The quality of mother-child interactions can affect child developmental outcomes, both positively and negatively. Little research has examined the factors that influence the quality of mother-infant interactions, particularly in a low-middle income country. Therefore, we examined sociodemographic, maternal, and child variables, to determine whether these were associated with the quality of maternal-infant interactions. 256 mother-infant dyads enrolled in a South African birth cohort study, the Drakenstein Child Health Study, were assessed. A comprehensive battery of sociodemographic and psychosocial questionnaires was utilised. Video footage of interaction between mothers and infants at a 14-week postnatal visit was coded and assessed using the Global Rating Scale (GRS). Hierarchical multiple linear regression models were used to examine the factors associated with the GRS domains. The domains included: (1) maternal sensitivities (sensitivity, intrusiveness, remoteness, depressive mood), (2) infant behaviours (sensitivity, inertness, distress), and (3) maternal-infant interaction. Maternal childhood trauma and smoking during pregnancy were associated with lower domain scores for the maternal contribution. Higher birth weight and initiated breastfeeding were associated with higher domain scores for infant behaviours, while maternal IPV exposure, and smoking tobacco were associated with lower domain scores for infant behaviours. Infant weight-for-age at birth and initiated breastfeeding were positively associated with the dyadic interaction. Factors associated with early positive and negative mother-infant interaction identified in this research could potentially serve as targets for intervention, with the ultimate aim of improving child developmental outcomes. Notably, no psychosocial variables were significantly associated with the dyadic interactions, emphasising how strong such interactions can be in the face of multiple stressors.
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The quality of early mother-child interactions (consisting of the maternal contribution, the infant contribution, and the nature of the dyadic interaction) can positively or negatively affect child development outcomes (Gunning et al., 1999; Murray, Fiori‐Cowley, et al., 1996). Reliable and consistent maternal responses that are optimally attuned to the infant’s experience may lead to positive child outcomes with enduring benefits (Murray, Fiori‐Cowley et al., 1996). Conversely, insensitive, intrusive, or non-responsive maternal responses are associated with poorer attachment, development, and growth (Erickson et al., 2019).
In high income countries (The World Bank Group, 2023), multiple factors including maternal and infant physical factors, maternal psychosocial variables, and maternal substance use have been associated with quality of mother-infant interactions. Maternal age and breastfeeding, for example, may play an important role in mother-infant interactions. Older maternal age has been associated with more sensitivity and greater attunement to the infant, while younger age has been associated with less optimal parenting (Camberis et al., 2016). Breastfeeding has been associated with improved mother-infant bonding with more interactive behaviours (such as touching) and more affectionate responses to the child (Johnson, 2013). Maternal depression has been associated with negative interactions, disengaged interactions (maternal remoteness) with infants, and diminished maternal sensitivity (overall interactive behaviour in terms of warmth, acceptance, responsiveness, non-demanding behaviour, and sensitivity) (Coyl et al., 2002; Murray, Fiori‐Cowley et al., 1996; Siqveland et al., 2014). Maternal exposure to traumatic events and IPV have been associated with negative mother-infant interactions (Erickson et al., 2019; Tambelli et al., 2015). Furthermore, mothers with substance abuse may be less sensitive and emotionally involved with their infants (Siqveland et al., 2014), with postnatal tobacco use associated with lower emotional availability scores in mother-infant dyads (Rossen et al., 2019).
Recent estimates indicate that around 250 million children from low-middle income countries (The World Bank Group, 2023) are at risk for poor developmental outcomes (Black et al., 2017). There is evidence that low socioeconomic status and low-income households are associated not only with lower maternal sensitivity to infant cues and greater infant inertness during interactions (Schiffman et al., 2003; Tomlinson et al., 2005), but also with poorer child cognitive outcomes (Najman et al., 2009). In low-middle income countries (LMICs), mothers may have increased rates of exposure to poverty and psychosocial risk factors (maternal depression, trauma exposure, IPV), substance use, as well as higher rates of HIV, and these risk factors have been associated with poorer mother-infant interactions (Black et al., 2017; Schiffman et al., 2003; Tomlinson et al., 2005).
Factors that are associated with sensitive and responsive caregiving have also been associated with mother-infant interactions and infant outcomes. For example, in the Drakenstein Child Health Study, maternal exposure to childhood trauma was associated with poorer mother-infant interactions (Choi et al., 2022). Furthermore, in this study, several risk and protective factors were associated with child development. Such risk factors included maternal depression, maternal HIV infection, and intimate partner violence exposure, while protective factors included maternal education and higher socioeconomic status (Donald et al., 2019). Understanding the multiple factors associated with mother-infant interactions could serve as a starting point for interventions, with the aim of improving child developmental outcomes.
Currently, research investigating factors that may challenge the provision of sensitive and responsive caregiving in LMICs remains limited. While there has been work on maternal depression (Cooper et al., 1999), for example, other risk factors, such as initiated breastfeeding, intimate partner violence (IPV), maternal exposure to childhood trauma have not been as extensively examined. While it is possible that similar associations may be seen as have been found in high income countries, it is also possible that in contexts where severe psychosocial stressors are more endemic, sensitive and responsive caregiving remains possible despite such stressors. A number of LMIC studies have focused on particular variables (e.g., maternal depression or exposure to childhood trauma), but adjustment for additional variables may significantly affect findings, speaking to the need for further multivariate studies (Choi et al., 2022).
The Drakenstein Child Health Study (DCHS), a birth cohort study in South Africa (Zar et al., 2015), provides an opportunity to help address these gaps in the literature. Here, we aimed to employ data from the DCHS to investigate the association of sociodemographic variables (e.g., household income, SES), maternal and child physical variables (e.g., age, initiated breastfeeding, HIV status), maternal psychosocial variables (e.g., maternal depression, exposure to intimate partner violence, exposure to childhood trauma), and maternal substance abuse, with quality of maternal-infant interactions.
Methods
Participants
Methods of the DCHS are described in detail elsewhere (Donald et al., 2018; Stein et al., 2015; Zar et al., 2015). Briefly, pregnant women were recruited and enrolled between 20- and 28-weeks’ gestation at one of two South African primary healthcare clinics. Participants were at least 18 years of age at enrolment. Gestational age was assessed by a second trimester ultrasound or in the absence of that, by a calculation from last menstrual period. All births occurred at a single public hospital serving the area; clinical information at birth including birth weight was obtained by the study team A sub-sample of 256 randomly selected mother-infant dyads were recruited during the 14-week postnatal study visit.
Materials/measures
Sociodemographic information was obtained antenatally with a self-report questionnaire adapted from the South African Stress and Health Study (Myer et al., 2008) and includes age, education, income, current employment, and marital status. Composite scores were calculated to create four quartiles (lowest SES, low-moderate SES, moderate-high SES and high SES).
Clinical data such as breastfeeding (never breastfed or initiated breastfeeding) was collected at the 6–10-week postnatal visit, and HIV status was prospectively collected.
Depressive symptom severity was assessed using the Edinburgh Postnatal Depression Scale (Cox et al., 1987), a reliable self-report scale that has been validated for use in South African samples (de Bruin et al., 2004; Murray & Carothers, 1990). A standard cutoff of ≥13 was used to categorise participants into those with clinically significant antenatal depressive symptoms and those without clinically significant depressive symptoms (Cox et al., 1987; Hartley et al., 2011).
The frequency of antenatal intimate partner violence (IPV) experienced by participants in the preceding 12 months was evaluated with a questionnaire adapted from the WHO multi-country study (Jewkes, 2002), and the Women’s Health Study from Zimbabwe (Shamu et al., 2013). This assesses emotional, physical, and sexual abuse by one’s intimate partner on a 4-point frequency scale (never, once, few times, and many times). For the purposes of these analyses, scores within the mid (‘a few times’) and high (‘many times’) frequency categories were classified as above threshold. Participants who scored below threshold were considered as IPV-naïve and participants who scored above threshold were considered as IPV-exposed.
Maternal participants were assessed for exposure to childhood adversity antenatally using the Childhood Trauma Questionnaire (CTQ) (Bernstein et al., 1994). The CTQ screens for childhood trauma on five subscales (emotional, physical, and sexual abuse, and emotional and physical neglect). Each subscale was summed and cut-off scores for each domain were applied to define the severity of the abusive experiences (none/minimal, minor, moderate, and severe). For analyses, the ‘none/minimal’ range was defined as below threshold for a history of childhood trauma, whereas any other category was defined as above-threshold. Participants who scored below threshold were considered as childhood trauma free, and participants who scored above threshold were considered as childhood trauma-exposed. The CTQ demonstrates strong psychometric properties in community and clinical samples, and has often been used in South Africa (Baker & Maiorino, 2010).
Antenatal maternal substance use was determined using the WHO Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST; WHO ASSIST Working Group (2002)). The ASSIST was developed to detect psychoactive substance use in individuals as it screens for alcohol, tobacco, and illicit drugs such as cocaine, amphetamines, and opioids (Humeniuk et al., 2008). Lifetime and use within the previous 3 months are screened on a 5-point Likert scale. This measure has been validated for use in low-income communities (Van Der Westhuizen et al., 2016) (Fig. 1).
Fig. 1
Exposures and outcomes
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Procedure
At the 14-week postnatal visit, mothers and their infants were invited to take part in a short (5 min) standardised interaction video, as described by Murray, Stanley, et al. (1996) and Murray, Fiori‐Cowley, et al. (1996). For the present study, the video recordings took place in a private, quiet, and bland room at each study site. The video showed a full-face view of the infant and of the mother in profile. A mirror was placed adjacent to the infant’s seat so that the frame included the infant’s face and whole body, as well as a full-face reflection of the mother. Mothers were instructed to engage in play with their infants without the use of toys. Filming took place when the infant was awake, and interactions were recorded for 5 min. Videos of the dyadic interaction were coded and scored by a clinical psychologist (MS) who is an accredited GRS rater.
The Global Rating Scale (GRS) was used to assess mother-infant interactions in the video footage. The GRS was developed to assess differences in mother-infant interaction between groups of women with and without postnatal depression (Gunning et al., 1999; Murray, Fiori‐Cowley, et al., 1996) and has since been used in various clinical populations (Agostini et al., 2014; Gunning et al., 2004), including South African samples where it has demonstrated cross-cultural validity (Cooper et al., 1999). The GRS includes three domains: (1) the maternal contribution to the interaction, (2) the infant contribution to the interaction, and (3) nature of the dyadic interaction itself. The maternal dimension describes (1) maternal sensitivity as the overall interactive behaviour in terms of warmth, acceptance, responsiveness, non-demanding behaviour, and sensitivity, (2) maternal intrusiveness as the ability to balance intrusive behaviour and speech, (3) maternal remoteness as remote behaviour and silence towards the infant, and (4) maternal depressive mood as affective behaviour such as cheerfulness, energetic engagement, self-absorbed/non-absorbed behaviour, and a relaxed/tensed demeanour. The infant dimension describes (1) infant sensitivity as infant interactive behaviour such as attentiveness or avoidance, active verbal and non-verbal communication, and positive vocalization, (2) infant inertness as the infant’s engagement level, a lively or inert spirit, and their engagement with the environment, and (3) infant distress as the level of distress experienced by the infant in the interaction. The dyadic dimension assesses whether the interaction is smooth or difficult, fun, or serious, mutually satisfying, or unsatisfying; and the amount of excited and/or quiet engagement. Each domain is scored out of 5, with a low score of 1 indicating poorer interaction, and a high score of 5 indicating better interaction.
Scoring was completed by a clinical psychologist (MS) who received training from the developer of the GRS at Reading University (United Kingdom). During training and accreditation, raters are required to score training video material until they can demonstrate reliable scoring. MS was accredited to independently score video material after having achieved interclass correlations of 0.7 to 0.9 for all Global Rating Scale scales. At regular intervals, the rater sent some video and coding material to the University of Reading to ensure that reliability levels remained high. The rater was blinded to the participants’ clinical, psychosocial, and sociodemographic status.
Data Analysis
Analyses were conducted with STATA version 14.0. Pearson Chi-square test or Fisher Exact tests were used to determine if there were differences between categorical variables. Hierarchical multiple linear regression models were used to examine the factors associated with maternal sensitivities (mother sensitivity, intrusiveness, remoteness, and depressive mood), infant behaviours (infant sensitivity, inert, and distressed), and quality of maternal-infant interaction. Other variables were included in four blocks, namely (1) sociodemographic (household income, SES, maternal education, and partner support) information, (2) maternal and child physical measures (age, gestational age, weight-for-age-z-score, initiated breastfeeding, maternal HIV exposure), (3) maternal psychosocial risk factors (maternal depression, exposure to IPV, exposure to childhood trauma), and (4) maternal substance use (tobacco, alcohol, cannabis). Variables from each block, as well as the fit for the final model, were assessed by minimising the Akaike information criterion (AIC). P-values <= 0.05 were considered statistically significant. See Figure for full information on the blocks used in the analyses. Data was reported as collected; no data were imputed. The analysis was cross-sectional in nature. Cronbach’s Alpha was used to determine the internal consistency and scale reliability of the maternal (α = 0.80), infant (α = 0.88) and the combination of maternal and infant (α = 0.91) GRS measures in the current sample. Additionally, Cronbach Alpha was high for the IPV questionnaire (α = 0.90), EPDS (α = 0.91), CTQ (α = 0.87), and the ASSIST demonstrated Cronbach Alphas ranging from 0.81 to 0.95 for alcohol and illicit drugs. As Cronbach’s Alpha was greater than 0.8, this indicates that the scale would likely provide stable and consistence measurements.
Results
A total of 256 mother-infant dyads were included from January 2013 to June 2015. Sociodemographic and psychosocial data for the sample can be found in Table 1. The average maternal age was 27.17 years (SD = 5.68) and only 31.3% of the mothers completed secondary school. Almost 45% of the sample reported a household income of less than 1000 ZAR, and 24.6% mothers were HIV exposed. Almost a third (30.7%) of mothers scored above threshold for depression, and 33.1% experienced recent IPV, while 73.2% of mothers initiated breastfeeding, and 36.4% of mothers smoked during pregnancy. In the infant sample, 45.7% were female and the mean gestational age was 38.59 weeks (SD = 2.31).
Table 1
Sample characteristics
Total
(n = 256)
Maternal characteristics
Maternal age, mean (SD)
27.17 (5.68)
Maternal education
Primary
23 (9.0%)
Some secondary
139 (54.3%)
Completed secondary
80 (31.3%)
Tertiary
14 (5.5%)
Socio-economic quartile (SES)
Lowest
75 (29.3%)
Low-moderate
69 (27.0%)
Moderate-high
63 (24.6%)
High
49 (19.1%)
Household income
<1000 [ZAR]
114 (44.5%)
1000–5000 [ZAR]
117 (45.7%)
>5000 [ZAR]
25 (9.8%)
HIV+
63 (24.6%)
Partner support
None-slight
23 (9.8%)
Moderate-considerable
110 (47.0%)
Extreme
101 (43.2%)
Parity
None
83 (32.4%)
1 child
93 (36.3%)
2 children
51 (19.9%)
3 or more children
29 (11.3%)
Current breast feeding
183 (73.2%)
Psychosocial risk factors
Antenatal maternal depression
71 (30.7%)
Antenatal maternal IPV (recent)
77 (33.1%)
Maternal childhood trauma
74 (31.6%)
Substance use in pregnancy
Maternal smoking
91 (36.4%)
Maternal alcohol use
34 (14.7%)
Maternal cannabis use
7 (3.0%)
Infant characteristics
Sex - Female
117 (45.7%)
Gestational age, mean (SD) weeks
38.59 (2.31)
Preterm (<37 weeks)
40 (15.6%)
Weight for age Z-score (birth), mean (SD)
−0.61 (1.07)
HIV exposure
63 (24.6%)
Note. Means are presented with standard deviations in parentheses.
Table 2 highlights the GRS maternal sensitivity and infant behaviour outcomes.
Table 2
Global Rating Scale outcomes for mother-infant interactions
Total
(n = 256)
Maternal sensitivities
Sensitivity
3.06 (0.89)
Intrusive
3.12 (0.97)
Remote
3.52 (0.92)
Depressive mood
3.21 (0.81)
Infant behaviour
Sensitivity
2.83 (1.07)
Inert
3.00 (0.91)
Distressed
3.28 (0.96)
Maternal-infant interaction
2.77 (1.11)
Note. Means are presented with standard deviations in parentheses.
Factors Associated with Maternal Contribution
Maternal sensitivity
In the first block, partner support was found to be positively associated with maternal sensitivity, however, this association disappeared when variables from the second block were included. Gestational age (adjusted coefficient = 0.06, 95% CI: 0.00; 0.11, p = 0.03) and weight-for-age Z-score at birth (adjusted coefficient = 0.15, 95% CI: 0.03; 0.27, p = 0.015) were positively associated with maternal sensitivity. When maternal psychosocial risk factors were included, antenatal depression symptoms were negatively associated with maternal sensitivity. The association remained when substance use was included in the final model. The final, adjusted model increased maternal depressive symptoms were associated with lower maternal sensitivity (adjusted coefficient = −0.30, 95% CI: −0.57; −0.04, p = 0.026). See Table 1 of Supplemental Material for hierarchical regression tables.
Maternal intrusiveness
Partner support was found to be positively associated with maternal intrusive outcome in the first block. This association remained significant in block 2. Maternal age was positively associated with the intrusive score (adjusted coefficient = 0.03, 95% CI: 0.00; 0.05, p = 0.036) indicating that older mothers were less intrusive. In block 3 and 4, exposure to maternal childhood trauma was found to be inversely associated with maternal intrusiveness, with the strongest association in block 4 with substance abuse added (adjusted coefficient = −0.34, 95% CI: −0.62; −0.05, p = 0.02). In the final adjusted model, maternal exposure to childhood trauma and smoking during pregnancy and were found to be associated with more intrusive interactions (adjusted coefficient = −0.31, 95% CI: −0.61; −0.02, p = 0.035). See Table 2 of Supplemental Material for hierarchical regression tables.
Maternal remoteness
No psychosocial factors or substance use during pregnancy were associated with maternal remoteness. See Table 3 of Supplemental Material for hierarchical regression tables.
Maternal depressive mood
SES was positively associated with maternal depressive mood score, with those in higher quartiles displaying fewer signs of depressive mood. However, this association disappeared when additional variables were included in the model. See Table 4 of Supplemental Material for hierarchical regression tables.
Factors Associated with Infant Behaviours
Infant sensitivity
Gestational age and weight-for-age Z-score at birth were positively associated with infant sensitivity in block 2. Weight-for-age Z-score at birth remained significant in the model after including maternal psychosocial risk factors (adjusted coefficient = 0.18, 95% CI: 0.03; 0.033, p = 0.016). However, this association disappeared when maternal substance use was included in the final model. See Table 5 of Supplemental Material for hierarchical regression tables.
Infant inertness
Gestational age and weight-for-age Z-score at birth were both positively associated with the infant inertness score. These associations fell away once maternal substance use during pregnancy was included in the final model. In the final model, infants who were breastfed were less likely to display signs of inertness, relative to those who were not breastfed (adjusted coefficient = 0.31, 95% CI: 0.02; 0.61, p = 0.038). See Table 6 of Supplemental Material for hierarchical regression tables.
Infant distress
Gestational age was consistently found to be linked to lower infant distress (adjusted coefficient = 0.07, 95% CI: 0.01; 0.13, p = 0.03). In addition, maternal antenatal IPV exposure was found to be negatively associated with the infant distress score in block 3 (adjusted coefficient = −0.31, 95% CI: −0.60; −0.03, p = 0.032). This association remained after adjusting for maternal substance use during pregnancy (adjusted coefficient = −0.30, 95% CI: −0.59; −0.01, p = 0.042). In the final adjusted model, maternal smoking during pregnancy and maternal antenatal IPV exposure were associated with increased infant distress, while gestational age was associated with decreased infant distress (adjusted coefficient = −0.26, 95% CI: −0.65; −0.06, p = 0.018). See Table 7 of Supplemental Material for hierarchical regression tables.
Factors Associated with Maternal-infant Interaction
‘Moderate-considerate’ partner support was found to be associated with improved maternal-infant interaction in blocks 1, 2, and 3. Weight-for-age Z-score at birth (adjusted coefficient = 0.15, 95% CI: 0.02; 0.29, p = 0.03) and initiated breastfeeding (adjusted coefficient = 0.37, 95% CI: 0.01; 0.73, p = 0.042) were found to be positively associated with better maternal-infant interaction. However, when maternal substance abuse was added to the final model, initiated breastfeeding was associated with improved mother-infant interactions. See Table 8 of Supplemental Material for hierarchical regression tables.
Discussion
This study found that maternal childhood trauma and smoking during pregnancy were associated with lower domain scores for the maternal sensitivities. Higher birth weight and initiated breastfeeding were associated with higher domain scores for infant behaviours, while maternal IPV exposure and smoking tobacco were associated with lower domain scores for infant behaviours. Initiated breastfeeding and infant weight-for-age at birth were associated with improved dyadic interactions. Notably, psychosocial risk variables were not associated with the dyadic interaction.
Investigation of the maternal contribution to dyadic interactions indicated that greater maternal childhood trauma and smoking during pregnancy were associated with more intrusive parenting during interactions. Although previous studies have not reported more intrusive parenting associated with exposure to childhood trauma, it has been reported that mothers with exposure to childhood trauma have attachment disturbances that influence mother-infant interactions, resulting in emotionally distant mothering behaviours (DiLillo & Damashek, 2003; Erickson et al., 2019). To the best of our knowledge, these are the first data demonstrating an association of maternal smoking with more intrusive parenting during mother-infant interactions. Antenatal depression was associated with less sensitivity towards the infant, which is supported by some LMIC studies (Cooper et al., 1999). In our study, mothers with greater depression symptoms exhibited a less sensitive mothering styles which contrasts with findings from a high income country that depressed mothers were significantly more intrusive in their mothering style (Murray, Fiori‐Cowley, et al., 1996). Work demonstrating cultural differences in the way individuals express psychological distress may be relevant to understanding such cross-national divergence in mothering styles.
In this study, maternal antenatal IPV exposure was associated with increased infant distress during interactions, consistent with previous findings reported in a high income country (DeJonghe et al., 2005). Furthermore, infants who were breastfed were less inert, and higher birth weight was positively associated with infant sensitivity during these interactions. Research indicates that mothers who breastfeed are more attuned to their infant (Jansen et al., 2008; Johnson, 2013) and these mothers are aware of and more responsive to their infants (Brandt et al., 1998). We also found that smoking tobacco during pregnancy was associated with greater infant distress. There is a paucity of literature examining the associations of smoking with mother or infant contributions to mother-infant interactions. However, Rossen et al. (2019) reported that mothers who smoked exhibited less emotional availability in mother-infant bonding, relative to mothers who did not smoke.
When examining the dyadic interaction, we found that infant weight-for-age at birth and initiated breastfeeding were associated with improved mother-infant interaction. While there is little literature specifically exploring the relationship of infant weight with mother-infant interactions, this association might depend on a number of different mechanisms, including more well-developed nervous systems in infants who are appropriately weight-for-age. Mothers who breastfeed may be more attuned and responsive to their infants (Brandt et al., 1998; Jansen et al., 2008; Johnson, 2013), therefore positively impacting the mother-infant interaction. Notably, no psychosocial variables were significantly associated with the dyadic interaction, emphasizing that positive mother-infant interaction can occur, even in the face of multiple stressors.
A possible limitation of this study is that GRS was developed in the global north and may not accurately assess mother-infant interactions in our sample. For example, the scale gives a high score of 5 to a warm, affirming mother, and a low score of 1 to a cold, critical mother. But some of our study participants were noted to be both warm and at the same time critical, which would yield a score of 3, and not capture the precise nature of this possibly culture-specific interaction. Adaptations to the GRS may allow for greater cultural sensitivity. Similarly, the mothers in the present sample displayed high levels of verbal aggression during the interaction with their infant. The Global Rating Scale does not code for such aggression, which warrants further exploration in our context. Thirdly, rating of the video material was undertaken by one rater, with inter-rater reliability determined during training, rather than during assessment of the videos.
In conclusion, key factors associated with suboptimal mother-infant interactions were antenatal depression, maternal exposure to IPV and childhood trauma, and maternal smoking. These variables could potentially serve as targets for intervention, with the aim of improving child developmental outcomes. In particular, interventions such as educating and encouraging mothers to breastfeed for longer periods may improve mother-infant interactions. It is notable, however, that psychosocial risk variables were not associated with the dyadic interaction, challenging notions that multiple stressors in LMICs are necessarily associated with worse mother-infant interactions in this context.
Data Sharing
Collaborations for the analysis of data are welcome. The DCHS has a large and active group of investigators and postgraduate students, and many have successfully partnered with researchers from other institutions. We encourage collaborations that lead to skills transfer and capacity building for postgraduate students. Researchers who are interested in datasets or collaborations can contact the PI, Heather Zar (heather.zar@uct.ac.za) with a concept note outlining the request. More information can be found on our website (http://www.paediatrics.uct.ac.za/scah/dclhs).
We thank the mothers and their children for participating in the study and the study staff, the clinical and administrative staff of the Western Cape Government Health Department at Paarl Hospital and at the clinics for support of the study.
Compliance with Ethical Standards
Conflict of interest
The authors declare no competing interests.
Ethical approval
The DCHS was approved by the Faculty of Health Sciences, Human Research Ethics Committee, University of Cape Town and by the Western Cape Provincial Health Research committee.
Informed consent
Mothers provided informed consent at enrolment and were re-consented annually. Consent was done in mother’s preferred language: English, Afrikaans, or isiXhosa. All study procedures complied with the Declaration of Helsinki.
Ethics
The DCHS was approved by the Faculty of Health Sciences, Human Research Ethics Committee, University of Cape Town (401/2009) and by the Western Cape Provincial Health Research committee (2011RP45). Mothers provided informed consent at enrolment and were re-consented annually. Consent was done in mother’s preferred language: English, Afrikaans, or isiXhosa.
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