Human Development Research Foundation

Maternal–infant bonding is essential for early development and long-term well-being. In low-resource settings like Pakistan, perinatal anxiety, though prevalent, remains under-recognized and can significantly disrupt bonding. While perinatal depression has garnered greater research attention, the cultural and relational dimensions linking anxiety to bonding remain underexplored. This qualitative study examined how maternal distress, sociocultural expectations and healthcare limitations influence bonding. Eighteen pregnant and postnatal women (aged 19–45 years) with clinically significant anxiety (Generalized Anxiety Disorder 7-item scale ≥ 10) were purposively recruited from public hospitals in Rawalpindi and Islamabad. In-depth interviews were conducted in Urdu and analyzed using Braun and Clarke’s thematic analysis. Five major themes emerged: (1) emotional vulnerability during the perinatal period, (2) interpersonal and family dynamics, (3) maternal health and role strain, (4) cultural scripts and structural barriers and (5) participant-driven recommendations. Anxiety often delays emotional connection. Judgment, limited autonomy and lack of support worsened distress, while faith, rituals and relational coping offered resilience. This study provides novel qualitative evidence that perinatal anxiety and maternal–infant bonding are co-constructed within the relational and sociocultural ecologies of low- and middle-income countries like Pakistan. Findings challenge purely symptom-focused approaches, underscoring that effective intervention must address not only the emotional invisibility of mothers but also the relational pathways of distress, such as hypervigilance, exhaustion and performance anxiety, which are intensified by a lack of respect, autonomy and validation. A shift toward contextually grounded, relationship-centered care is urgently needed.

Maternal–infant bonding is essential for early development and long-term well-being. In low-resource settings like Pakistan, perinatal anxiety, though prevalent, remains under-recognized and can significantly disrupt bonding. While perinatal depression has garnered greater research attention, the cultural and relational dimensions linking anxiety to bonding remain underexplored. This qualitative study examined how maternal distress, sociocultural expectations and healthcare limitations influence bonding. Eighteen pregnant and postnatal women (aged 19–45 years) with clinically significant anxiety (Generalized Anxiety Disorder 7-item scale ≥ 10) were purposively recruited from public hospitals in Rawalpindi and Islamabad. In-depth interviews were conducted in Urdu and analyzed using Braun and Clarke’s thematic analysis. Five major themes emerged: (1) emotional vulnerability during the perinatal period, (2) interpersonal and family dynamics, (3) maternal health and role strain, (4) cultural scripts and structural barriers and (5) participant-driven recommendations. Anxiety often delays emotional connection. Judgment, limited autonomy and lack of support worsened distress, while faith, rituals and relational coping offered resilience. This study provides novel qualitative evidence that perinatal anxiety and maternal–infant bonding are co-constructed within the relational and sociocultural ecologies of low- and middle-income countries like Pakistan. Findings challenge purely symptom-focused approaches, underscoring that effective intervention must address not only the emotional invisibility of mothers but also the relational pathways of distress, such as hypervigilance, exhaustion and performance anxiety, which are intensified by a lack of respect, autonomy and validation. A shift toward contextually grounded, relationship-centered care is urgently needed.

The ENHANCE non-inferiority trial that took place in a deprived setting in Pakistan demonstrated that a technology-assisted digital adaptation of the Technology Assisted Thinking Healthy Programme (THP-TAP) was no different than the face-to-face THP in improving symptoms of perinatal depression. The present study examines the mechanisms through which THP-TAP improved symptoms of perinatal depression (or not) compared to the face-to-face THP.We applied a counterfactual-based approach to mediation – particularly interventional effects – to decompose the total effect of the THP-TAP intervention on symptoms of perinatal depression into the following pre-specified indirect effects: number of sessions attended; behavioural activation; perceived social support; problem-solving and cognitive-restructuring skills; and peer empathy. Mediators were assessed at 3 months post-partum, and depressive symptoms were measured at 6 months using the Patient Health Questionnaire-9 (PHQ-9).Perceived social support in THP-TAP arm mediated an improvement in symptoms of perinatal depression compared to the standard face-to-face THP group (adjusted mean difference in PHQ-9 scores attributable to perceived social support in the technology-assisted digital adaptation of the THP group compared to the World Health Organisation THP group: −0.072, bias-corrected 95% confidence interval: −0.170, −0.018). There was no difference to support the indirect effects for all other mediators.Even in the absence of treatment superiority, our findings suggest that levels of perceived social support were an important feature of the THP-TAP intervention, which resulted in improved symptoms of perinatal depression. From a practical perspective, these findings highlight the importance of social connectedness as a mechanism of change, demonstrating that peer-delivered digital psychosocial interventions can successfully cultivate this relational component.

Maternal–infant bonding is essential for early development and long-term well-being. In low-resource settings like Pakistan, perinatal anxiety, though prevalent, remains under-recognized and can significantly disrupt bonding. While perinatal depression has garnered greater research attention, the cultural and relational dimensions linking anxiety to bonding remain underexplored. This qualitative study examined how maternal distress, sociocultural expectations and healthcare limitations influence bonding. Eighteen pregnant and postnatal women (aged 19–45 years) with clinically significant anxiety (Generalized Anxiety Disorder 7-item scale ≥ 10) were purposively recruited from public hospitals in Rawalpindi and Islamabad. In-depth interviews were conducted in Urdu and analyzed using Braun and Clarke’s thematic analysis. Five major themes emerged: (1) emotional vulnerability during the perinatal period, (2) interpersonal and family dynamics, (3) maternal health and role strain, (4) cultural scripts and structural barriers and (5) participant-driven recommendations. Anxiety often delays emotional connection. Judgment, limited autonomy and lack of support worsened distress, while faith, rituals and relational coping offered resilience. This study provides novel qualitative evidence that perinatal anxiety and maternal–infant bonding are co-constructed within the relational and sociocultural ecologies of low- and middle-income countries like Pakistan. Findings challenge purely symptom-focused approaches, underscoring that effective intervention must address not only the emotional invisibility of mothers but also the relational pathways of distress, such as hypervigilance, exhaustion and performance anxiety, which are intensified by a lack of respect, autonomy and validation. A shift toward contextually grounded, relationship-centered care is urgently needed.

Prenatal anxiety is associated with poor postpartum infant-child relationships. Thus strategies that improve prenatal anxiety could also affect this relationship. We investigated the effects of an intervention to address prenatal anxiety on maternal-infant bonding and examined the potential mediating roles of maternal self-efficacy, maternal-infant responsiveness, and postpartum depression. Data were collected between 2019 and 2022 as part of a randomized controlled trial to treat prenatal anxiety using cognitive behavioral therapy. Participants included 701 pregnant women aged 18 or older with symptoms of anxiety, but not depression, attending a tertiary hospital in Rawalpindi, Pakistan. Women randomized to the intervention arm demonstrated significantly lower scores on the postpartum bonding questionnaire (B=-3.05, 95% CI: -4.98, -1.12), indicating stronger bonding. Responsiveness, self-efficacy, and postpartum depression significantly mediated 38%, 66%, and 95% of the association between the intervention and bonding, respectively. These mediators may be useful targets to improve maternal-infant bonding among women with prenatal anxiety.

Task sharing is endorsed as one of the strategies to address the treatment gap in common perinatal mental health conditions. There is a well-established body of evidence on the effectiveness of psychological interventions delivered by nonspecialist health workers (NSHWs); however, there is a dearth of evidence documenting factors determining the feasibility, acceptability and sustainability of integrating and implementing these interventions. This systematic review aims to synthesize the implementation outcomes and implementation process of NSHWs-delivered psychological interventions for the management of perinatal depression and anxiety using Proctor’s implementation science framework outlining eight constructs: feasibility, acceptability, appropriateness, adoption, cost, fidelity, penetration and sustainability. We searched PubMed, Web of Science and Cochrane Center Register of Controlled Trials for studies published in English and between 2000 and 2022 using search terms under five broad categories: (a) “perinatal”; (b) “common mental disorders”; (c) “psychological interventions”; (d) “nonspecialist” and (e) “implementation outcomes.” Secondary publications were also hand-searched for data extraction. Two authors independently reviewed abstracts and full-text articles. Data for included articles were extracted using a standard data extraction sheet. A narrative synthesis of qualitative evidence was conducted. Initial searches identified 885 articles of which full text of 128 articles were screened for eligibility, with 56 studies meeting the inclusion criteria. Out of the eight constructs of Proctor’s framework, “feasibility,” “acceptability,” “appropriateness” and “fidelity” were the most evaluated outcomes. None of the studies reported “penetration” and very few reported “sustainability,” “adoption” or “cost.” None of the studies used any implementation science framework for the study evaluation. Despite the well-established evidence on the effectiveness of psychosocial interventions for perinatal depression and anxiety by NSHWs, these interventions are rarely adopted into the health system. More studies applying systems thinking are needed to explore facilitators, barriers and mechanisms for integrating interventions in the health system. Using implementation science frameworks to design, plan, execute and evaluate psychosocial interventions by NSHWs can address this gap in evidence.

Perinatal depression affects one in four women in low- and middle-income countries. The World Health Organization's Thinking Healthy Programme (WHO-THP) is an established 'task-shared' cognitive-behavioral therapy intervention for perinatal depression. However, efforts to scale up are hampered by overburdened health systems struggling to maintain quality and fidelity. Here, to overcome these challenges, we coproduced with end users a technology-assisted digital version of the THP delivered by lived-experience peers (technology-assisted peer-delivered THP (THP-TAP)). We aimed to evaluate the effectiveness of THP-TAP compared to the established WHO-THP. A single-blind cluster-randomized controlled noninferiority trial was conducted in rural Rawalpindi, Pakistan, with 70 village clusters randomly distributed to the two interventions. From June 2022 to May 2023, we recruited 980 women with perinatal depression registered with primary healthcare centers. The primary outcome was remission from the depressive episode at 3 months postnatal. On assessment of 846/980 (86.3%) participants at 3 months postnatal, the difference in the remission rate was 8.91% with the lower boundary of the one-sided 97.5% confidence interval being 4.25%, larger than the prespecified -10% noninferiority margin (Pnoninferiority < 0.0001). In settings where health systems are weak and overburdened, THP-TAP offers an effective and potentially scalable alternative to the delivery of psychosocial interventions. ClinicalTrials.gov registration: NCT05353491 .

Empathy plays a crucial role in psychosocial and psychological interventions, greatly impacting rapport building, patient adherence, and satisfaction with treatment. Empathetic interactions enhance patient’s self-reflection and the delivery of more personalized therapeutic interventions tailored to the unique needs of each patient, thereby improving the overall quality of care. Despite empathy being central to psychosocial interventions, there are currently no valid and reliable patient-centered tools that assess the lay-therapist empathy that they show and/or exhibit toward their patients.In this study, the patient-rated Empathy Scale for Lay Therapists was developed to assess empathy in community health workers delivering psychosocial interventions. Psychometric validation was based on a cross-sectional study embedded in a non-inferiority cluster randomized trial of the Thinking Healthy Programme for perinatal depression in Pakistan.Community testing with perinatal women confirmed the scale’s understandability and logical structure, highlighting its face validity. Among the 980 trial participants, a high level of agreement with the Empathy Scale for Lay Therapists (mean score 2.616) was observed, indicating effective communication and empathy from health workers. The scale demonstrated excellent internal consistency (Cronbach’s alpha 0.96). Exploratory Factor Analysis revealed a unidimensional structure, capturing 87.81% of the total variance, with strong factor loadings.

Empathy plays a crucial role in psychosocial and psychological interventions, greatly impacting rapport building, patient adherence, and satisfaction with treatment. Empathetic interactions enhance patient’s self-reflection and the delivery of more personalized therapeutic interventions tailored to the unique needs of each patient, thereby improving the overall quality of care. Despite empathy being central to psychosocial interventions, there are currently no valid and reliable patient-centered tools that assess the lay-therapist empathy that they show and/or exhibit toward their patients.In this study, the patient-rated Empathy Scale for Lay Therapists was developed to assess empathy in community health workers delivering psychosocial interventions. Psychometric validation was based on a cross-sectional study embedded in a non-inferiority cluster randomized trial of the Thinking Healthy Programme for perinatal depression in Pakistan.Community testing with perinatal women confirmed the scale’s understandability and logical structure, highlighting its face validity. Among the 980 trial participants, a high level of agreement with the Empathy Scale for Lay Therapists (mean score 2.616) was observed, indicating effective communication and empathy from health workers. The scale demonstrated excellent internal consistency (Cronbach’s alpha 0.96). Exploratory Factor Analysis revealed a unidimensional structure, capturing 87.81% of the total variance, with strong factor loadings.