Discussion
In rural Pakistan, mothers often reported grandmothers being involved in child caregiving activities in the first year of life. Mothers commonly reported grandmothers providing support to the mother when she was busy or unwell and playing and interacting with the child. We found cross-sectional and longitudinal associations between grandmother involvement and child growth and development. Specifically, early grandmother involvement had positive relationships with child weight, but this association became negative as the child grew older. Grandmother involvement was positively associated with cognitive, fine motor and socioemotional development cross sectionally and longitudinally, but was not associated with language skills. Our findings demonstrate the important contribution grandmothers have early in life and highlights the need to better understand how grandmothers influence child growth and development.
Grandmother involvement in the first year of life was associated with several indicators of better early child development. Twelve-month grandmother involvement was associated with greater child cognitive and motor development at 12 months and better socioemotional development at 24 months. While we did not find studies examining grandmother involvement and developmental outcomes in LMIC, evidence from high-income countries corroborate our findings.59–62 We speculate that the positive associations are driven by grandmothers reportedly playing and interacting with children. Grandmother involvement may also improve child development through indirect pathways. For example, grandmother involvement may decrease family stress by allowing mothers to work or perform chores in the household. Grandmother participation in household chores may also free up time for the mother to engage in responsive caregiving with her child. Yet another hypothesis is that the type of caregiver may not be salient, but rather the frequency with which the child receives stimulation. Further research examining such pathways is needed to inform the development and delivery of caregiving interventions in low-resource settings. Our findings highlight the significant role of grandmothers for children early in life and suggest the need to consider the larger family context to understand early childhood outcomes. Research from Burkina Faso demonstrate the unique opportunities grandmothers could play in providing low-cost, interactive play for children.63 Moreover, while early childhood interventions in LMIC largely focus on the mother–child dyad, our results suggest grandmothers can have positive impacts for children and should be included in addition to mothers in parenting programmes in order to optimise caregiving and promote healthy development.
In contrast to the findings with cognitive, motor and socioemotional developmental indicators, we found largely null results for the language domains across 3-month and 12-month grandmother involvement. It may be that grandmothers in our study do not interact with young children in ways that are specific for the development of language skills, such as talking or singing to the child. This points to the need for further research into the specific types of play and interactions grandmothers have with young children that influence different domains of development.
Three-month grandmother involvement was associated with improved child weight at 12 months; however, 12-month grandmother involvement was associated with poorer child weight at 24 months. This conflicting finding has been documented in other LMIC. Prior work in Mali found that grandmother involvement was associated with poorer child weight28 and in rural Gambia, children living with their grandmother were significantly heavier in the first year of life; however, this effect disappeared later in childhood.36 Related, the grandmother hypothesis proposes that grandmothers past reproductive age invest time and resources to their daughter’s fertility and their grandchildren’s care in order to increase the chances of the next generation’s survival.64 65 This hypothesis suggests while grandmothers can increase the survival chances of the grandchild, they can also decrease the weaning age of the grandchild so her daughter can have more children.65 Earlier weaning without the introduction of healthy and nutritionally dense foods can lead to poorer weight. Our measure of grandmother involvement describes the presence of grandmother caregiving at 3 and 12 months; while we did not have data on the types of food and snacks grandmothers fed children, grandmother involvement with respect to feeding meals and snacks increased over time (feeding: 4.1% at 3 months and 11.9% at 12 months; snacks: 8.5% at 3 months and 26.3% at 12 months). It is also plausible that child temperament and health affect grandmother involvement; for example, a grandmother may participate in feeding if a child is not gaining weight, or she may not if a child is fussy or difficult to feed. Child temperament has been linked to caregiver stress, parenting styles and subsequent child development in the USA.66 67 In Bangladesh, child temperament moderated the relationship between maternal depressive symptoms and child development.68 Further research is needed to characterise child temperament and how it may influence caregiving and child development in low-resource contexts. Additionally, our finding may be partially due to the beliefs of grandmothers surrounding infant and young child feeding practices and their decision-making power within the household. Previous research has identified grandmothers as significant influencers when it comes to early cessation of exclusive breast feeding and early introduction of complementary foods.12 17 21 69–72 In South Asia, grandmothers can exert strong influence on issues related to child care and rearing and maternal knowledge and practices of optimal infant and young child feeding practices.71–74 It may be that grandmothers in our sample begin feeding children more often at 12 months, but potentially not nutrient-dense foods. Future research examining the impact of grandmother involvement on child nutritional status should include measures that capture the types and quantities of food grandmothers provide to grandchildren, which can inform behaviour change interventions. Research from sub-Saharan Africa countries and China highlights when grandmothers are engaged in infant feeding and child interventions; they not only change their beliefs and behaviours, but can also influence maternal caregiving to promote such practices.15 16 70 75 76
The key strength of our study was a detailed assessment of caregiving activities routinely performed by the child’s grandmother(s). Moreover, this measure encompassed involvement independent of grandmother–grandchild coresidence, which extends beyond the current literature that largely uses household coresidence as proxy for involvement. Additional strengths include the population-representative sample, validated child outcome measures and the longitudinal study design. Our measure of grandmother involvement incorporated both instrumental and non-instrumental childcare and included specific activities such as playing and soothing the child. This allowed us to examine how early grandmother involvement affected future child outcomes.
However, some limitations warrant discussion. First, our measure of grandmother involvement was maternally reported. Maternal report may not capture all caregiving activities grandmothers are involved in and may be vulnerable to social desirability bias, interpersonal relationships and maternal depression status. Future research should incorporate grandmother-reported caregiving and direct observation. Second, we combined all caregiving activities into a summed score in order to categorise grandmother involvement; however, this may mask the effects of specific activities on child outcomes (eg, instrumental vs non-instrumental care). Since this score is independent of coresidence status, the non-involved category included coresident, non-resident and absent grandmothers. However, this may not be particularly important for the child given both situations suggest non-involvement. Third, we acknowledge that biases can result from missing data, including loss to follow-up.77 78 Our analytic samples were substantially smaller than the baseline sample (figure 1). However, we employed stabilised IPW to account for missingness. Importantly, excluding these weights did not change estimates or precision, suggesting that our results were not sensitive to the weighting procedure (online supplementary tables 8 and 9). Fourth, we were unable to capture the age or morbidity status of grandmothers. Prior research suggests varying levels of impact by grandmother age.24 26 The parabolic age hypothesis suggests that very young grandmothers are still taking care of their own households and may not be as involved while older grandmothers may not be capable of contributing to caregiving. A recent study in Brazil found that grandmother mental health symptoms were associated with more emotional and behavioural problems in grandchildren.79 Future work should examine effect measure modification of grandmother involvement on child outcomes by grandmother age and morbidity. Additionally, other factors such as child sex and maternal depression can have strong influences on caregiving behaviours and child outcomes. We conducted preliminary examinations of modification by child sex and maternal depression and found some evidence of modification by child sex, but this varied based on outcome and grandmother involvement timepoint (online supplementary tables 10–12). Ongoing work is exploring the potential impact of child sex on caregiving and developmental outcomes. We were unable to assess modification by maternal depression given reductions in the prevalence of maternal depression over time. Future research is needed to determine whether and how grandmother involvement varies by maternal depression and the impacts on child outcomes.
We add to the literature by describing the types of grandmother child caregiving activities in a LMIC. Our findings highlight the beneficial roles grandmothers have on early child cognitive, motor and socioemotional development. Our results on child weight demonstrate the complex relationship between grandmothers and child weight and underscore the need to understand the role of grandmothers on infant and young child feeding practices in rural Pakistan. Future research should focus on characterising the caregiving activities of grandmothers and examining grandmother beliefs surrounding child nutrition, such as breast feeding, introduction of complementary foods and types of nutritious foods, as well as child stimulation and parenting practices. Forthcoming research will examine the relationship between grandmother involvement and maternal mental health and perceived stress. This research can inform how other caregiver support impacts maternal well-being, which may subsequently affect maternal caregiving and early child development. In addition to potential benefits to mothers, research from high-income settings highlight the possible contributions of child caregiving to grandmother health.80–82 Programmes and future interventions may benefit by engaging all key actors within a household, including parents and grandmothers, in order to promote optimal early child growth and development.