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


1. Black MM, Walker SP, Fernald LCH, Andersen CT, DiGirolamo AM, Lu C, et al. Early childhood development coming of age: science through the life course. The Lancet. 2017;389(10064):77–90.

2. Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B. Developmental potential in the first 5 years for children in developing countries. The Lancet. 2007;369(9555):60–70.

3. Walker SP, Wachs TD, Grantham-McGregor S, Black MM, Nelson CA, Huffman SL, et al. Inequality in early childhood: risk and protective factors for early child development. The Lancet. 2011;378(9799):1325–38.

4. McDonald S, Kehler H, Bayrampour H, Fraser-Lee N, Tough S. Risk and protective factors in early child development: Results from the All Our Babies (AOB) pregnancy cohort. Res Dev Disabil. 2016;58:20–30. doi: 10.1016/j.ridd.2016.08.010 27587353

5. Ngure FM, Reid BM, Humphrey JH, Mbuya MN, Pelto G, Stoltzfus RJ. Water, sanitation, and hygiene (WASH), environmental enteropathy, nutrition, and early child development: making the links. Ann N Y Acad Sci. 2014;1308:118–28. doi: 10.1111/nyas.12330 24571214

6. Glover V., Hill J. Sex differences in the programming effects of prenatal stress on psychopathology and stress responses: an evolutionary perspective. Physiol. Behav. 2012;106(5):736–740. doi: 10.1016/j.physbeh.2012.02.011 22353310

7. Evans GW, Li D, Whipple SS. Cumulative risk and child development. Psychol Bull. 2013;139(6):1342–96. doi: 10.1037/a0031808 23566018

8. Di Rosa G, Pironti E, Cucinotta F, Alibrandi A, Gagliano A. Gender affects early psychomotor milestones and long‐term neurodevelopment of preterm infants. Inf Child Dev. 2018;28(1):e2110.

9. Weber A, Darmstadt GL, Rao N. Gender disparities in child development in the east Asia-Pacific region: a cross-sectional, population-based, multicountry observational study. The Lancet Child & Adolescent Health. 2017;1(3):213–24.

10. Hawkes SJ, Buse K. Analysis of gender in health and development. Lancet Child Adolesc Health. 2017;1(3):166–7. doi: 10.1016/S2352-4642(17)30072-X 30169162

11. Bhopal S, Roy R, Verma D, Kumar D, Avan B, Khan B, et al. Impact of adversity on early childhood growth & development in rural India: Findings from the early life stress sub-study of the SPRING cluster randomised controlled trial (SPRING-ELS). PLoS ONE. 2019;14(1):e0209122. doi: 10.1371/journal.pone.0209122 30625145

12. Health TPfMNC. The Global Strategy For Women’s, Children’s and Adolescents’ Health (2016–2030). Available from: http://www.who.int/pmnch/activities/advocacy/globalstrategy/2016_2030/en/.

13. Richter LM, Daelmans B, Lombardi J, Heymann J, Boo FL, Behrman JR, et al. Investing in the foundation of sustainable development: pathways to scale up for early childhood development. Lancet. 2017;389(10064):103–18. doi: 10.1016/S0140-6736(16)31698-1 27717610

14. Zar HJ, Barnett W, Myer L, Stein DJ, Nicol MP. Investigating the early-life determinants of illness in Africa: the Drakenstein Child Health Study. Thorax. 2015;70(6):592–4. doi: 10.1136/thoraxjnl-2014-206242 25228292

15. Stein DJ, Koen N, Donald KA, Adnams CM, Koopowitz S, Lund C, et al. Investigating the psychosocial determinants of child health in Africa: The Drakenstein Child Health Study. Journal of neuroscience methods. 2015;252:27–35. doi: 10.1016/j.jneumeth.2015.03.016 25797842

16. Donald KA, Hoogenhout M, du Plooy CP, Wedderburn CJ, Nhapi RT, Barnett W, et al. Drakenstein Child Health Study (DCHS): investigating determinants of early child development and cognition. BMJ Paediatr Open. 2018;2(1):e000282. doi: 10.1136/bmjpo-2018-000282 29942867

17. Myer L, Stein DJ, Grimsrud A, Seedat S, Williams DR. Social determinants of psychological distress in a nationally-representative sample of South African adults. Soc Sci Med. 2008;66(8):1828–40. doi: 10.1016/j.socscimed.2008.01.025 18299167

18. Vanker A, Barnett W, Nduru PM, Gie RP, Sly PD, Zar HJ. Home environment and indoor air pollution exposure in an African birth cohort study. Sci Total Environ. 2015;536:362–7. doi: 10.1016/j.scitotenv.2015.06.136 26231768

19. Victora CG, Bahl R, Barros AJ, Franca GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475–90. doi: 10.1016/S0140-6736(15)01024-7 26869575

20. WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System (VMNIS). 2011.

21. Perkins JM, Kim R, Krishna A, McGovern M, Aguayo VM, Subramanian SV. Understanding the association between stunting and child development in low- and middle-income countries: Next steps for research and intervention. Soc Sci Med. 2017;193:101–9. doi: 10.1016/j.socscimed.2017.09.039 29028557

22. Myers B, Koen N, Donald KA, Nhapi RT, Workman L, Barnett W, et al. Effect of Hazardous Alcohol Use During Pregnancy on Growth Outcomes at Birth: Findings from a South African Cohort Study. Alcohol Clin Exp Res. 2018;42(2):369–77. doi: 10.1111/acer.13566 29197115

23. Donald KA, Fouche JP, Roos A, Koen N, Howells FM, Riley EP, et al. Alcohol exposure in utero is associated with decreased gray matter volume in neonates. Metab Brain Dis. 2016;31(1):81–91. doi: 10.1007/s11011-015-9771-0 26616173

24. Jewkes R. Intimate partner violence: causes and prevention. Lancet. 2002;359(9315):1423–9. doi: 10.1016/S0140-6736(02)08357-5 11978358

25. Shamu S, Abrahams N, Temmerman M, Musekiwa A, Zarowsky C. A systematic review of African studies on intimate partner violence against pregnant women: prevalence and risk factors. PLoS ONE. 2011;6(3):e17591. doi: 10.1371/journal.pone.0017591 21408120

26. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. The British journal of psychiatry: the journal of mental science. 1987;150:782–6.

27. Lawrie TA, Hofmeyr GJ, de Jager M, Berk M. Validation of the Edinburgh Postnatal Depression Scale on a cohort of South African women. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde. 1998;88(10):1340–4. 9807193

28. Tsai AC, Scott JA, Hung KJ, Zhu JQ, Matthews LT, Psaros C, et al. Reliability and validity of instruments for assessing perinatal depression in African settings: systematic review and meta-analysis. PLoS ONE. 2013;8(12):e82521. doi: 10.1371/journal.pone.0082521 24340036

29. Murray D, Cox JL. Screening for depression during pregnancy with the Edinburgh Depression Scale (EDDS). J Reprod Infant Psychol. 1990;8(2);99–107.

30. Bernstein DP, Fink L, Handelsman L, Foote J, Lovejoy M, Wenzel K, et al. Initial reliability and validity of a new retrospective measure of child abuse and neglect. The American journal of psychiatry. 1994;151(8):1132–6. 8037246

31. Beusenberg M, Orley JH. A user's guide to the self reporting questionnaire (SRQ). Geneva: World Health Organization, Division of Mental Health; 1994.

32. Ventevogel P, De Vries G, Scholte WF, Shinwari NR, Faiz H, Nassery R, et al. Properties of the Hopkins Symptom Checklist-25 (HSCL-25) and the Self-Reporting Questionnaire (SRQ-20) as screening instruments used in primary care in Afghanistan. Social psychiatry and psychiatric epidemiology. 2007;42(4):328–35. doi: 10.1007/s00127-007-0161-8 17370049

33. Bayley N. Bayley scales of infant and toddler development, Technical manual. 3rd ed. Bloomington, MN: NCS Pearson; 2006.

34. Ballot DE, Potterton J, Chirwa T, Hilburn N, Cooper PA. Developmental outcome of very low birth weight infants in a developing country. BMC Pediatr. 2012;12:11. doi: 10.1186/1471-2431-12-11 22296705

35. Rademeyer V, Jacklin L. A study to evaluate the performance of black South African urban infants on the Bayley Scales of Infant Development III. South African Journal of Child Health. 2013;7(2):54–9.

36. Albers CA, Grieve A J. Review of Bayley Scales of Infant and Toddler Development—Third Edition. Journal of Psychoeducational Assessment. 2007;25(2):180–90.

37. Chopra M. Risk factors for undernutrition of young children in a rural area of South Africa. Public Health Nutrition. 2006;6(7):645–652.

38. Lawless JF, Singhal K. Efficient Screening of Nonnormal Regression Models. Biometrics. 1978;34(2):318–27.

39. Furnival GM, Wilson RWJ. Regressions by Leaps and Bounds. Technometrics. 1974;16(4):499–511.

40. StataCorp. Stata Statistical Software: Release 14. College Station, TX: StataCorp; 2015.

41. McCoy DC, Peet ED, Ezzati M, Danaei G, Black MM, Sudfeld CR, et al. Early Childhood Developmental Status in Low- and Middle-Income Countries: National, Regional, and Global Prevalence Estimates Using Predictive Modeling. PLoS Med. 2016;13(6):e1002034. doi: 10.1371/journal.pmed.1002034 27270467

42. WHO. Nurturing care for early childhood development: Linking survive and thrive to transform health and human potential. 2018. Available from: https://www.who.int/maternal_child_adolescent/child/nurturing-care-framework/en/.

43. Britto PR, Lye SJ, Proulx K, Yousafzai AK, Matthews SG, Vaivada T, et al. Nurturing care: promoting early childhood development. The Lancet. 2017;389(10064):91–102.

44. Benki-Nugent S, Wamalwa D, Langat A, Tapia K, Adhiambo J, Chebet D, et al. Comparison of developmental milestone attainment in early treated HIV-infected infants versus HIV-unexposed infants: a prospective cohort study. BMC Pediatr. 2017;17(1):24. doi: 10.1186/s12887-017-0776-1 28095807

45. Evans C, Jones CE, Prendergast AJ. HIV-exposed, uninfected infants: new global challenges in the era of paediatric HIV elimination. Lancet Infect Dis. 2016;16(6):e92–e107. doi: 10.1016/S1473-3099(16)00055-4 27049574

46. le Roux SM, Donald KA, Brittain K, Phillips TK, Zerbe A, Nguyen KK, et al. Neurodevelopment of breastfed HIV-exposed uninfected and HIV-unexposed children in South Africa. AIDS. 2018;32(13):1781–91. doi: 10.1097/QAD.0000000000001872 29794831

47. Brittain K, Myer L, Koen N, Koopowitz S, Donald KA, Barnett W, et al. Risk Factors for Antenatal Depression and Associations with Infant Birth Outcomes: Results From a South African Birth Cohort Study. Paediatr Perinat Epidemiol. 2015;29(6):505–14. doi: 10.1111/ppe.12216 26236987

48. Koen N, Brittain K, Donald KA, Barnett W, Koopowitz S, Mare K, et al. Maternal posttraumatic stress disorder and infant developmental outcomes in a South African birth cohort study. Psychol Trauma. 2017;9(3):292–300. doi: 10.1037/tra0000234 28459271

49. Levendosky AA, Bogat GA, Martinez-Torteya C. PTSD symptoms in young children exposed to intimate partner violence. Violence against women. 2013;19(2):187–201. doi: 10.1177/1077801213476458 23420836

50. Osofsky JD. Prevalence of children's exposure to domestic violence and child maltreatment: implications for prevention and intervention. Clinical child and family psychology review. 2003;6(3):161–70. 14620577

51. Kernic MA, Holt VL, Wolf ME, McKnight B, Huebner CE, Rivara FP. Academic and school health issues among children exposed to maternal intimate partner abuse. Archives of pediatrics & adolescent medicine. 2002;156(6):549–55.

52. Yount KM, DiGirolamo AM, Ramakrishnan U. Impacts of domestic violence on child growth and nutrition: a conceptual review of the pathways of influence. Soc Sci Med. 2011;72(9):1534–54. doi: 10.1016/j.socscimed.2011.02.042 21492979

53. Wright RJ. Epidemiology of stress and asthma: from constricting communities and fragile families to epigenetics. Immunol Allergy Clin North Am. 2011;31(1):19–39. doi: 10.1016/j.iac.2010.09.011 21094921

54. Darmstadt GL, Khan NZ, Lombardi J, Richter LM. Scaling up early childhood development programmes in low and middle-income countries. Child Care Health Dev. 2018;44(1):1–3. doi: 10.1111/cch.12441 29235168

Interní lékařství

Článek vyšel v časopise

PLOS Medicine

2019 Číslo 9
Nejčtenější tento týden
Nejčtenější v tomto čísle

Zvyšte si kvalifikaci online z pohodlí domova

Deprese u dětí a adolescentů
nový kurz
Autoři: MUDr. Vlastimil Nesnídal

Konsenzuální postupy v léčbě močových infekcí

COVID-19 up to date
Autoři: doc. MUDr. Vladimír Koblížek, Ph.D., MUDr. Mikuláš Skála, prof. MUDr. František Kopřiva, Ph.D., prof. MUDr. Roman Prymula, CSc., Ph.D.

Betablokátory a Ca antagonisté z jiného úhlu
Autoři: prof. MUDr. Michal Vrablík, Ph.D., MUDr. Petr Janský

Chronické žilní onemocnění a možnosti konzervativní léčby

Všechny kurzy
Zapomenuté heslo

Nemáte účet?  Registrujte se

Zapomenuté heslo

Zadejte e-mailovou adresu, se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.


Nemáte účet?  Registrujte se