The care, stimulation and nutrition of children from 0-2 in Malawi-Perspectives from caregivers; "Who's holding the baby?".

Introduction: Universal access to quality early childhood development and care is a fundamental part of Sustainable Development Goal 4.2.1. Research from diverse settings, including that in low and middle income countries, now demonstrates the positive impact that interventions to promote play, stimulation, early communication and responsiveness can have, not just on child development, but on long term gains in education and economic growth. International agencies have recently produced the Nurturing Care Framework for Early Child Development in order to promote this and to encourage countries to move the focus from child survival to child thrival. Research on the best methods of integration of these programmes into present care practices, particularly in African settings is still very limited.

Methods: We used qualitative methods to gain an understanding of care practices (play, developmental stimulation, early communication and responsive feeding) for children 0-2 years. We conducted 18 focus groups (FGDs), six PFGDs (Participatory Research focus groups), 18 in depth interviews (IDIs) and 20 observations with caregivers in rural and urban settings of Malawi. We used a topic guide, audio-recorded the FGDs and IDIS and transcribed them in Chichewa or Yao and then into English. We coded data using an inductive approach to thematic analysis. We placed the data within a framework with the emerging major and minor themes. We conducted quality assurance for translations and coding frameworks through cross comparison of data and used respondent validation to check our results.

Results: Malawian caregivers see children's play as a consequence of good health and wellbeing, less an interaction that a parent undertakes to promote wellbeing and learning. Non-verbal communication and responsiveness with infants is clearly present and caregivers have many one-on-one interactions with young infants. Furthermore, many caregivers have good knowledge of feeding recommendations but cannot always follow these due to constraints on money. When children become mobile (toddlers), play is an activity done more often between children or with other caregivers such as siblings or grandparents. Community members consider that caring for children from 0-2 years is a woman's domain. Despite this, both men and women acknowledge the importance of maternal wellbeing in enabling good care of children. The present socioeconomic situation of most families in our study means that income generation and food security come first. Many mothers spend most of their time managing the responsibilities of daily living and have limited time to dedicate to children's play, responsiveness and communication with their children.

Discussion: Programmes promoted as part of the Nurturing Care Framework which provide advice on developmental stimulation, play, early communication and responsive feeding should ensure that topics within these programmes are culturally appropriate for the setting. Furthermore, programmes must not be an added burden to parents but be supportive to parents managing many responsibilities of daily living. Multi-sectorial approaches where both men and women are provided with knowledge but are also supported through programmes which address family finances, safe spaces for children whilst families are working, and family mental health and relationships may enable programmes to work more effectively.