This prospective birth cohort study (Safe Passage Study; BONO follow-up) examined associations between 104 early life environmental factors (prenatal, perinatal, postnatal) and emotional-behavioral problems (externalizing and internalizing) in 1,284 South African children and adolescents aged 5–16 years, using caregiver-reported Strengths and Difficulties Questionnaire (SDQ).
Prenatal maternal self-harm showed the strongest associations (externalizing β=0.69; internalizing β=0.60), followed by prenatal infections (externalizing β=0.65; internalizing β=0.45). Maternal depression and anxiety were also linked to both problem types. Prenatal substance use, asthma, paternal education, and infant secondhand smoke were associated only with externalizing problems; enlarged placenta was linked only to internalizing problems.
- Emotional-behavioral outcomes were measured only once (cross-sectional SDQ), limiting longitudinal tracking of trajectories. - The BONO follow-up sample (n=1,284) is a subset of the original cohort (5,889 dyads), raising risk of attrition bias. - Regression models adjusted only for child sex and age, leaving residual confounding by socioeconomic and other factors possible.
Screen and treat maternal mental health conditions (depression, anxiety, self-harm) and infections during pregnancy as early intervention points to reduce children's risk of both externalizing and internalizing behavioral problems. These findings, from a low- and middle-income country setting, support integrating maternal mental health care into routine antenatal services.
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