Risk and protective factors for child development: An observational South African birth cohort

Autoři: Kirsten Ann Donald aff001;  Catherine J. Wedderburn aff001;  Whitney Barnett aff001;  Raymond T. Nhapi aff001;  Andrea M. Rehman aff005;  Jacob A. M. Stadler aff001;  Nadia Hoffman aff006;  Nastassja Koen aff006;  Heather J. Zar aff001;  Dan J. Stein aff006
Působiště autorů: Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, Cape Town, South Africa aff001;  Neuroscience Institute, University of Cape Town, Cape Town, South Africa aff002;  Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom aff003;  Unit on Child and Adolescent Health, South African Medical Research Council (SAMRC), Cape Town, South Africa aff004;  Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom aff005;  Department of Psychiatry and Mental Health, University of Cape Town, South Africa aff006;  Unit on Risk and Resilience in Mental Disorders, South African Medical Research Council (SAMRC), Cape Town, Cape Town, South Africa aff007
Vyšlo v časopise: Risk and protective factors for child development: An observational South African birth cohort. PLoS Med 16(9): e32767. doi:10.1371/journal.pmed.1002920
Kategorie: Research Article
doi: 10.1371/journal.pmed.1002920



Approximately 250 million (43%) children under the age of 5 years in low- and middle-income countries (LMICs) are failing to meet their developmental potential. Risk factors are recognised to contribute to this loss of human potential. Expanding understanding of the risks that lead to poor outcomes and which protective factors contribute to resilience in children may be critical to improving disparities.

Methods and findings

The Drakenstein Child Health Study is a population-based birth cohort in the Western Cape, South Africa. Pregnant women were enrolled between 20 and 28 weeks’ gestation from two community clinics from 2012 to 2015; sociodemographic and psychosocial data were collected antenatally. Mothers and children were followed through birth until 2 years of age. Developmental assessments were conducted by trained assessors blinded to background, using the Bayley-III Scales of Infant and Toddler Development (BSID-III), validated for use in South Africa, at 24 months of age. The study assessed all available children at 24 months; however, some children were not able to attend, because of loss to follow-up or unavailability of a caregiver or child at the correct age. Of 1,143 live births, 1,002 were in follow-up at 24 months, and a total of 734 children (73%) had developmental assessments, of which 354 (48.2%) were girls. This sample was characterised by low household employment (n = 183; 24.9%) and household income (n = 287; 39.1% earning <R1,000 per month), and high prevalence of maternal psychosocial risk factors including alcohol use in pregnancy (n = 95; 14.5%), smoking (n = 241; 34.7%), depression (n = 156; 23.7%), lifetime intimate partner violence (n = 310; 47.3%), and history of maternal childhood trauma (n = 228; 34.7%). A high proportion of children were categorised as delayed (defined by scoring < −1 standard deviation below the mean scaled score calculated using the BSID-III norms from a United States population) in different domains (369 [50.5%] cognition, 402 [55.6%] receptive language, 389 [55.4%] expressive language, 169 [23.2%] fine motor, and 267 [38.4%] gross motor). Four hundred five (55.3%) children had >1 domain affected, and 75 (10.2%) had delay in all domains. Bivariate and multivariable analyses revealed several factors that were associated with developmental outcomes. These included protective factors (maternal education, higher birth weight, and socioeconomic status) and risk factors (maternal anaemia in pregnancy, depression or lifetime intimate partner violence, and maternal HIV infection). Boys consistently performed worse than girls (in cognition [β = −0.74; 95% CI −1.46 to −0.03, p = 0.042], receptive language [β = −1.10; 95% CI −1.70 to −0.49, p < 0.001], expressive language [β = −1.65; 95% CI −2.46 to −0.84, p < 0.001], and fine motor [β = −0.70; 95% CI −1.20 to −0.20, p = 0.006] scales). There was evidence that child sex interacted with risk and protective factors including birth weight, maternal anaemia in pregnancy, and socioeconomic factors. Important limitations of the study include attrition of sample from birth to assessment age and missing data in some exposure areas from those assessed.


This study provides reliable developmental data from a sub-Saharan African setting in a well-characterised sample of mother–child dyads. Our findings highlight not only the important protective effects of maternal education, birth weight, and socioeconomic status for developmental outcomes but also sex differences in developmental outcomes and key risk and protective factors for each group.

Klíčová slova:

anémia – Birth weight – Depression – Child development – Children – Language – Medical risk factors – Pregnancy


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