Objective: To create a more culturally relevant developmental assessment tool for use in children in rural Africa. Design: Through focus groups, piloting work and validation, a more culturally appropriate developmental tool, based on the style of the Denver II, was created. Age standardised norms were estimated using 1130 normal children aged 0–6 years from a rural setting in Malawi. The performance of each item in the tool was examined through goodness of fit on logistic regression, reliability and interpretability at a consensus meeting. The instrument was revised with removal of items performing poorly. Results: An assessment tool with 138 items was created. Face, content and respondent validity was demonstrated. At the consensus meeting, 97% (33/34) of gross motor items were retained in comparison to 51% (18/35) of social items, and 86% (69/80) of items from the Denver II or Denver Developmental Screening Test (DDST) were retained in comparison to 69% (32/46) of the newly created items, many of these having poor reliability and goodness of fit. Gender had an effect on 23% (8/35) of the social items, which were removed. Items not attained by 6 years came entirely from the Denver II fine motor section (4/34). Overall, 110 of the 138 items (80%) were retained in the revised instrument with some items needing further modification. Conclusions: When creating developmental tools for a rural African setting, many items from Western tools can be adapted. The gross motor domain is more culturally adaptable, whereas social development is difficult to adapt and is culturally specific.