beyond the postpartum phase, generally considered to be the period up to eight weeks after childbirth. One exception is the Hentschel et al. (2024) study of parenting during the COVID-19 pandemic period showing that 57% of parents of children 0-3 years reported feeling distressed and distress was one of the strongest predictors of reduced ECD among those children.

This study aims to address the need for a more nuanced understanding of the contributing factors that influence caregiving in FCV settings, as called for in previous research (e.g., Burgund Isakov et al., 2022). More specifically, this study examines whether maternal depression, anxiety or parenting stress independently or jointly predict ECD, and additionally considers whether potential relationships remain even after accounting for stressors that could be expected to influence outcomes. The study also evaluates whether young children in certain vulnerable groups—namely, those living in rural areas, those with caregivers with less than a primary school education, or refugees, respectively—have mothers with more severe mental health conditions and are more atrisk developmentally. These topics have not yet been well-explored in FCV settings in general, nor in Pakistan in particular. Therefore, this study aims to answer the following questions: (i) How do levels of maternal mental health—specifically depression, anxiety and parenting stress—differ by education level, refugee status, and living in an urban vs. rural area? (ii) What is the compounding influence of multiple maternal mental health conditions, namely depression, anxiety and parenting stress, on child development for children 0-6 years old? (iii) How, if at all, is this association altered by controlling for stressors and other confounders?

This study builds on a nascent literature in the following ways: (i) it examines multiple maternal mental health outcomes for caregivers at the same time; (ii) it differentiates between maternal mental health outcomes for hosts and refugees; (iii) it assesses the severity of various maternal mental health conditions, not just the onset of the condition itself; (iv) it documents differences in child outcomes – both from caregiver reports and from a direct assessment of children; (v) it examines outcomes separately for children between 0-35 months of age and those aged 36-72 months. To the best of our knowledge this is the first study to assess the compounding association of multiple maternal mental health conditions on child development for children 0-72 months in Khyber Pakhtunkhwa, Pakistan.

# <mark>Methods</mark>

## <mark>Research Design and Data Collection Strategy</mark>

This household survey was commissioned by The World Bank and carried out by the Center for Evaluation and Development between December 2023 and February 2024 in Khyber Pakhtunkhwa, Pakistan. Households were selected based on being located in the catchment area of one of 200 public schools across Khyber Pakhtunkhwa (excluding newly merged districts).<sup>2</sup> In most cases, the boundaries of a catchment area represented a maximum of a 30-minute walk from the proximate school. Households living in a given catchment area who had at least one child under the age of 72 months (for either of the 0-35-month or 36-72-month age groups) available to be

> 2 <mark>The sample of 200 public schools was drawn for a different World Bank survey in 2022. These 200 schools are a representative sample of public schools across all districts of Khyber Pakhtunkhwa (excluding newly merged districts). The households in question are thus representative of those in the catchment area of a representative sample of schools.</mark>

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