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

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 [&ge;]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. Key messagesO_ST_ABSWhat is already known on this topic?C_ST_ABSO_LICash 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. C_LIO_LIParenting 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. C_LIO_LINutrition-sensitive agricultural interventions can reduce depressive symptoms by improving food security, food access, and household income; however, evidence is scarce. C_LIO_LIEvidence on the additive or synergistic effects of cash transfers, nutrition-sensitive agriculture, and parenting interventions on perinatal mental health is lacking. C_LI What this study adds?O_LILarger 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. C_LIO_LICash transfers had an added benefit for maternal depressive symptoms on top of SBC regardless of the size of the transfer. C_LI How this study might affect research, practice or policy?O_LIComprehensive 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. C_LIO_LIAdditional research is needed to understand the precise pathways through which integrated intervention packages work to improve perinatal mental health. C_LI