How have children and their health been developing in South Africa? "The Birth to Thirty study" has been tracking 3,273 newborns from 1990 to the present day. Erasmus MC collaborates in the Research for Health Impact in Africa program (RHIA), building on this extensive dataset. The data is being used to understand how early childhood interventions can improve the health and development of children in South Africa.
In 1990, Nelson Mandela was released from prison, and several years later, Apartheid in South Africa officially ended. That same year, the Birth to Thirty study began, with its participants often referred to as "Mandela’s Children". Following newborns from Soweto-Johannesburg over three decades, it is the largest and longest longitudinal study of its kind in Africa. Despite the official end of Apartheid, inequality remains deeply entrenched in South Africa, with many people still trapped in cycles of poverty and ill-health.
Inequalities persist
The Birth to Thirty study provides a wealth of data that quantifies and explains these persistent inequalities. 'A small group is thriving in modern-day South Africa, but we see that many black children are still unable to fully reach their potential', says Sara Naicker, a researcher at the Centre of Excellence in Human Development in South Africa. 'Often, they experience poorer health, lower educational attainment, limited employment opportunities, and greater exposure to violence. Where you are born plays a significant role in determining your future outcomes.'
From Health to Early Child Development
The study not only focuses on inequalities in health outcomes but also examines a broad range of factors that influence child development. 'Historically, global child health research has concentrated on child mortality', says Tanja Houweling, Assistant Professor at the Department of Public Health at Erasmus MC. 'But most children, even in the harshest conditions, survive. Now, we want to understand what makes a healthy and flourishing child. Early Child Development takes a more holistic approach, including social-emotional development, motor development and cognitive development, in addition to physical health.'
Research for Health Impact in Africa
The Department of Public Health, Erasmus MC (Dr. Tanja AJ Houweling), and the DSI-NRF Centre for Excellence in Human Development at the University of the Witwatersrand, South Africa (Dr. Sara Naicker and Prof. Linda Richter) collaborate in the ‘Research for Health Impact in Africa’ program. This program is supported by the D.P. Hoijer Fonds - a named fund at the Erasmus Trustfonds. They use Birth to Thirty data to support more effective policies for young children in South Africa and they strengthen the translation of scientific evidence into policy-making.
Linda Richter, one of the principal investigators and founders of Birth to Thirty, remains actively involved. Sara herself was only three years old when the cohort was set up. 'I’m now about the same age as the study participants. This underscores the exceptional duration of the Birth to Thirty study, which is truly one-of-a-kind. Often people lose interest, and it is hard to maintain funding. To collaborate with Erasmus MC in the Research for Health Impact in Africa program is a real joy. It’s great to see their interest in the data and their statistical expertise helps us get the most out of the data. There is much that hasn’t been explored yet.'
Some participants have become grandparents
Tanja specializes in socioeconomic inequalities in health and development during the first two decades of life, and the intergenerational transmission of socioeconomic and health (dis)advantages. Many of the study’s participants are now parents, and in some cases, even grandparents. 'Studying three generations is remarkable and provides a wealth of information. We are fortunate to collaborate with Sara and Linda, who bring invaluable expertise on early child development, on-the-ground knowledge and can offer essential context to the data.'
The Birth to Thirty cohort aims to understand how children develop into adults and answer questions like: Why do some become poor and others become rich? Why do some become healthy adults while others suffer from health problems? And why do some achieve higher education than others? By studying this, the researchers hope to generate evidence to support these children and help set up policies so that all children have equal opportunities.
Systems mapping: a key tool
One of the methods used in the RHIA project is systems mapping. Researchers create a web of all factors that influence child development, from the educational system and the level of social security to urban design, to understand the dynamics that lead to the intergenerational transmission of (dis)advantage and how to make policymaking more effective for sustainable change. 'A lot of people are living below the poverty line. We hope to contribute to breaking the cycle. That is what we try to do with systems mapping', says Sara. 'Not that there are any easy switches you can turn,” adds Tanja. 'Mapping this is insightful and encourages both researchers and policymakers from different disciplines to work together and get out of their comfort zones.'
Close relations with participants
The Bt30 staff developed close connections with the participants, as many from the same team that started the cohort are still involved. Sometimes this meant that they would catch children smoking and call the parents, or in some cases, participants disclosed abuse to researchers. Linda Richter bundled these stories in the book Birth to Thirty. Sara: 'We also saw markers of high blood pressure. We asked ourselves, do we sit and wait, or is it unethical not to act upon this? That is why we decided to propose an intervention study as well, which will hopefully be funded.'
Sara and Tanja hope the project will create more awareness of the importance of early child development. Researchers and practitioners in South Africa anticipate a policy shift, as the early childhood development portfolio has just transitioned to their Department of Education. The researchers believe integrated policies are needed, across sectors, including urban planning, social security, housing, and education, and this may be an opportune time. Sara: 'For sustained improvement, this is the way forward. We feel we have a real opportunity to give input to the new plans. If these policies reflect our findings and recommendations, that would be a really big win for us.'
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The Rotterdam Global Health Initiative (RGHI) is an academic network of global health research and education at Erasmus University and Erasmus MC. Our mission is to address and alleviate health inequalities worldwide, contributing to improved living conditions and advancing high-quality, equitable healthcare globally.