**4. Discussion**

#### *4.1. Discussion of Findings*

The data provided insight into the various factors that could potentially influence the first 1000 days of the lives of children. In the context of this study, these factors relate to the three key areas outlined in the First 1000 Days campaign that was launched in the Western Cape, South Africa, namely (1) health and nutrition; (2) love and attention; and (3) play and stimulation [10].

The health of mothers (Theme 1) involved their physical and mental health, nutrition, and substance abuse of the participants, which played a vital role during their pregnancy and after the birth of their children. Many participants in this study suffered from severe illnesses and medical conditions, such as extreme high blood pressure, a stroke, and TB

during their pregnancy. These conditions increased the risk of complications for both the mothers and their children [50–52]. Numerous complications occurred during pregnancy, especially during the birth process, including the following—preterm birth, low birth weight, umbilical cord prolapse, ectopic pregnancy, hypertension, and breech births [53]. In addition, various children in this study suffered from oxygen deprivation after birth, which could have caused disabilities and developmental delays [54,55]. The participants revealed various aspects that influenced their emotional and mental well-being during this time-period. Although some participants encountered positive experiences and emotions during their pregnancy, others endured severe stress, especially since it seemed that all these pregnancies were unplanned. Several participants described their pregnancy experience in a negative light, as a result of morning sickness, swelling, uncertainty, sleeping challenges, and high blood pressure caused by their pregnancy. A mother's well-being during pregnancy influences the baby's well-being [56], which could have longlasting physical, cognitive, and emotional outcomes for the child [57]. During pregnancy, the participants experienced stressors related to their circumstances. Some participants were teenagers during their pregnancy, and they had to attend school, and the relationship with the biological father also added strain. Numerous participants experienced internal stressors, especially relating to the announcement of the pregnancy to their family, which caused intense emotions. The findings also indicated that a few participants experienced sadness, anxiety, guilt, and feelings of worthlessness, which could possibly be associated with symptoms of depression [58]. Prenatal exposure to maternal depression could affect the brain development of the fetus [59].

During the time from the child's birth to two years, the stressors mentioned were mostly related to motherhood and losing a loved one. One of the mother's mental health after the birth of her child showed signs of postpartum depression [60,61], or even postpartum psychosis [62], as she attempted to kill her baby. Although most participants ate healthy during their pregnancy, poor nutrition occurred amongst some participants. Nutritional deficiencies during pregnancy could affect children's cognition, behavior, and productivity later in life [63,64]. The occurrence of substance use/abuse during pregnancy was considerably high, with cigarette smoking the highest, followed by alcohol use, and lastly, drug abuse. Illicit drugs that were consumed during pregnancy included Methamphetamine (Tik), dagga (Marijuana), and Mandrax. Substance use/abuse during pregnancy poses severe risks to both mothers and their unborn babies, especially physical and neurological damage [65]. Prenatal use of alcohol, as consumed by many participants, could have long-term consequences on their children's cognitive, behavioral, social, and emotional development [66]. The prenatal use of alcohol by the participants in this study corresponds to the high prevalence rates of FASD in South Africa [67].

The health of the children (Theme 2) during the first 1000 days establishes the foundation for optimal health and development later in life [68]. Although a few participants highlighted their children's good health, many of these children in this study experienced poor health. Several children suffered from oxygen deprivation directly after birth, which can cause disabilities, developmental delays, and other long-term effects [55,56]. The children of four participants who smoked during their pregnancy experienced respiratory problems after birth, which could possibly be caused by prenatal cigarette smoking [69]. A number of children of participants suffered more severe illnesses and conditions, such as TB, kidney disease, colon problems, and physical disabilities. A few children were hospitalized, causing sleep deprivation and severe psychological stress. A number of participants confirmed taking their children for their medical check-ups and immunization at the scheduled times, which played a vital role in the health of their children [70]. The study also focused on the children's feeding and nutrition, from birth to two years, and many participants breastfed their babies during the first few months, as recommended by the World Health Organization [71]. Some participants complied with the guidelines set by the Department of Health in South Africa, by introducing solid foods to their infant's diet at six months [72]. Many participants provided good food choices like fruit, vegetables, meat, and dairy products, as suggested by the Australian Government [73]. In terms of the children's weight, several participants regarded their children's weight as healthy, while a few stated that their children were underweight or overweight. Many participants experienced challenges regarding their children's feeding and nutrition, with a lack of or limited food. Nutritional deficiencies occurred, due to poor nutrition and other challenges, which possibly caused stunting in some of these children, which affected their brain development and resulted in learning difficulties at school [74].

Support (Theme 3) from others could influence the health and well-being of individuals [75]. The participants' experience of support during pregnancy was affected by their emotions and thoughts, as well as the announcement of their pregnancy and other people's responses. Many participants were unmarried at the time when they became pregnant, and the announcement of the pregnancy caused anxiety and fear. Several mothers experienced family members not talking to them, threatening to put them out of the house, or the biological father denying fatherhood. Many participants felt supported during their pregnancy and after the birth of their child, while numerous participants experienced a lack of support that resulted in a sense of loneliness. A lack of support caused the participants to be more vulnerable to depression and anxiety. Support from the biological father is paramount [76], as experienced by some participants. A number of participants received support from the child's father, however, several participants experienced no support from the biological father during that time-period. Many participants expressed challenges pertaining to their relationship with the biological father, including an unstable relationship, conflict, drug abuse of the father, and lack of financial support. A few biological fathers engaged with their children, and played an active role in their lives, which could have had a positive influence on these children's social, emotional, and cognitive development [77]. It was clear that other significant people, especially the grandparents, siblings, and the participants' male friends, played a positive role in the lives of their children.

The circumstances of the mothers and their children (Theme 4) referred to their living and financial circumstances during pregnancy and birth to two years. More than half of the mothers described their living circumstances as suitable and pleasant, while others experienced adverse living conditions, such as unsuitable housing, lack of water or electricity, a significant amount of family conflict, and substance abuse in the home, which led to an increased vulnerability experienced by the mothers and their children [78]. The living circumstances remained the same in most cases after the birth of the child, however, there were changes and even improvements for some participants during that time-period. Financial circumstances had a huge impact on the participants, as most of them experienced some form of financial strain, often lacking the resources to supply their child's basic needs.

The attachment and relationship between the participants and their children (Theme 5) during pregnancy, and during the two-year period after birth were influenced by various aspects. Some participants were happy and excited when they found out they were pregnant, whereas many of them initially experienced negative emotions, such as shock, confusion, disappointment, anger, sadness, and panic, due to an unplanned pregnancy [79]. These negative emotions made the mothers more susceptible to the risk of maternal depression [80]. The child's gender influenced the emotional responses of participants. Many participants felt relief, happiness, and excitement when the gender coincided with their preferences. Several participants considered abortion or adoption. The movement of the unborn baby activated various positive emotions, such as happiness, excitement, enjoyment, love, acceptance, and protection. These positive emotions indicated signs of bonding [81,82]. Some participants interacted with their unborn babies in various ways, by talking and singing to them. These interactions promoted the children's development [81], and enhanced bonding between them and their unborn babies [83]. Many participants expressed positive initial responses, interaction, and emotions, directly after the birth of their child, while some experienced an internal motivation for self-improvement. These positive responses immediately after birth influenced them to be more inclined towards

their children's needs [84]. It was noticeable that attachment between the participants and their children formed during the two-year period after they were born. However, a few participants expressed certain negative emotions and thoughts towards their child, which included irritation, lack of attachment, and serious harmful emotions and thoughts by one of the participants specifically.

The development and care of the children (Theme 6) involved a variety of aspects. Although most participants showed an understanding of some of their children's developmental needs—especially their physical needs—many participants had a limited understanding about their children's emotional, linguistic, and cognitive developmental needs. Some participants felt that their children met their developmental milestones, while others highlighted their children's rapid development. One of the mothers who abused drugs during her pregnancy, emphasized her child's cognitive and physical developmental challenges. Many participants used 'serve and return' to stimulate and play with their babies, which is beneficial for building a strong foundation in the child's brain architecture [85]. Many participants used educational toys or activities to incorporate stimulation and play into their children's lives. Only some participants played with their children when they were older, since they felt that the children could play with their siblings.

Reflecting on the findings of this study and various theories relating to child development, it appears that these theories play a significant role in the following way. The first two stages of Erikson's Psychosocial theory [86,87] refer to children's development of trust and autonomy. The sensorimotor stage of Piaget's theory of cognitive development was noticeable in the way the participants described their children's understanding of their environment through different activities involving their senses. Attachment between the participants and their children, as indicated by the attachment theory [28], was highlighted as one of the themes and occurred various times in this study. The four phases of the attachment theory [28,86] were also evident during the time from birth to two years, as the participants described the bond between them and their child, and the reaction of their child when separation occurred. However, specific types of attachment [28,86] were not definite. Bronfenbrenner's bioecological theory [88] was clearly evident throughout the study, where both the mothers' and children's interaction with various systems played a vital role. Lastly, Maslow's hierarchy of needs [87,89], mainly the first three needs, namely (1) physiological needs; (2) the need for safety; and (3) the need for love; were strongly visible in the findings. A lack in basic physiological needs, such as food and baby goods due to poverty, had an enormous effect on some of the participants, and were highlighted by many of them.

Finally, it should be noted that although the aim of this study was not to determine a correlation between the first 1000 days and absenteeism, the findings of this study indicated that many factors played a vital role during the first 1000 days of the absent learners in this study. Literature further confirmed that specific aspects revealed in the findings of this study, such as nutritional deficiency [25], substance abuse during pregnancy [29,30], toxic stress [32], attachment, [34] and stimulation [36] could have negative effects on the schooling of children. Some of these aspects include academic, social, emotional problems at school, and school absenteeism.
