Peer-reviewed article

Common elements-based nurturing care intervention to improve mother–infant responsive interaction and maternal psychological wellbeing in rural Pakistan: findings of a single-blinded individual randomised controlled trial

Syed Usman Hamdani, Zille Huma, Ayella Gillani, Huda Jamil, Syeda Wajeeha Zafar et al. · 1 Oct 2026

Abstract

Objectives To evaluate the effectiveness of a common elements–based Nurturing Care for Early Child Development Intervention delivered by non-specialists in improving mother–infant responsive interaction at 12 months postpartum among pregnant women experiencing psychological distress in rural Pakistan. Design Two-arm, single-blinded, individually randomised controlled trial. Setting Community-based primary care settings in a rural sub-district of Rawalpindi, Pakistan. Participants Pregnant women in their third trimester aged 18–40 years who screened positive for psychological distress (Self-Reporting Questionnaire score ≥9). Of 1962 women assessed for eligibility, 250 were enrolled and randomised to the intervention (n=125) or treatment-as-usual (TAU) arm (n=125). Interventions Participants in the intervention arm received 15 monthly individual sessions of a Nurturing Care for Early Child Development intervention delivered by trained non-specialist facilitators from the third trimester of pregnancy until 12 months postpartum. The intervention included early stimulation, learning through play, responsive feeding, guided discovery using pictures, behavioural activation and problem-solving. Participants in the control arm received routine maternal and child health services (treatment as usual). Primary and secondary outcome measures The primary outcome was caregiver–infant responsive interaction measured using the Observation of Mother–Child Interaction (OMCI) at 12 months postpartum. Secondary outcomes included maternal psychological well-being, quality of life, functioning and perceived social support, as well as infant growth including birth weight, nutrition, cognitive development and socio-emotional development. Data were collected at baseline (third trimester), 6 months and 12 months postpartum. Endpoint assessments were delayed by 2 months due to COVID-19 lockdown restrictions. Results Of the 250 participants randomised, 206 completed the 12-month follow-up assessment. At the endpoint, mother–infant dyads in the intervention arm demonstrated significantly higher OMCI total scores compared with TAU (mean (SD) 42.05 (8.65) vs 29.74 (8.19); adjusted mean difference 12.31, 95% CI 9.99 to 14.62; p<0.0001). As a secondary outcome, infants in the intervention arm had higher birth weight (mean difference 0.78 kg, 95% CI 0.30 to 1.25; p<0.001). Improvements were also observed in infant cognitive and socio-emotional development and maternal psychological well-being, functioning and quality of life. Conclusions A common element–based nurturing care intervention delivered by trained non-specialists improved mother–infant responsive interaction among infants of mothers experiencing psychological distress. Trial registration number NCT04252807.