Contemporary prenatal care has made major contributions to maternal and infant health through advances in medical monitoring, risk assessment, and evidence-based intervention. However, within this framework, the fetus is typically positioned as an object of care. This paper proposes Responsive Prenatal Engagement (RPE) as a conceptual framework that reframes the fetus as a relational participant within an emerging parent-child relationship. RPE does not claim evidence of fetal consciousness, intentional communication, or prenatal memory. Rather, it offers a relational perspective for understanding how parents may engage with the unborn child during pregnancy. Drawing on clinical observation, obstetric practice, and scholarship in attachment, prenatal psychology, and early relational development, the framework is organized around three principles: recognition, inclusion, and engagement. These principles describe how parents may acknowledge the fetus as meaningfully present within family life before birth and how such a stance may shape prenatal experience. RPE is presented as a complementary lens to existing models such as prenatal attachment, reflective functioning, and nurturing care, with potential implications for prenatal education, family involvement, and future research.
Global attention on early child development, inclusive of those with disability, has the potential to translate into improved action for the millions of children with developmental disability living in low- and middle-income countries. Nurturing care is crucial for all children, arguably even more so for children with developmental disability. A high proportion of survivors of neonatal conditions such as prematurity and neonatal encephalopathy are affected by early child developmental disability. The first thousand days of life is a critical period for neuroplasticity and an important window of opportunity for interventions, which maximize developmental potential and other outcomes. Since 2010, our group has been examining predictors, outcomes, and experiences of neonatal encephalopathy in Uganda. The need for an early child intervention program to maximize participation and improve the quality of life for children and families became apparent. In response, the "ABAaNA early intervention program," (now re-branding as 'Baby Ubuntu') a group participatory early intervention program for young children with developmental disability and their families, was developed and piloted. Piloting has provided early evidence of feasibility, acceptability, and impact and a feasibility trial is underway. Future research aims to develop programmatic capacity across diverse settings and evaluate its impact at scale.
Cally J Tann, Maya Kohli-Lynch, Ruth Nalugya et al.
BACKGROUND: Millions of children globally are at risk of not reaching their developmental potential because of early adversities. We hypothesised that responsive caregiving and learning opportunities, components of nurturing care, at pre-school ages might mitigate the effects of adversities. METHODS: We analysed longitudinal birth cohort data from Brazil (1993 Pelotas Birth Cohort, n=632) and South Africa (Birth to Twenty Plus [Bt20+] Birth Cohort, n=1130) to assess whether responsive caregiving and learning opportunities at pre-school ages (2-4 years) modified associations between cumulative early adversities and adolescent human capital. The cumulative adversities score (range 0-9) included household wealth and crowding; mothers' schooling, height, age, and mental health; and children's birthweight, gestational age, and length at age 12 months. We extracted data on responsive caregiving and learning opportunities from the Early Childhood Home Observation for Measurement of the Environment inventory, assessed at age 4 years (1993 Pelotas cohort) and 2 years (Bt20+ cohort). We examined three human capital indicators: intelligence quotient (IQ) assessed at age 18 years (1993 Pelotas cohort) and 16 years (Bt20+ cohort); psychosocial adjustment assessed at age 15 years and 14 years, respectively; and height assessed at age 18 years and 16 years, respectively. We used linear models with interaction terms between cumulative adversities, and responsive caregiving and learning opportunities, to predict adolescent human capital. FINDINGS: For each additional Z score of total cumulative adversity, adolescent IQ decreased by 5·89 (95% CI -7·29 to -4·50) points in the 1993 Pelotas cohort (p<0·0001) and 2·69 (-4·52 to -0·86) points in the Bt20+ cohort (p=0·0039). After adjusting for total cumulative adversities, adolescent IQ points increased by 5·47 (95% CI 4·20 to 6·74) with each additional Z score of learning opportunities and by 2·26 (0·93 to 3·59) with each additional Z score of responsive caregiving in the 1993 Pelotas cohort, but not in the Bt20+ cohort (0·86 [-0·12 to 1·83] and 0·65 [-0·32 to 1·61], respectively). Associations between early adversities and IQ were modified by learning opportunities in the 1993 Pelotas cohort (beta coefficient for interaction 1·74, 95% CI 0·43 to 3·04; p=0·0092) and by responsive caregiving in the Bt20+ cohort (2·24, 0·94 to 3·54; p=0·0075). High nurturing environment attenuated the negative effects of early cumulative adversities on IQ. INTERPRETATION: Early nurturing home environments protect young children against effects of early adversities on adolescent IQ, with long-term positive associations on adolescent cognition in two middle-income countries. FUNDING: Bill & Melinda Gates Foundation.
Angela C. B. Trude, Linda Richter, Jere Richard Behrman et al.
Objective. The aim of this study was to carry out a survey on the guardians’ views on nurturing in primary schools. The focus was on three dimensions: guardians' views on nurturing in general, nurturing in primary school and co-operation, and the need for cooperation in primary school nurturing. The secondary aim was to investigate whether there were statistically significant differences between the guardians’ background variables, regarding their views on nurturing within these three dimensions, and whether correlations/relations could be identified. Research on nurturing in our primary schools was considered important because the curriculum for basic education in Finland describes the school as an nurturing arena, which is visible especially in the lower grades of primary school where nurturing is constantly present in both teaching and interaction, and emphasises individual national goals for nurturing. However, studies conducted in Sweden showed that teachers do not always agree, or are unsure, on how to approach the nurturing task.In Finland, guardians perceive the general co-operation between the school and home to relate specifically to the child's learning and success, but not to the child's overall well-being. The child's closest adults, in this case carers and teachers, play a major role in the child's learning, development and growth. Cooperation between home and school, including in nurturing, therefore plays a significant role in children's well-being and makes the theme important. The views of parents and carers were considered extremely important in order to get an overall picture of the situation regarding the theme. The studies and theories of Joyce L. Epstein on partnership serve as a theoretical frame of reference for this study. Methods. The research approach was mainly quantitative, with an electronic questionnaire as the primary data collection tool. The response options regarding education consisted of 5-point Likert scales. Most of the questions/statements also included an optional open comment field, which enabled the collection of qualitative data. Therefore, the study could also be seen as a mixed methods study. The voluntary comments were analysed phenomenographically to visualize the variety of views on nurturing in primary schools. A total of 144 respondents, carers, answered the questionnaire. Results and conclusions. According to the quantitative data, guardians' views on the nurturing role of schools were on average relatively positive. Guardians were somewhat satisfied with the nurturing in the school and were comfortable or somewhat comfortable with the nurturing role of the school in the specified themes. The need for closer co-operation regarding nurturing was moderately perceived. However, the qualitative data showed that a large proportion of the parents did not really know how the school worked regarding nurturing and therefore found it difficult to answer the questionnaire. A few carers also felt that nurturing is not really part of the school's mission, while a large proportion were very satisfied with the school's efforts in this area. On average, they seemed to have confidence in the nurturing role of the school and felt that it was a good support for the nurturing role of the home. On the whole, lack of time and insufficient communication were perceived as obstacles to cooperation. A statistically significant difference was found between school sizes and how comfortable guardians were regarding the nurturing theme: behaviour and etiquette. Carers with children in a small school were more comfortable with the nurturing role of the school in the stated theme than carers with children in a large school. The following correlations were identified: The better the child did in primary school, both academically but also socially and behaviourally, the more satisfied the parent was with the nurturing in the school, more comfortable with the stated nurturing themes and perceived the quality of nurturing in the school to be higher. The more positive the carer's attitude towards the curriculum's nurturing objectives, the more satisfied they were with the nurturing in primary school. The higher the guardian's perception of the quality of co-operation, the lower the need for co-operation and the more satisfied they were with primary school nurturing. Thus, the problem remained a lack of clarity about the school's approach to nurturing and mutual exchange between school and home. Improved dialogue and common guidelines could be crucial to strengthen cooperation, which in turn can have a positive impact on the holistic development of children.
Background: Caregivers in urban settings often face unique challenges in providing nurturing care. This qualitative study explores the complex realities of caregiving among mothers and grandmothers in urban poor neighbourhoods of Bangalore, South India. Grounded in Bronfenbrenner’s ecological systems theory, this is the first study in urban India that examines how caregivers’ perceptions, along with individual and systemic factors, shape caregiving practices in this setting. Methods: In-depth interviews (IDIs) were conducted with 22 mothers and grandmothers of 4–6-year-old children from the urban MAASTHI cohort in Bangalore, South India. Topic guides were developed, pre-tested, and piloted. IDIs were conducted in local languages (Kannada and Hindi). Transcripts were coded using NVivo 12 plus and analyzed via a thematic analysis approach using Bronfenbrenner’s ecological systems framework to organize themes. Findings: At the microsystem level, caregivers engaged with children through storytelling and play, though competing demands like household chores often constrained these interactions. Disciplining techniques varied, and the absence of fathers placed additional burdens on mothers. The mesosystem revealed the critical role of extended family in providing support. At the exosystem level, unsafe neighbourhoods limited children’s opportunities for outdoor play. The macrosystem highlighted how religious values provided moral frameworks for parenting and the presence of stigma against single mothers. The chronosystem explored declining social support over time and challenges. Conclusions: These findings emphasize that caregiving inequities are not isolated but structurally embedded, demanding interventions that address sociocultural, economic, and spatial barriers to equitable support for caregivers, particularly those in disadvantaged settings. It calls for context-sensitive interventions, including community-based parenting programmes including maternal well-being, strengthening community and public support systems, improving safe play spaces, and longitudinal research. By amplifying marginalized caregivers’ voices, this research highlights the need for policies that support nurturing care in low-resource settings to break intergenerational cycles of disadvantage.
Eunice Lobo, Giridhara R. Babu, Debarati Mukherjee et al.
Introduction: The first three years of a child's life are the most critical to child development and have an impact on the future achievement of the child. Young children's healthy development depends on nurturing care that ensures health, nutrition, responsive caregiving, safety, and security. Parents & other adult caregivers play a critical role in moderating children's early experiences, which has a lasting impact be it positive or negative on the children's future. Parenting education programs are proven to improve parental skills, capacity, and efficacy in a way that supports improved child development outcomes. Yet, most parents in low-middle-income countries such as Rwanda lack access to information and skills on how to support their children's holistic development. In response, Save The Children implemented the First Steps "Intera za Mbere" holistic parenting education project in Rwanda from 2014 to 2021. This paper reflects on how monitoring, evaluation, accountability, and learning (MEAL) approaches were applied throughout the project cycle and their impact on program improvement and national policy and advocacy. This paper explores how the aspirations for measurement for change, considerations for innovation uptake and frameworks for learning about improvement are reflected in this project. Methods: The project utilized qualitative and quantitative MEAL across the program cycle. Action research at the start of the project identified promoters and inhibitors of high-quality nurturing care and program delivery modalities. The project utilized a randomized control trial to provide insight into components that work better for parenting education. Evidence from surveys done remotely via phones was used to inform COVID-19 adaptations of the program. Results: The application of MEAL evidence led to the successful development and improvement of the program. At the policy level, evidence from the project influenced the review of the 2016 National Integrated ECD policy and the development of the national parenting education framework. Conclusion: The regular use of evidence from MEAL is critical for program improvement, scale-up, and policy influence.
Caroline Dusabe, Monique Abimpaye, Noella Kabarungi et al.
The Moments that Matter® parenting program aims to promote nurturing care and healthy early childhood development (ECD) through monthly home visits and monthly community group meetings that are delivered by ECD promoters and coordinated with faith leaders in rural Western Kenya. We designed a process evaluation in August 2023 during the first quarter of program implementation. We conducted in-depth interviews and focus group discussions with caregivers, ECD promoters, faith leaders, and program staff to capture their program experiences, assess program quality, and explore the implementation barriers and facilitators during this early stage of program roll-out. Although ECD promoters delivered the program with fidelity, the roles and responsibilities of faith leaders were relatively weaker and inconsistent. Key facilitators of quality implementation included visual aids of key messages and supportive supervision. Barriers included a lack of clarity about faith leaders' roles and relatively long group session duration. We highlight several key recommendations for improving fidelity, quality, and eventual program effects with respect to enhancing nurturing care and early child development. Overall, our study showcases how a process evaluation conducted during the early phase of program implementation can reveal practical insights that can be used to inform program adaptations and quality improvement.
Joshua Jeong, Juliet K. McCann, Alina Bhojani et al.
With an increasing awareness of the importance of nurturing care and within a framework of Infant- and Family-Centred Developmental Care (IFCDC), zero separation, keeping parent and infant in continuous close physical and psychological proximity to each other, is key. In modern neonatology, high technological and pharmaceutical treatments are consistently integrated with caregiving considerations. Mother-Newborn Couplet Care is a concept of care where the dyad of the ill or prematurely born infant and the mother, needing medical care of her own, are cared for together, from the birth of the baby to its discharge. Mother-Newborn Couplet Care requires systems changes in both obstetrics and paediatrics considering planning and organisation of care, equipment and design of units. Accordingly, strong leadership setting clear goals and changing the professional mindset by providing targeted education and training is crucial to ensure the warranted high quality of care of all mother-baby dyads.
Preterm infants have maturational delays in several neurobehavioral systems. This study assesses the impact of the Family Nurture Intervention (FNI) in the neonatal intensive care unit (NICU) on the maturation of autonomic regulation of preterm infants. Preterm infants born at 26-34 weeks postmenstrual age (PMA) were assigned to groups receiving either standard care (SC) or SC plus FNI, using a randomized controlled trial design. At two collection time points, approximately 35 weeks and 41 weeks PMA, electrocardiograms (ECG) were monitored for approximately 1 hour during sleep. Heart rate and respiratory sinus arrhythmia (RSA) were quantified from the ECG. Across the two time points, the FNI group exhibited greater increases in RSA (Cohen's d = 0.35) and slope between RSA and heart rate, as a measure of vagal efficiency (Cohen's d = 0.62). These results document that FNI resulted in enhanced autonomic regulation consistent with greater maturation of cardiac function. These and previous findings strongly suggest that facilitating early nurturing interactions and emotional connection between preterm infants and their mothers is a practicable and effective means of optimizing postnatal development in preterm infants. Interpretation of these autonomic function results also enriches our understanding of the potential long-term beneficial outcomes of FNI by drawing upon polyvagal theory, which explains how autonomic state provides a neurophysiological platform for optimal co-regulation between infant and caregiver, and by drawing upon calming cycle theory, which provides a model for understanding how repeated mother/infant calming interactions positively condition autonomic state and reinforce approach, prosocial behaviors.
Stephen W. Porges, Maria I. Davila, Gregory F. Lewis et al.
Introduction: Early childhood development is a crucial period in a child's life, forming the basis for their future growth and overall well-being. Research has highlighted the significant impact of healthcare settings on a child's health. However, limited literature exists on the evaluation of healthcare professionals' understanding and perspectives concerning early childhood development in Pakistan, despite its proven significance in other nations. Therefore, our study aimed to evaluate the awareness and attitude of healthcare providers employed at secondary hospitals regarding early childhood development.Methods: A sequential explanatory mixed-method research approach was utilized. Initially, the population of healthcare workers, including physicians, nurses, trainees, and midwives, currently serving at secondary hospitals in the Garden and Karimabad regions, was recruited to complete the CKCDI questionnaire. This questionnaire was specifically designed to evaluate their knowledge of early childhood development. Subsequently, a semi-structured interview guide was employed to conduct interviews and gather insights into their perceptions concerning the concepts of ECD and their practices. The results were analyzed using SPSS software to determine the mean and standard deviation for knowledge, while themes were derived from the dialogues of the healthcare professionals.Results: The results of the study reveal a concerning trend in the knowledge levels of healthcare professionals, with 125 out of 159 participants demonstrating a low understanding of Early Childhood Development (ECD). Moreover, a minimal number of participants, only 3 individuals, reported having attended any specific ECD training. Through the qualitative interviews, several key themes emerged, shedding light on the complex landscape of ECD in the context of secondary care hospitals. These themes included the importance of nurturing care by parents and caregivers, emphasizing the critical roles of parenting and caregiving as well as the Doctor[1]Patient/Caregiver relationship. Additionally, the study uncovered insights into the knowledge and practices of healthcare workers, emphasizing the need for continuous 9 learning and training programs to improve ECD practices. The integration of early childhood services within secondary hospitals revealed various challenges and barriers, highlighting the importance of healthcare professional and caregiver engagement. Furthermore, the study emphasized the significance of national policies for ECD implementation, focusing on ensuring access and equity, as well as proper funding and resource allocation for effective ECD services within the healthcare system.Conclusion: In conclusion, this extensive research has highlighted significant findings regarding early childhood development (ECD) in the healthcare sector. The study underscores the crucial need for comprehensive educational interventions and continuous training programs to bridge the evident knowledge gap among healthcare professionals. While healthcare providers exhibit a fundamental understanding of ECD, time constraints often limit their ability to provide comprehensive guidance to caregivers and parents. Additionally, advocating for parenting interventions has emphasized their potential in nurturing healthier parent-child interactions and improving parenting practices. Addressing these identified challenges is vital for creating a nurturing environment that supports the optimal growth and development of young children, emphasizing the importance of targeted initiatives and policy measures within healthcare institutions. Effective approach to promoting Early Childhood Development (ECD) involves organizing regular workshops and seminars for healthcare professionals, along with integrating ECD modules into medical education. Furthermore, implementing a robust monitoring and evaluation system can help assess the effectiveness of EC
