An Article published Online First and an upcoming Lancet shows that use of public sector workers known as "Lady Health Workers" (LHWs) in Pakistan reduces stillbirths by 21% and newborn deaths by 15%, even though these LHWs could not reach all their planned appointments. The authors, led by Professor Zulfiqar A Bhutta (Aga Khan University, Karachi), say that results support the scale-up of preventive and promotive maternal and newborn interventions through community health workers.
16 clusters were assigned to intervention (23 353 households, 12 391 total births) and control groups (23 768 households, 11 443 total births). 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 care-seeking; control clusters received routine care.
LHWs in the intervention clusters were, in the end, only able to undertake 4428 (63%) of 7084 planned group sessions, and pay home visits to 2943 newborns (24%) of a total 12 028 livebirths in their catchment villages. Thus, say the authors, the intervention could have potentially achieved even more than it did. Despite this, stillbirths were reduced in intervention clusters (39•1 stillbirths per 1000 total births) compared with control (48•7 per 1000; risk reduction 21%). The neonatal mortality rate was 43•0 deaths per 1000 livebirths in intervention clusters compared with 49•1 per 1000 in control groups (risk reduction 15%).
The authors say: "The results of our study suggest that trained public sector community health workers in rural Pakistan can deliver a package of preventive and promotive health care messages to community members. Despite limitations of time and competing tasks, LHWs were able to build a rapport with community members and implement a package of promotive and preventive maternal and newborn care interventions."
They note: "Although the overall coverage achieved by the LHW-supported intervention was low, the effect on crucial household behaviours and care-seeking patterns was promising... These findings add to the growing evidence base for the efficacy and effectiveness of community-based approaches to address newborn mortality in difficult to-reach areas and support use of strategies involving outreach workers in such settings."
In a linked Comment, Professor Hoosen Coovadia, University of the Witwatersrand and University of Kwazulu‐Natal, South Africa, and Dr Nigel Rollins, Department of Child and Adolescent Health and Development, WHO, Geneva, ask: "What reductions in neonatal and child mortality rates are reasonable to expect in poor communities when health interventions are implemented at scale in routine health services without concurrent improvements in wealth, education and gender equity?"
They add that policy makers in Pakistan and countries with similar newborn mortality rates need to consider how much to invest in such programmes, while researchers need to ask "how to better optimise health outcomes at population level given the severe socio‐economic constraints in communities and in health services that are likely to prevail for the near to medium future."
Professor Zulfiqar A Bhutta, Aga Khan University, Karachi, Pakistan. T) +92-300-8236813 E) zulfiqar.bhutta@aku.edu
Professor Hoosen Coovadia, University of the Witwatersrand and University of Kwazulu‐Natal, South Africa. T) +27 31 388 6819 E) hcoovadia@match.org.za
Journal
The Lancet