your home or apartment for not paying the rent or mortgage?” 5.3% 1.7% 8.0% 0% ↓
“In the past month, have you had to use fewer diapers than you would have liked because you can’t afford enough?”  Never true 73.7% 75.6% 60.2% 72.5% ↑
“I feel like I have the freedom and choice to decide how household money is spent.”  Agree or Strongly Agree 63.5% 61.7% 59.8% 77.2% ↑ *
“Do you have cash available that could be used in an emergency?”  Yes 38.5% 41.7% 29.7% 39.2% ↑

Maternal Mental Health and Wellbeing

Parenthood should be a joyful experience, but too often, families are burdened by the unaffordable cost of child-rearing. Research has found that economic pressure translates to psychological distress across racial and ethnic demographics and rural and urban contexts.25 Nationally, 1 in every 5 birthing parents experience perinatal mental health disorders such as stress, depression, and anxiety; tragically, perinatal mental health disorders are a leading cause of maternal death in the United States.26 Maternal wellbeing is predictive of interparental conflict, parenting quality, and child and adolescent adjustment.25

Improvements in maternal wellbeing can positively impact the family system across the entire life course.

Universal and unconditional prenatal and infant cash prescriptions are an evidence-based, efficient way to reduce economic pressure27,28 during this economically challenging period, and in turn, improve maternal mental health and wellbeing. Cash transfers have been associated with decreased symptoms of depression and anxiety,15 improved happiness, higher self-esteem,29 decreased psychological distress, improved emotional wellbeing,30 and a reduced number of bad mental health days.31 Additionally, there is a sizeable body of qualitative research that demonstrates the clear connection between cash benefits and improved wellbeing.32

Based on the research survey findings, there is evidence to conclude that Rx Kids maternal and infant cash prescriptions are positively impacting maternal mental health and wellbeing. These estimates are both statistically and clinically significant: compared to Flint mothers in 2023, mothers in the Rx Kids group are nearly 10 percentage points less likely to exhibit symptoms of depression based on the Center for Epidemiologic Studies Depression Scale (CESD-10), with a positive depression result defined as having a score of 10 or greater.33 In addition, 2024 Flint moms are 6 percentage points less likely to report anxiety than 2023 Flint moms, defined as scoring a 3 or greater on the General Anxiety Disorder (GAD2) questionnaire.34 Rx Kids mothers are the most likely to rank their general mental health as “excellent or very good” as compared to the other groups. Affirming the maternal wellbeing values imparted in the universal and unconditional design of Rx Kids, Rx Kids mothers are at least 10 percentage points more likely to report they feel loved, hopeful, valued, and respected. These differences are not nearly as large when comparing 2023 and 2024 births outside of Flint, allowing us to conclude that much of the difference within Flint is driven by the introduction of Rx Kids. On all seven outcomes examined, Flint 2024 families saw improvement in comparison to Flint 2023 families, and on five of seven meaningful improvements relative to non-Flint families. The difference-in-differences comparison is statistically significant (p<0.05) for four of seven outcomes examined and marginally significant for one (+ = p<0.1).

Maternal Mental Health & Wellbeing Outcomes, Maternal Wellbeing Research Study, Low-Income Respondents
  2023
non-Flint		 2024
non-Flint		 2023
Flint		 2024
Flint Rx Kids 		DID Stat Sig p<0.05
High depressive symptom score
(CESD-10 score ≥ 10) 		42.5% 41.8% 47.7% 38.0% ↓ *
High anxiety score
(GAD-2 score ≥ 3) 		31.7% 26.1% 31.5% 25.5% ↓
“In general, would you say your mental health is…”.
Excellent or Very Good 		25.8% 30.6% 33.0% 38.1% ↑
 “I feel loved.”
Agree or Strongly Agree 		72.8% 79.3% 68.1% 78.4% ↑ *
“I feel hopeful.”
Agree or Strongly Agree 		69.7% 65.9% 60.0% 73.2% ↑ *
“I feel valued as a person”
Agree or Strongly Agree 		52.4% 57.4% 52.8% 64.7% ↑ +
“I feel respected”
Agree or Strongly Agree 		56.2% 56.8% 57.6% 67.8% ↑ *

Conclusion

The preliminary findings of this Maternal Wellbeing Research Study, coupled with the Rx Kids

Participant Survey, indicate – both quantitatively and qualitatively – that the implementation of Rx Kids has been successful in strengthening family financial security and improving maternal mental health and wellbeing. Based on the data, Flint moms and babies are faring better in 2024 than in previous years or in nearby geographies.

As Rx Kids continues to grow and expand, data will continue to be analyzed, and research findings will continue to be shared. Consistent with the extensive evidence base, we anticipate sharing positive impacts regarding maternal and infant health, disparities reduction, maternal and infant morbidity and mortality, child welfare involvement, childhood vaccinations and development, societal savings, and economic reinvestment.

The Rx Kids program, including the research and evaluation, is only made possible through the generous support of many funders and supporters. We are especially grateful to the dedicated Rx Kids research team, and the incredible number of mothers who completed the surveys to help inform this important work and advance the science.

References

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https://www.hks.harvard.edu/centers/taubman/programsresearch/rappaport/research-and-publications/special-collections/covid-19-relief-chelsea-ma
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22  Parolin Z, Giupponi G, Lee EK, Collyer S. Consumption responses to an unconditional child allowance in the United States. Nature Human Behaviour. 2024;8(4):657-667. doi:10.1038/s41562-024-01835-6
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31  Evans WN, Garthwaite CL. Giving mom a break: The impact of higher EITC payments on Maternal Health. American Economic Journal: Economic Policy. 2014;6(2):258-290. doi:10.1257/pol.6.2.258
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