Saving Brains and unlocking human potential depends on reliable parental care that is sensitive to the developmental needs of children. In the context of poverty and high adversity the capacity of parents to provide the kind of care that promotes good child developmental outcome can be severely compromised. There is emerging evidence that sensitive maternal care and associated secure infant attachment are strong predictors of a range of child developmental outcomes, including child growth and physical health status, child cognitive development, and socio-emotional functioning.

In the original Thula Sana study,  arly mother-infant relationships in Khayelitsha, an impoverished South African peri-urban settlement, were found to be characterized by insensitive and unresponsive parenting, and a high rate of insecure infant attachment in this population. In response, the project team developed an intervention to address these disturbances. This manualized home-based intervention was designed to be suitable for routine delivery by community health workers within low resource settings.  The intervention consists of specific measures for encouraging mothers in sensitive, responsive, interactions with their infant. Now at 13 years of age, as part of the Saving Brains programme, the children have been re-assessed to see if this intervention has had any long-term outcome on child cognitive functioning, educational performance, mental health and risk behavior.

Funders

• The Wellcome Trust, United Kingdom, funded the initial project
• Grand Challenges Canada funded the 13 year follow up re-enrolment project

Key Partners

• Stellenbosch University, South Africa
• Winnicott Research Unit, University of Reading, UK
• Parent Centre, Cape Town, South Africa
• University of Cape Town, South Africa

The re-enrolment project has the following additional partners:

• University of Western Ontario, Canada
• University College London, UK
• Oxford University, UK
• Yale University, USA

Key Drivers

• The intervention was delivered by community health workers who were selected in conjunction with assistance from the local community council.
• The intervention was highly acceptable to the women receiving it, with very low dropout rates for those who did not move away.
• The CHWs underwent comprehensive general training in parenting and counseling skills, as well as in the delivery of the specific mother-infant intervention. They also participated in ongoing group supervision throughout the project.
• The intervention was developed and adapted from existing resources that had been widely used in other settings. [2, 3, 4]

Challenges

There are high levels of migration among women with young children in the project area, with many women travelling from low resourced, rural areas to use the relatively better resourced obstetric services in the city.  In many instances, these women then return to their rural homes while their children are infants.

In the randomized controlled trial assessing the efficacy of this intervention,  the intervention was found to be associated with significant benefit to the mother-infant relationship. [1] At both six and 12 months post-partum, compared to control mothers, in directly observed, videotaped, interactions with their infants, mothers in the intervention group were significantly more sensitive (6 months: p<.05, d=0.24; 12 months: p<.05, d=0.25) and less intrusive (6 months: p<.05, d=0.25; 12 months: p<.05, d=0.24). [6] The intervention was also associated with a higher rate of secure infant attachments at 18 months (i.e. 74% versus 63%; Wald=4.74, OR=1.70, p<.05). [6] There was also a benefit of the intervention in terms of maternal depressed mood at six months. With regard to child cognitive outcome, infant functioning was assessed with the Bayley Scales of Development (Mental Development Index) at 18 months. There was some evidence for the benefit of the intervention in relation to this outcome, even at this early stage: the mean MDI scores for infants in the intervention group was 85.25 (SD 10.87), while for the controls it was 83.10 (9.96), (F(261)=2.82, p = .094). When the level of family adversity was taken into account, this effect was found to be strengthened for those with less extreme family adversity: thus, for families experiencing less extreme adversity, the mean MDI score was 87.27 (11.16) in the intervention group, vs. 82.72 (10.72) in the control group (F(1,259)=4.98, p=.03).

At present, the intervention is being evaluated by assessing the long term impact on cognitive and socio-emotional development in the children who participated in the original project.  Thirteen years later, 75% of the original sample, has been re-recruited and a range of systematic standardized assessments have been completed to measure child cognitive functioning, school attainment, child emotional/behavioral functioning, the home environment, child health and growth, family functioning, as well as neural functions implicated in self-regulation (e.g. inhibitory control, self-monitoring, and working memory) and the stress response (e.g. cortisol secretion).  In addition, data has been collected from mothers on a range of other child and maternal outcomes.  The project team is currently in the process of analyzing these data.

• In the short term, it was found that mothers in the intervention group were significantly more sensitive in interaction with their infants, and their infants were significantly more likely to be securely attached.
• The project team is in the process of investigating the long-term impact of the programme.

1. Cooper et al (2009). Improving quality of mother-infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial. Brit Med J. 338: 974.
2. Murray, L. and E. Andrews, The Social Baby2002, London: The Children’s Project.
3. WHO, Improving the Psychosocial Development of Children, 1995: Geneva.
4. Brazelton, T.B. and J.K. Nugent, Neonatal behavioral assessment scale: clinics in developmental medicine1995, London: McKeith Press.