Promotion of Breastfeeding and Evaluation Study: a community-based maternal-focused approach to promote exclusive breastfeeding in rural Pakistan

All assessments will be carried out using instruments that have been translated, field-tested and validated in the local population through our previous work. Assessments will be carried out at baseline (third trimester), and prospectively for 6 months after birth.

Baseline measures:
1. Socioeconomic status (household income and assets)
2. Maternal age
3. Education
4. Body mass index
5. Scores of psychosocial distress on the Self-Reporting Questionnaire (SRQ)
6. Number of children
7. Family structure
8. Levels of post-traumatic stress and depressive reactions to the 2005 earthquake in the study area, assessed using the Earthquake Exposure Scale

Main outcome:
The duration of exclusive breastfeeding (EBF) and its rate at 6 months, measured prospectively using the following method: each mother enrolled into the study will be visited fortnightly by an independent team, blind to the allocation status of the mother, to record the breastfeeding status and practice in the last 24 hours. For this study, EBF was defined as: only breastfeeding being practiced with no other semi-solid or liquid foods (other than medication and/or oral rehydration solutions).

1. Psychological distress, measured at baseline, 3 and 6 months using the Self-Reporting Questionnaire (SRQ-20). This psychiatric screening instrument, which was developed specifically for use in primary care by health workers in developing countries, has 20 items with a 'yes' or 'no' response to questions about psychological and somatic symptoms in the past 30 days.
2. Rates and duration of predominant and partial breastfeeding, assessed at 6 months of infant's age prospectively using the above mentioned method
3. Process outcomes: studied qualitatively using key-informant interview and focus groups. At the 'system' level, the opinion of key personnel from the programme and primary health care (including LHWs), will be obtained on all aspects of training, delivery, usefulness and potential costs of the intervention (in terms of extra time and material needed to deliver the intervention). At the family level, we will obtain feedback from mothers and other significant family members about the intervention.