This story was originally published by Next City.

Amaryllis Castillo gets to work at 7:45 a.m. for her job as a certified home health aide. The mother of two, who was 26 weeks pregnant when we spoke, works a six-hour shift caring for elderly patients, taking them to activities and out for lunch. At 5 p.m., she clocks in for her second job providing customer service, which she works until 9 p.m. She does that from home, which allows her to be with her children, who are 12 and 2. 

But despite working these two jobs — for a combined 50 or more hours a week — Castillo, who lives in Philadelphia, barely makes enough to cover rent, day care, car payments, utilities and groceries (though she makes too much to qualify for food stamps). Neither job comes with benefits: no health insurance, no paid sick leave, no 401(k), and no paid time off to recover from the upcoming birth of her baby.

“I’m just making it happen,” she said. 

The American approach to pregnancy and birth has largely been to leave families to manage the transition to new parenthood on their own. The United States is one of the only countries in the world without paid parental leave, and while a handful of states have started their own paid-leave initiatives — though Pennsylvania isn’t one of them — even these programs do not cover all workers. Nor is there a national program for preventing or treating postpartum mood disorders (PPMDs) — mental health conditions that include postpartum depression, postpartum anxiety, PTSD and postpartum psychosis — which affect about 15 to 20 percent of new birthing parents in America. 

Financial stress is among a myriad of factors that can trigger PPMDs. Being low-income is a risk factor for developing depression, and one of the greatest predictors for developing a PPMD is having previously experienced a mental health disorder. When it comes to postpartum depression in particular, financial strain and hardship have been found to exert a “small but significant” impact on the likelihood of developing it. This effect, researchers assert, is “consistent across different cultures and countries.”

The impacts of postpartum mood disorders are significant: One of the drivers of the United States maternal health crisis is suicide, which accounts for about 1 in 5 pregnancy-related deaths during pregnancy or up to a year postpartum. PPMDs are also costly in other ways, with a recent study in the American Journal of Public Health estimating that over five years, each mother and baby affected by PPMDs cost $31,800 — from their higher usage of health care, lost time at work and greater use of public services like Medicaid — adding up to an estimated $14 billion public cost over five years. New programs in Philadelphia and Flint, Michigan have implemented a simple solution to the patchwork of paid leave programs and potentially protect against some of the harm of PPMDs: a universal basic income during pregnancy and for the first year postpartum. The Flint program, Rx Kids, is so promising that Kamala Harris modeled her proposed tax-credit initiative on it.

These programs are expected to demonstrate improved health outcomes for mothers and babies: maternal stress has been linked to preterm birth and low birth weight, for instance. And there’s ample evidence for their efficacy in reducing parents’ symptoms of anxiety, initiating changes to infant brain activity and increasing the likelihood that children of recipients will finish high school and college. A 2022 review of 20 studies of cash transfer programs in Canada, which has hosted such initiatives since 1945, demonstrates similar improvements to parents’ and children’s health over time.   

Here in the United States, these programs demonstrate the unique role that cities can play in reducing high financial stress — and thereby reducing the risk of developing a PPMD and initiating a cascade of harms. Though some amount of postpartum mood disorders cannot be prevented, reducing financial stressors may prove protective. 

Three cities take on postpartum health

Castillo is one of the 250 mothers from three Philadelphia neighborhoods receiving $1,000 a month from the city’s new Philly Joy Bank, beginning in their second trimester of pregnancy and lasting until their baby’s first birthday. 

The money has already made a difference: She opened a savings account and now can afford life insurance, both tasks that alleviate existential fear about the future. The funds will also enable her to put money toward school, she said, which will help her work toward a job in optometry — that would pay $7 an hour more than what she’s currently making. Castillo also plans to put the money toward taking six weeks off from work after her baby’s birth, though she notes that the monthly $1,000 isn’t enough to cover her bills for that whole period.

The Philly Joy Bank, which launched in June, is funded by local philanthropic organizations and administered by the city’s Department of Health’s Division of Maternal, Child and Family Health. The initiative emerged from the city’s Community Action Network, a collaborative group that includes parents, physicians and community organizations focused on reducing infant mortality in the city. Together, the group agreed that guaranteed income would significantly reduce pregnant people’s stress. The program enrolls mothers from three neighborhoods with the city’s highest rates of low birthweights and preterm birth. The money is offered unconditionally. Participants are also offered a menu of other support — financial counseling and other programs, for instance — but they do not have to participate in them.

Briana Mitchell, a new enrollee whose fourth baby is due January 2, is using some of the money to move. When we spoke in September, she was doubled up with family. She will be relocating to a three-bedroom house, which wouldn’t have been possible without the Philly Joy Bank money, or the assistance from a program that provides security deposits. Mitchell, who works independently to do hair, does not have access to paid leave. Her husband, who recently started his own construction company, does not have access to paid leave either.  

“Entrepreneurs don’t get paid leave at all,” she said. 

And while she’s accustomed to working as much as possible — seeing as many as 20 clients in a three-day span — “I don’t have to do as much” because of the Philly Joy Bank funds, she said. “I don’t have to take as many people.”

Rx Kids, the Flint program, differs slightly from Philly Joy Bank’s design. For one, it’s universal: Every new mother in Flint is eligible. The initiative, launched in January, is a public-private partnership that uses $16.5 million of government Temporary Assistance for Needy Families (TANF) funding, earmarked for low-income people, over five years and $30 million in philanthropic and other funds, including corporations and American Rescue Plan money. Participants receive $1,500 once during the second trimester of pregnancy and $500 each month for the first year of their baby’s life. This money, too, is no-strings-attached.

 “Families have the freedom of choice to best meet their needs,” said Dr. Mona Hanna, Rx Kids cofounder and the associate dean of public health and professor at Michigan State University College of Human Medicine. Hanna, a pediatrician, identified elevated levels of lead in Flint’s children from the city’s water in 2015 and led a community initiative to respond to the crisis.

Luke Shaefer, a cofounder of the program and a professor of social justice and social policy and director of Poverty Solutions at the University of Michigan, identified an “obscure provision” in state TANF funds that allows families to receive four months of financial aid during an acute economic crisis without triggering time limits or work requirements. Shaefer and Hanna made the case that childbirth qualifies as an acute crisis. At that point, a person is at her poorest; earnings go down toward the end of pregnancy and mothers step out of the workforce, while babies also bring on additional costs. Yet pregnancy and the newborn period are “the most critical for child development,” Hanna said. “It’s crazy when you think of the science of it.” 

The philanthropic money Hanna and Shaefer raised enabled them to make the program available to every person who has a baby in Flint — as opposed to only those who would be eligible for Medicaid or a small pilot serving only a few families — and to extend the support to a year. The initiative, she said, is a “place-based intervention. It’s not about poor people, but about poor places.” The universality of the program is key, Hanna said. It “conveys dignity, as opposed to” programs “that convey shame or stigma.” More than 90 percent of newborns in Flint have participated since its inception — about 1,185 families.

So far, the program has shown a reduction in depressive symptoms and increases in positive wellbeing, with larger numbers of participants indicating that they feel loved, hopeful and respected. Preliminary outcomes also show lowered anxiety scores (though these findings were not statistically significant). Other data that’s still emerging shows lower rates of smoking during the third trimester and that mothers are starting their prenatal care earlier in their pregnancies. Shaefer adds that they’re seeing improvements in birth weight, with fewer babies born in the very lowest birthweight category (under 3 pounds, 4 ounces) and fewer extremely premature babies (those born before 28 weeks). Participating families have shown profound improvement in housing stability, and no low-income Rx Kids families have been evicted. 

Several other communities in Michigan are planning to adopt Rx Kids, Shaefer and Hanna said, including Kalamazoo, which will begin in February. Michigan Gov. Gretchen Whitmer included $20 million more TANF dollars in the state’s 2025 budget to make it possible to expand the program to other low-income parts of the state. Shaefer and Hanna have raised another $40 million to make that public-private partnership possible, and are still raising money to explore how such a program might work in rural parts of Michigan such as the Upper Peninsula. 

Dr. Stacey Kallem, director of the Philadelphia’s Department of Public Health’s Maternal, Child and Family Health division, said that if programs like Philly Joy Bank demonstrate their efficacy, they might also provide leverage to change how federal funding can be used for maternal-child health. Presently, many public maternal and child health funding mechanisms like the Healthy Start program cannot be used to give cash to people as guaranteed income programs. But, Kallem said, “if programs like ours show they’re effective,” and ultimately improve outcomes and save money for communities, “shouldn’t we change the way that government funding flows?” 

In that way, the cash transfer programs in Philadelphia and Flint attest to how nimble local governments can be, said Rachel Louise Moran, associate professor of history at the University of North Texas and author of “Blue: A History of Postpartum Depression.” Previous attempts to pass federal legislation supporting mothers with postpartum depression stumbled over unrelated issues that ultimately stripped the legislation of real power or funding or killed it altogether. 

“When you’re going big and national, you’re dealing with some really entrenched political issues,” she said. But with local governments, she points out, the “intense performing for CSPAN politics are not there.” 

That’s how the California Abundant Birth Project has functioned; the program, which provides no-strings-attached cash and started in 2021, has enrolled 561 mothers so far at risk of preterm birth in Alameda, Contra Costa, Los Angeles and Riverside Counties, who each receive money starting in their first or second trimester and lasting through the first year of the baby’s life. (Mothers in San Francisco, in Contra Costa County, receive $1,000 a month; mothers in other places receive slightly less.)

Doing this work requires overcoming an entrenched American ideology about maternal mental health, which is that it’s an individual, private problem — something a mother must overcome on her own. But that approach is inadequate, not least because the impacts of postpartum mood disorders extend far beyond a mother’s life and relationship to her child and last longer than the first few months after birth. 

But it also matters how and whether a city indicates that PPMDs are an issue of public health. On its city website, Santa Barbara includes information and links to Postpartum Education for Parents, one of the country’s earliest organized postpartum depression advocacy groups, that helps mothers with postpartum mood disorders; the City of Toronto does so too. In doing so, these cities demonstrate that PPMDs aren’t a private problem; they’re definitively a public issue, deserving not only of attention, but resources — a critical argument to make given that research and treatment of PPMDs has historically been underfunded. 

Still, the Philly Joy Bank, Rx Kids and Abundant Birth Fund initiatives differ from other supports because they provide cash unconditionally. That also stands out from the kind of support that large postpartum depression advocacy groups have pushed for, Moran points out. “The large organizations have had a very strong emphasis on bipartisan support for legislation, sometimes to the detriment of being able to think systemically,” she said. 

“I feel like [programs like] Philly Joy Bank should be everywhere,” Castillo said. “You can see the economy is bad. The cost of food is bad. And as you can see, these jobs are not paying [anything]. If they paid us more money, we could possibly make things happen, but we’re really making under what we should be making.” 

Which is why the extra money from Philly Joy Bank is so critical: “Having the extra money makes me feel less stressed,” she said. “Way less stressed.”