A Common Elements-based Intervention to Improve Maternal Psychological Well-being and Mother-infant Interaction

Bayley's Scales of Infant Development (BSID III) will be used to measure cognitive, language, motor, socio-emotional development and adaptive behaviours. Each item is rated on 0 or 1. Higher scores indicate better development and functioning.

Ages and Stages Questionnaire 3rd Edition (ASQ3) will be used to measure developmental delays in communication, gross motor, fine motor, problem solving, and personal social domains. It provides cut-off score in 5 domains of development that indicates possible need for further evaluation. It highlights results that fall in a "monitoring zone," to make it easier to keep track of children at risk. Items are rated on 3-point likert scale, yes (10), sometime (5) and not yet (0). Higher score indicates that child is developing well.

Quality and quantity of stimulation and support in the child's home will be measured using home inventory. It has 45 items, rated on dichotomous scale, yes (1) or no (0). It has six sub-scales including parental responsiveness, acceptance of child, organization of environment, learning materials, parental involvement, variety in experience. Higher score shows more enriched home environment.

Infants in both groups will be weighed and measured with standard techniques. Growth data will be converted into SDs (Z scores) for weight and length with Epi Info 2002 (version 3.4.1).

Assessors will document what the infant was fed in the last 24 hours at 6 months postpartum. This information will be categorized as either EBF, partial breastfeeding (giving an infant some breastfeeding, and some artificial foods, either milk, cereal, or other food items), or no breastfeeding, using three items scale. The items will be rated on 3-point likert scale; yes (1), no (0) and don't know (888). Lower score represents that infant is not exclusively breastfed. If the infant will not exclusively breastfeed, details of when (age of infant) and why EBF was discontinued will be recorded. At the first follow-up immediately after delivery, details about early initiation, discarding colostrum, use of pre-lacteals, and reasons for delaying or not initiating breastfeeding will be assessed۔

The number of diarrhoeal episodes in the infants during the 2 weeks before interview will be recorded at 6 and 12 months post-partum, with a questionnaire used in previous studies. Diarrhoea will be defined as three or more unformed stools passed in 24 h, and a diarrhoeal episode will be defined as being separated from another episode by at least 3 diarrhoea-free days.

Records of immunization will be assessed for all infants in the study, and infants will be classified as those with or without up-to-date immunisation status 6 and 12 months postpartum.

Maternal distress will be measured by the Self Reporting Questionnaire (SRQ). SRQ is a 20-item self-report measure to detect non-specific psychological distress, developed by the World Health Organization. The SRQ items are scored 0 or 1. A score of 1 indicates the presence of symptoms of psychological distress during past month and a score of 0 indicates absence of symptoms. The maximum score indicates presence of higher psychological distress.

Caregivers' health related quality of life will be measured by Paediatric Quality of Life Inventory (PedsQL) family impact module. The PedsQL is 36 item impact module scale that encompasses 6 sub-scales measuring parent self-reported functioning. These subscales measure physical functioning, emotional functioning, social functioning, daily activities and family relationships. Items are rated on a 5-point Likert scale (0 = never to 4 = almost always). Higher scores indicate better functioning

The level of social support will be measured using Multi-Dimensional Scale of Perceived Social Support (MSPSS). It includes 12 items which cover three dimensions: support from family, friends and significant other. Each item is rated on a 7-point Likert-scale (1 = very strongly disagree; 7 = very strongly agree). A total score is calculated by summing the responses of all items (range 12-84) with higher scores indicating higher levels of perceived social support.

Caregiver's level of functioning will be measured using World Health Organization Disability Assessment Schedule (WHODAS-12). WHODAS assesses participants' health-related difficulties in the level of functioning in six domains of life (understanding and communicating; moving and getting around; attending to one's hygiene, dressing, eating and staying alone; interacting with other people; domestic responsibilities, leisure, work and school and joining in community activities, participating in society) over the past 30 days. It has 12 items rated on 5-point likert scale, 1 to 5. High score represents more disability/ impaired functioning.

Women's empowerment will be measured using a questionnaire consisting of: (a) two items previously used in the same population that assess financial empowerment (i.e., whether a woman is given a lump-sum of money for day-to-day expenses and whether she can make independent decisions about its use) and (b) 7 items to measure relative freedom from domination within the family (i.e., whether in the past year family had taken money, land, jewellery or livestock from her against her will, prevented her from visiting her parental home, or prevented her from working outside the home) and economic security and contribution (i.e., does she possess any land, productive assets, and or cash). Women who answer 'yes' to both items on financial empowerment and three items from economic security and contribution subscales and 'no' to all items regarding family domination will be classified as 'empowered'.

Utilization of health care will be measured by Client Service Receipt Inventory (CSRI) adapted for perinatal population of Pakistan. It measures participants' use of health and social care services, accommodation and living situation, family income and social benefits. The data collected through the CSRI can be used to calculate service costs and total costs of care for each research participant.