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Pediatrics. 2015 Feb;135(2):e424-31. doi: 10.1542/peds.2014-1628. Epub 2015 Jan 12.

Cognitive-behavioral counseling for exclusive breastfeeding in rural pediatrics: a cluster RCT.

Author information

Human Development Research Foundation, Islamabad, Pakistan;
School of Medicine, Duke University, Durham, North Carolina;
Human Development Research Foundation, Islamabad, Pakistan;
Health Services Academy, Islamabad, Pakistan; and.
Institute of Psychology, Health, and Society, University of Liverpool, Liverpool, United Kingdom.



To test the effectiveness of cognitive-behavioral counseling on the rate and duration of exclusive breastfeeding (EBF) during the first 6 months of an infant's life compared with routine counseling.


A single blind cluster-randomized controlled trial was undertaken in 40 Union Councils of a rural district in the northwest province of Pakistan between May 2009 and April 2010. By simple unmatched randomization, 20 Union Councils were each allocated to intervention and control arms. Two hundred twenty-four third trimester pregnant women in the intervention and 228 third trimester pregnant women in the control arm were enrolled and followed-up biweekly until 6 months postpartum. Analyses were by intention to treat. Mothers in the intervention group received 7 sessions of cognitive-behavioral counseling from antenatal to 6 months postpartum, whereas the control group received an equal number of routine sessions. Proportion of mothers exclusively breastfeeding at 6 months postpartum and duration of EBF through these 6 months was assessed.


At 6 months postpartum, 59.6% of mothers in the intervention arm and 28.6% in the control arm were exclusively breastfeeding. This translates into a 60% reduced risk of stopping exclusively breastfeeding during the first 6 months (adjusted hazard ratio, 0.40 [95% confidence interval: 0.27-0.60], P < .001). Mothers in the intervention group were half as likely to use prelacteal feeds with their infants (adjusted relative risk, 0.51 [95% confidence interval: 0.34-0.78]).


Compared with routine counseling, cognitive-behavioral counseling significantly prolonged the duration of EBF, doubling the rates of EBF at 6 months postpartum.


Pakistan; cluster randomized controlled trial; cognitive-behavioral counseling; community health workers; exclusive breastfeeding; nonliterate population; rural population

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