Effect of combining lower- and higher-value monthly cash transfers with nutrition-sensitive agriculture, male engagement, and psychosocial intervention on maternal depressive symptoms in rural Malawi: a secondary analysis of a cluster-randomised controlled trial

Abstract Maternal depression affects one in five women in Malawi. Integrated interventions simultaneously addressing multiple risks are a promising strategy to improve mental health. This study evaluated the impact of a nutrition-sensitive social behaviour change (SBC) interventions (agriculture and livelihoods, male engagement, and Caring for the Caregiver) with or without cash transfers on maternal perinatal depression during the lean season in rural Malawi. A midline survey for a cluster-randomised controlled trial was conducted, where 156 clusters were randomly assigned to four arms (39 clusters/arm): (1) Standard of care (SoC), (2) SBC, (3) SBC+low cash (USD17 per month), and (4) SBC+high cash (USD43 per month). Pregnant women and mothers of children <2 years of age (n=2,682) were enrolled at baseline (May-June 2022). A subsample of 1,303 women were followed-up at midline (November-December 2023). Maternal perinatal depression was assessed using the Self-reporting Questionnaire (SRQ-20) with a score of ≥8 indicating symptoms consistent with depression. Intervention effects were estimated using linear mixed effects models. At midline, SBC+high cash reduced depression scores relative to SoC (mean difference (MD) -1.13 (95% CI -1.96, -0.31)) but had no impact on the proportion of women with depressive symptoms. SBC+low cash and SBC alone had no impact on depression scores or the proportion of women with depressive symptoms. Relative to SBC alone, adding cash to SBC reduced depressions scores and the proportion of women with depressive symptoms regardless of the size of the cash transfer. Cash transfers integrated with SBC can benefit maternal perinatal depression health in rural Malawi during the lean season. What is already known on this topic? Cash transfers can improve mental health by addressing financial and economic risks, but evidence on perinatal mental health is limited, particularly during periods of peak food insecurity. Parenting interventions have no overall impact on maternal mental health, but individual interventions and interventions engaging male caregivers have shown positive effects on perinatal mental health. Nutrition-sensitive agricultural interventions can reduce depressive symptoms by improving food security, food access, and household income; however, evidence is scarce. Evidence on the additive or synergistic effects of cash transfers, nutrition-sensitive agriculture, and parenting interventions on perinatal mental health is lacking. What this study adds? Larger cash transfers with nutrition-sensitive social behaviour change (SBC) interventions comprising nutrition-sensitive agriculture, male engagement, and psychosocial components reduced maternal depressive symptoms during the lean season. Smaller cash transfers with SBC or SBC alone had no impact on perinatal mental health. Cash transfers had an added benefit for maternal depressive symptoms on top of SBC regardless of the size of the transfer. How this study might affect research, practice or policy? Comprehensive intervention packages addressing multiple vulnerabilities and risks for mental health and providing a variety of coping and thriving strategies can help improve perinatal mental health, particularly during peak periods of food insecurity. Additional research is needed to understand the precise pathways through which integrated intervention packages work to improve perinatal mental health. Competing Interest Statement The authors have declared no competing interest. Clinical Trial ISRCTN53055824 Clinical Protocols https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-023-07782-3 Funding Statement This work was supported by Power of Nutrition and the National Science Foundation (2242341). The funder had no role in the study design, collection, analysis, and interpretation of the data, writing of the article or decision to submit for publication. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The trial was approved by the institutional review boards of the University of Malawi (protocol number: 02/22/128) and the International Food Policy Research Institute (protocol number: PHND-22-0214). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data sharing Data described in the manuscript, code book, and analytic code will be made available by the corresponding author upon request.