Child development and maternal wellbeing: family perspectives for low-income and middle-income countries
Authors: Maureen M Black, Pamela J Surkan
Journal: The Lancet Global Health (2015)

Throughout the world, families are central to children's development.1Bronfenbrenner U Ecology of the family as a context for human development: Research perspectives.Developmental Psychol. 1986; 22: 723-742Crossref Scopus (3714) Google Scholar In addition to health and nutrition, children gain cognitive, language, and personal–social skills through interactions with family members. When symptoms of maternal depression disrupt parenting interactions, children's health and development can be compromised.2Wachs T Black M Engle P Maternal Depression: a global threat to children's health, development, and behavior and to human rights.Child Dev Perspect. 2009; 3: 51-59Crossref Scopus (232) Google Scholar Despite the recognition that, in low-income and middle-income countries, millions of young children are not reaching their developmental potential3Grantham-McGregor S Cheung Y Cueto S Glewwe P Richter L Strupp B Over two hundred million children fail to reach their developmental potential in the first 5 years in developing countries.Lancet. 2007; 369: 60-70Summary Full Text Full Text PDF PubMed Scopus (1973) Google Scholar and that the prevalence of maternal depressive symptoms might exceed 50%,4Fisher J Cabral de Mello M Patel V et al.Prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: a systematic review.Bull World Health Organ. 2012; 90: 139G-149GCrossref PubMed Scopus (929) Google Scholar most intervention strategies have been directed towards the promotion of either early child development or maternal mental health, not both. The article by Daisy Singla and colleagues in The Lancet Global Health5Singla DR Kumbakumba E Aboud FE Effects of an integrated intervention on child development and maternal depressive symptoms in rural Uganda: a cluster-randomized trial.Lancet Glob Health. 2015; 3: e458-e469Summary Full Text Full Text PDF PubMed Scopus (166) Google Scholar is a striking example of an integrated, manualised maternal wellbeing and child development intervention in rural Uganda with beneficial effects on young children's cognitive and receptive language skills and on maternal depressive symptoms. Unlike most successful interventions delivered through home visits, this 12 session integrated intervention was delivered in a group format. Participants received activity booklets and encouragement to follow recommended activities, but no direct intervention. The changes in parenting practices (dietary diversity, preventive practices, stimulation, and maternal knowledge), plus the mediating effects of the Home Observation for Measurement of the Environment inventory on the children's development suggest that parents altered their parenting practices in response to the intervention, with beneficial effects on their children's receptive language and cognition. These findings are in contrast to the adage that direct intervention and practice are necessary to alter parenting behaviour and child development, and suggest that, in some cultures, group interventions are effective. There are at least four possible explanations for the beneficial effects of the group intervention. First, the maternal wellbeing intervention emphasised "love and respect" in a parent's relationships with self, child, and spouse, using a process that has been effectively implemented in other low-income and middle-income countries.6Rahman A Fisher J Bower P et al.Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis.Bull World Health Organ. 2013; 91: 593-601Crossref PubMed Scopus (219) Google Scholar By halting the increase in depressive symptoms reported by the control group, the intervention provides evidence that many maternal depressive symptoms are modifiable by group interventions delivered by community volunteers. Without depressive symptoms, mothers might have been receptive to the recommendations for stimulating activities with their children. Second, the intervention was delivered by community volunteers and administered through a local non-governmental organisation (NGO) that was committed to ongoing community involvement. Intervention success is dependent on quality.7Engle P Black M Behrman J et al.Strategies to avoid the loss of developmental potential among over 200 million children in the developing world.Lancet. 2007; 369: 230-242Summary Full Text Full Text PDF Scopus (684) Google Scholar In this Ugandan trial, quality was enhanced by the reputation, maturity, and education of the volunteers (mean age 36 years and mean education level eighth grade), a 14 day training period, and weekly supervision by NGO staff, including direct observations of 50% of the sessions. The attention to quality might have ensured the fidelity of the intervention delivery, with the professional support from the NGO to manage resistance or unanticipated events. Third, the intervention was offered to the entire community through a population-based approach, irrespective of maternal depressive symptoms or enrolment in the protocol. Evidence from prevention science8Rose GA The strategy of preventive medicine. Oxford University Press, New York1992Google Scholar suggests that reduction of the mean level of population risk factors can be more effective than the targeting of a vulnerable minority of high-risk families. In the Ugandan trial, the population-based group session format might have increased acceptance and facilitated a change in parenting norms, as friendships formed and social support was enhanced. Finally, one of the most innovative features of the study was the family focus, with sessions for fathers, sessions about mother–father communication, and men as community volunteers (seven of the 13 volunteers were men). Research across Africa9Ngwaru JM Promoting children's sustainable access to early schooling in Africa: reflections on the roles of parents in their children's early childhood care and education.New Dir Child Adolesc Dev. 2014; 146: 61-76Crossref Scopus (14) Google Scholar has shown that children's access to school and their academic success are dependent on supportive and engaged families. If the study improved couple relationships, which in turn resulted in better maternal wellbeing and parenting practices, child development could have been improved through enhanced family interactions. The findings from this intervention have shown that family perspective can effectively promote children's development, halt the progression of maternal depressive symptoms, and alter the underlying parenting and maternal care practices. The involvement of community volunteers in promoting maternal mental health is consistent with activities promoted by Africa Focus on Intervention Research for Mental health (AFFIRM), a collaborative research group that is attempting to narrow the treatment gap for mental health problems in Africa.10Lund C Alem A Schneider M et al.Generating evidence to narrow the treatment gap for mental disorders in sub-Saharan Africa: rationale, overview and methods of AFFIRM.Epidemiol Psychiatr Sci. 2015; 24: 233-240Crossref PubMed Scopus (65) Google Scholar Evidence from a meta-analytical review of programmes delivered by community health workers in low-income and middle-income countries suggests that perinatal depression can be reduced.6Rahman A Fisher J Bower P et al.Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis.Bull World Health Organ. 2013; 91: 593-601Crossref PubMed Scopus (219) Google Scholar Community volunteers have been successfully incorporated into the health-care system in many low-income and middle-income countries, including Uganda, where task shifting has been informally adopted.11Nabudere H Asiimwe D Mijumbi R Task shifting in maternal and child health care: An evidence brief for Uganda.Int J Technol Assess Health Care. 2011; 27: 173-179Crossref PubMed Scopus (36) Google Scholar However, the absence of unified policies, assessment, and incentives,11Nabudere H Asiimwe D Mijumbi R Task shifting in maternal and child health care: An evidence brief for Uganda.Int J Technol Assess Health Care. 2011; 27: 173-179Crossref PubMed Scopus (36) Google Scholar together with concerns about the sustainability of an unpaid work force12Kasteng F Settumba S Källander K Vassall A inSCALE Study GroupValuing the work of unpaid community health workers and exploring the incentives to volunteering in rural Africa.Health Policy Plan. 2015; (PII:czv042.)PubMed Google Scholar highlight the need to clarify the roles of community volunteers. Additional work is warranted to understand the roles that fathers have in their children's development and to identify strategies to involve fathers in parenting interventions. Future studies should examine the sustainability of group intervention effects, extend measures of child development to include additional domains, and employ standard methods to measure children's health and nutrition, including recumbent length for children younger than 2 years. The Ugandan trial makes a valuable contribution to the field of maternal wellbeing and child development. If replicated, such integrated, population-based, family-focused group interventions could be effective means of promoting maternal wellbeing and child development in low-income and middle-income countries. We declare no competing interests. Effects of a parenting intervention to address maternal psychological wellbeing and child development and growth in rural Uganda: a community-based, cluster-randomised trialThe 12 session integrated parenting intervention delivered by non-professional community members improved child development and maternal wellbeing in rural Uganda. Because this intervention was largely managed and implemented by a local organisation, using local community members and minimal resources, such a programme has the potential to be replicated and scaled up in other low-resource, village-based settings. Full-Text PDF Open Access