Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial

Summary

Background

Newborn deaths account for 57% of deaths in children younger than 5 years in Pakistan. Although a large programme of trained lady health workers (LHWs) exists, the effectiveness of this training on newborn outcomes has not been studied. We aimed to evaluate the effectiveness of a community-based intervention package, principally delivered through LHWs working with traditional birth attendants and community health committees, for reduction of perinatal and neonatal mortality in a rural district of Pakistan.

Methods

We undertook a cluster randomised trial between February, 2006, and March, 2008, in Hala and Matiari subdistricts, Pakistan. Catchment areas of primary care facilities and all affiliated LHWs were used to define clusters, which were allocated to intervention and control groups by restricted, stratified randomisation. The intervention package delivered by LHWs through group sessions consisted of promotion of antenatal care and maternal health education, use of clean delivery kits, facility births, immediate newborn care, identification of danger signs, and promotion of careseeking; control clusters received routine care. Independent data collectors undertook quarterly household surveillance to capture data for births, deaths, and household practices related to maternal and newborn care. Data collectors were masked to cluster allocation; those analysing data were not. The primary outcome was perinatal and all-cause neonatal mortality. Analysis was by intention to treat. This trial is registered, ISRCTN16247511.

Findings

16 clusters were assigned to intervention (23 353 households, 12 391 total births) and control groups (23 768 households, 11 443 total births). LHWs in the intervention clusters were able to undertake 4428 (63%) of 7084 planned group sessions, but were only able to visit 2943 neonates (24%) of a total 12 028 livebirths in their catchment villages. Stillbirths were reduced in intervention clusters (39·1 stillbirths per 1000 total births) compared with control (48·7 per 1000; risk ratio [RR] 0·79, 95% CI 0·68–0·92; p=0·006). The neonatal mortality rate was 43·0 deaths per 1000 livebirths in intervention clusters compared with 49·1 per 1000 in control groups (RR 0·85, 0·76–0·96; p=0·02).

Interpretation

Our results support the scale-up of preventive and promotive maternal and newborn interventions through community health workers and emphasise the need for attention to issues of programme management and coverage for such initiatives to achieve maximum potential.

Funding

WHO; Saving Newborn Lives Program of Save the Children USA, funded by the Bill & Melinda Gates Foundation.

Introduction

Although there has been some reduction in global child mortality,¹ there is little evidence to suggest that newborn deaths have reduced significantly from the estimated yearly figure of 4 million deaths in 2000.² Pakistan has one of the highest rates of mortality in children younger than 5 years in south Asia (94 deaths per 1000 livebirths), and many (57%) of these deaths occur in the newborn period, most in the first few days after delivery.³ There are significant urban–rural differentials in neonatal mortality rates (48 newborn deaths per 1000 livebirths in urban areas vs 55 per 1000 in rural areas) and overall 65% of births take place at home (43% urban vs 74% rural).³ More than half (52%) of these births are in the hands of traditional birth attendants (Dais),4, 5 who are generally untrained and who charge for their services.

To help to strengthen primary care and preventive services, the government of Pakistan introduced the National Program for Family Planning and Primary Health Care, commonly called the lady health workers (LHW) programme, in 1994.⁶ LHWs are mostly young women, resident in the local communities, with at least 8 years of formal schooling, who are trained for 15 months to deliver care in community settings either through home visits or from their residences, known as health homes. Each LHW is responsible for a population of about 1000–1500 and provides antenatal care, contraceptive advice, growth monitoring, and immunisation services.⁷ The emphasis in the existing curriculum is on recognition and referral rather than home-based management of common neonatal problems, and two recent evaluations have concluded that they do provide reasonable primary care promotive and preventive services.8, 9

The potential of community-based interventions to reduce newborn morbidity and mortality is well recognised.10, 11 Such interventions include community health workers (CHWs) delivering preventive and therapeutic interventions such as antibiotics at home,12, 13 community mobilisation through women's support groups14, 15 or community mobilisers working through individual and group sessions,¹⁶ and community-based interventions delivered through non-governmental organisations¹⁷ or community volunteers.¹⁸ Common features of these interventions include civil society engagement, flexibility of approaches, community volunteers, social mobilisers, or CHWs dedicated to the designated tasks through home visits or group sessions. However, despite the success of these projects (largely undertaken as efficacy trials), translation of these interventions into packages of care and complex interventions that can be delivered within public health systems at scale remains a major challenge.¹⁹ Most of these studies were fairly small and none principally used the public sector, making translation of this evidence to public health systems difficult.

We undertook the first effectiveness trial of a package of preventive maternal and newborn care strategies in rural Pakistan, delivered through public sector LHWs in collaboration with voluntary community health committees (CHCs) and Dais. We have previously reported findings from the development and pilot testing phase of the project,¹⁶ which showed the feasibility of delivering the package of care through government sector LHWs.