Implementing community-based perinatal care: results from a pilot study in rural Pakistan

452 Bulletin of the World Health Organization | June 2008, 86 (6) Implementing community-based perinatal care: results from a pilot study in rural Pakistan Zulfiqar A Bhutta,a Zahid A Memon,a Sajid Soofi,a Muhammad Suhail Salat,a Simon Cousens b & Jose Martines c Objective This pilot study investigated the feasibility of delivering a package of community-based interventions for improving perinatal care using lady health workers (LHWs) and traditional birth attendants (Dais ) in rural Pakistan. Methods The intervention was implemented in four of eight village clusters (315 villages, total population 138 600), while four served as a comparison group. The LHWs in intervention clusters received additional training focused on essential maternal and newborn care, conducted community education group sessions, and were encouraged to link up with local Dais. The intervention was delivered within the regular government LHW programme and was supported by the creation of voluntary community health committees. Findings In intervention villages, there were significant reductions from baseline in stillbirth (from 65.9 to 43.1 per 1000 births, P < 0.001) and neonatal mortality rates (from 57.3 to 41.3 per 1000 live births, P < 0.001). The proportion of deliveries conducted by skilled attendants at public sector facilities also increased, from 18% at baseline to 30%, while the proportion of home births decreased from 79% to 65%. A household survey indicated a higher frequency of key behaviours (e.g. early and exclusive breastfeeding, delayed bathing and cord care) in intervention villages. Conclusion The improved stillbirth and neonatal mortality rates observed indicate that community health workers (i.e. LHWs and Dais ) can be effective in implementing a community and outreach package that leads to improved home care practices by families, increased care-seeking behaviour and greater utilization of skilled care providers. These preliminary observations require confirmation in an adequately powered trial. Bulletin of the World Health Organization 2008;86:452–459. Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. .ةلاقلما هذهل لماكلا صنلا ةياهن في ةصلاخلا هذهل ةيبرعلا ةمجترلا a Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan. b London School of Tropical Medicine and Hygiene, London, England. c Department of Child and Adolescent Health, World Health Organization, Geneva, Switzerland. Correspondence to Zulfiqar A Bhutta (e-mail: zulfiqar.bhutta@aku.edu). doi:10.2471/BLT.07.045849 (Submitted: 9 July 2007 – Revised version received: 13 November 2007 – Accepted: 27 November 2007 – Published online: 1 April 2008 ) Background Globally, some 4 million neonatal deaths occur each year, the majority within the first few days of birth in communities with poorly developed health systems.1 There is evidence that a small number of effectively delivered interventions could substantially re- duce newborn deaths in low-income communities.2,3 Although a few, large- scale, community-based randomized trials have been carried out, understand- ing of how these interventions can best be delivered in public health-care sys- tems is limited.3–6 Consequently, there is an urgent need to evaluate the effec- tiveness of intervention programmes.7 We developed a package of in- terventions for improving perina- tal and newborn care that could be implemented by lady health workers (LHWs), traditional birth attendants (Dais) and members of the local com- munity in rural Pakistan. Here we pres- ent our experience and the findings of a pilot study that involved implementing the package of interventions in a rural part of Sindh province, in preparation for a larger randomized trial. The trial is registered in the International Standard Randomised Controlled Trial Registry (ISRCTN16247511). Methods Study site The Hala and Matiari subdistricts (hereafter called Hala), located 250 km north of Karachi, comprise two towns and 1400 villages with a population of 0.6 million. The population largely works on the land and development indicators are typical of rural Sindh. A household survey conducted in 2000–2001 reported infant and neo- natal mortality rates of 82 and 43 per 1000 live births, respectively.8 In 2002, a memorandum of understanding was signed between Aga Khan University in Karachi and the Directorate of Health of the government of Sindh to under- take collaborative work on maternal and newborn care in the area. Pre-existing health infrastructure and services In Pakistan, a typical district health infrastructure comprises basic health units, rural health centres and a referral hospital. However, in many rural set- tings, staffing levels are inadequate and referral systems function poorly. Almost 70% of births take place at home, usu- ally attended by a Dai.9 Basic health units do not function after 14:00 and some do not have trained medical staff. Current training programmes for pub- lic sector nurses and physicians place little emphasis on common early neo- natal problems. To address some of these limita- tions, the government of Pakistan Research Community-based perinatal care in rural Pakistan 453Bulletin of the World Health Organization | June 2008, 86 (6) Zulfiqar A Bhutta et al. introduced the Lady Health Workers (LHW) programme in 1994. Women from local communities, with at least 8 years of formal education, undergo 6 months of training to deliver care in the home,10 and each LHW is responsible for a population of about 1000 (i.e. approximately 200 families). By the end of 2006, some 93 000 LHWs had been trained and they covered 60–70% of the rural population. The official stipend for LHWs is 1800 Pakistan rupees (approximately US$ 30) per month plus local travel costs. Although LHWs receive no training in delivering babies, they should liaise closely with Dais and medical staff at basic health units or rural health centres to monitor growth and to provide antenatal care, contraceptive advice and immunization services. An external evaluation of the LHW programme concluded that it was effective in delivering family planning services and immunization services and in the management of diarrhoea.11,12 However, indicators of newborn care were not evaluated. Development and implementation of the intervention package We developed an intervention package that involved the community and the two main providers of primary care: the LHWs and Dais. The intervention consisted of three components: 1. LHW training in home-based newborn care An enhanced module was developed in collaboration with the Directorate of Health for incorporation into the regular LHW training programme. It covered community mobilization, basic newborn care and group counselling. Box 1 lists the topics covered by both the standard LHW training programme and the additional module used in the intervention. Standard LHW training takes 18 months, including 3 months of lectures. Our training programme added an extra day every 3 months, making a total of 6 extra days. The LHWs were encouraged to identify all pregnant women in their area, to pro- vide basic antenatal care and to work with the Dais to identify when the birth would occur. In addition, LHWs were encouraged to visit mothers at specific times: twice during pregnancy, within 24 hours of birth, and on days 3, 7, 14 and 28 after delivery. No resus- citation equipment or injectable anti- biotics were provided, and only travel costs were reimbursed. 2. Dai training for basic newborn care The Dais largely work independently of the public health sector. The last large-scale Dai training programme in Pakistan was conducted almost three decades ago but no system for supervi- sion or follow-up was put in place.13 We developed a 3-day voluntary train- ing programme in basic newborn care for Dais, which included basic resus- citation and immediate newborn care. Only the cost of transport and meals was reimbursed. The Dais were also encouraged to attend LHW-led com- munity education sessions. Training for LHWs and Dais was carried out between August and September 2003. 3. Community organization and mobilization and group education sessions Two community mobilizers from Aga Khan University assisted LHWs in identifying community volunteers, who helped set up community health committees for maternal and newborn care in their villages in close liaison with LHWs. These committees supported LHWs in conducting 3-monthly group education sessions in the intervention villages and helped to establish an emergency transport fund for mothers and newborns. Sessions were attended by women of reproductive age, adoles- cent girls and older women. The LHWs used standard materials, specially devel- oped flip charts and a two-part video docudrama on pregnancy and newborn care made in the local language to promote the knowledge and behaviour detailed in Box 1. In communities in which the in- tervention package was not imple- mented, the LHW training programme continued as usual, with regular re- fresher sessions, but no attempt was made to link LHWs with the Dais. Special training in basic and interme- diate newborn care was offered to all public-sector rural health centre and hospital-based medical and nursing staff, irrespective of whether the in- tervention was implemented in their community. All health-care facilities were provided with basic and interme- diate newborn care equipment courtesy of the United Nations Children’s Fund (UNICEF) in Sindh. Data collection In total, 24 village clusters were identi- fied from the catchment areas of pri- mary care facilities. They comprised the estimated sample required for the final cluster-randomized trial.14 Each cluster contained a basic health unit or a rural health centre which provided the train- ing base for the corresponding LHW. Eight clusters were randomly selected for this pilot study. A baseline house- hold and facility survey was carried out in these eight clusters between May and June 2003 to assess their socio- economic characteristics and baseline perinatal and neonatal mortality rates, Box 1. Curriculum of the lady health worker training programme Standard curriculum (all village clusters) 1. Promotion of antenatal care 2. Iron and folate use in pregnancy 3. Immediate newborn care 4. Cord care (cleaning and avoiding the use of traditional materials, such as ash and lead powder) 5. Promotion of exclusive breastfeeding Additional curriculum (for intervention village clusters) 1. Promotion of adequate maternal nutrition and rest 2. Early breastfeeding (within the first hour) and colostrum administration (avoidance of prelacteal feeds) 3. Thermoregulation 4. Home care of low-birth-weight infants 5. Treatment of neonatal pneumonia with oral trimethoprim-sulphamethoxazole 6. Recognizing sick newborns and danger signs requiring 7. Training in group counselling and communication strategies 454 Bulletin of the World Health Organization | June 2008, 86 (6) Research Community-based perinatal care in rural Pakistan Zulfiqar A Bhutta et al. which were based on all births and deaths in the preceding 12 months. Subsequently, the four clusters cho- sen to receive the intervention were matched with four control clusters for population size and birth and neonatal mortality rates. In addition to the baseline survey, two further cross-sectional surveys of all households were conducted by a sepa- rate team in both the middle (June–July 2004) and at the end (August –Septem- ber 2005) of the pilot study to collect data on births, deaths and care-seeking behaviour in the preceding 12 months. The LHWs also routinely recorded information on births and deaths. Information on referrals was collected from the LHWs, the Dais and com- munity health committees, and a team of trained anthropologists carried out verbal and social autopsies of stillbirths and neonatal deaths. Finally, in September 2005, a team of anthropologists undertook a more detailed survey of 400 randomly selected households from each study arm in which there had been a live birth in the preceding 12 months. This survey collected information on maternal knowledge and behaviour with regard to newborn care and on care provision by various care providers. Results Table 1 shows the baseline demo- graphic and socioeconomic character- istics of the eight village clusters and Table 1. Baseline characteristics of the intervention and control village clusters, June–August 2003 Characteristics Intervention village clusters Control village clusters Bhanoth Bhit Shah KK Nizamani Suhrab Pur Total Miran Pur Khyber Khandu Pir Jhando Total Demographic characteristics Population 12 461 25 099 20 741 15 782 74 083 12 953 26 025 14 852 10 687 64 517 Households 1 630 3 810 3 170 2 538 11 148 1 828 3 941 2 184 1 592 9 545 Villages 28 35 50 37 150 27 60 46 32 165 Women of reproductive age 3 085 6 397 5 416 3 850 18 748 3 186 6 240 3 740 2 646 15 812 Pregnant women 388 630 575 463 2 056 387 644 380 280 1 691 Live births 474 866 663 493 2 496 430 895 553 441 2 319 Stillbirths 34 51 66 25 176 23 53 36 31 143 Total births 508 917 729 518 2 672 453 948 589 472 2 462 Early neonatal deaths 22 33 43 22 120 20 32 25 13 90 Late neonatal deaths 3 8 4 8 23 8 11 7 5 31 Total neonatal deaths 25 41 47 30 143 28 43 32 18 121 Perinatal deaths 56 84 109 47 296 43 85 61 44 233 Perinatal mortality rate (per 1000 live births) 110.24 91.60 149.52 90.73 110.8 94.92 89.66 103.57 93.22 94.64 Stillbirth rate (per 1000 births) 66.9 55.6 90.5 48.3 65.9 50.8 55.9 61.1 65.7 58.1 Early neonatal mortality rate (per 1000 live births) 46.4 38.1 64.9 44.6 48.1 46.5 35.8 45.2 29.5 38.8 Late neonatal mortality rate (per 1000 live births) 6.3 9.2 6.0 16.2 9.2 18.6 12.3 12.7 11.3 13.4 Total neonatal mortality rate (per 1000 live births) 52.74 47.34 70.89 60.85 57.29 65.12 48.04 57.87 40.82 52.18 Socioeconomic indicators Home ownership (%) 89.8 90.4 77.4 88.7 86.3 93.4 71.2 85.1 74.1 79.2 Households with electricity (%) 85.3 91.1 80.1 89.6 86.7 92.7 67.6 56.1 65.9 69.5 Firewood used for cooking (%) 98.8 77.4 97.7 99.2 90.8 99.3 93.0 99.7 98.7 96.7 Functional dry toilets (%) 57.6 43.9 58.0 80.0 56.9 73.5 56.4 74.8 76.8 67.5 Water pump in village (%) 53.1 58.5 71.7 86.9 66.6 64.7 68.2 27.5 55.1 55.9 Open drainage system for waste and sewage disposal (%) 51.0 47.3 32.3 12.7 37.3 16.6 30.8 12.9 18.1 21.8 Research Community-based perinatal care in rural Pakistan 455Bulletin of the World Health Organization | June 2008, 86 (6) Zulfiqar A Bhutta et al. details of births and newborn deaths. On average, more households in the intervention clusters had electricity (87% versus 70% in the control clus- ters) and water pumps (67% versus 56%, respectively) but overall stillbirth, perinatal and neonatal mortality rates were comparable. Implementation Eight training sessions were organized for Dais between August and Septem- ber 2003. Of the 150 Dais identified in the intervention clusters, 104 (69%) attended an average of two training sessions each. All 96 LHWs in the in- tervention clusters attended additional training in home-based newborn care. Of the 150 villages in the interven- tion clusters, 129 (86%) established community health committees and 46 (31%) set up an emergency transport and treatment fund. Four training ses- sions in primary- and intermediate-level newborn care were held for physicians at the health facilities in both interven- tion and control clusters. All LHWs continued to receive regular refresher training sessions. According to LHW records, over the 2-year period from August 2003 to August 2005, 875 community group education sessions were held in the intervention clusters, averaging one session per LHW every 4 months. In total, around 18 500 individuals at- tended these sessions. Of these, 64% were aged 14–30 years, 68% were mar- ried, 17% were pregnant and 11% were mothers-in-law. In almost half the ses- sions (47%), the LHW used the video docudramas to facilitate discussion. Retention of health-care staff was an issue. Of the 28 medical officers in the eight clusters initially trained in neonatal care and resuscitation, 19 (68%), including the paediatrician at the single district referral hospital, were transferred during the course of the pilot study. There were three different director-generals of health for Sindh province during the period 2002–2005, Fig. 1. Change in place of delivery for women from intervention villages, during the study Pl ac e of d el iv er y (% ) 0 90 Sep. 03– Nov. 03 80 70 60 50 40 30 20 10 Dec. 03– Feb. 04 Mar. 04– May 04 Jun. 04– Aug. 04 Sep. 04– Nov. 04 Dec. 04– Feb. 05 Mar. 05– May 05 Jun. 05– Aug. 05 79 75 75 68 64 71 59 65 18 18 21 29 33 26 38 30 3 6 4 4 3 3 2 3 Private health-care facility Government health-care facility Home Fig. 2. Change in still birth rate and in early and late neonatal birth rates, in intervention and control village clusters Ra te (p er 1 00 0 bi rt hs o r l iv e bi rt hs ) 0 70 2003 Early neonatal mortality rate (intervention) Stillbirth rate (intervention) Stillbirth rate (control) 2004 2005 60 50 40 30 20 10 Year Late neonatal mortality rate (control) Late neonatal mortality rate (intervention) Early neonatal mortality rate (control) which made it more difficult for proj- ect staff to communicate and build a consensus with health system managers and staff. However, more encouragingly, all LHWs in the study area remained in place. Effectiveness This pilot study was not designed for statistical evaluation and, consequently, analysis of the intervention’s impact was constrained by the small number of clusters. However, the data obtained are encouraging. The records of LHWs and health fa- cilities in the intervention clusters show that the proportion of births taking place at home declined in the intervention villages from 79% at baseline to 65% at the end of the study period (P = 0.01). This was largely explained by the increase in the proportion of births at which a skilled attendant in a public sector facility was present, which rose from 18% at baseline to 30% at the end of the study (P = 0.03; Fig. 1). The proportion of infants weighed and ex- amined by a LHW within 48–72 hours of birth increased from 58% at baseline to 87% at the end of the study. The average stillbirth rate at base- line in the intervention clusters was slightly higher than in control clusters, at 65.9 versus 58.1 per 1000, as was the average neonatal mortality rate, at 57.3 versus 52.2 per 1000 (Table 1). Moreover, the stillbirth rate varied significantly across the eight clusters (range 48.3–90.5 per 1000; P = 0.04), but the neonatal mortality rate did not (range 40.8–70.9 per 1000; P = 0.33). 456 Bulletin of the World Health Organization | June 2008, 86 (6) Research Community-based perinatal care in rural Pakistan Zulfiqar A Bhutta et al. In each of the four intervention clusters, stillbirth and neonatal mor- tality rates were lower following the intervention than before (Table 1 and Table 2). The average stillbirth rate decreased from 65.9 to 43.1 per 1000 births (Mantel-Haenszel risk ratio: 0.66; 95% confidence interval, CI: 0.53–0.83; P < 0.001), while the neo- natal mortality rate decreased from 57.3 to 41.3 per 1000 live births (Mantel- Haenszel risk ratio: 0.72, 95% CI: 0.56–0.91; P = 0.006). In control clus- ters, the pattern was less clear (Fig. 2). The stillbirth rate was largely un- changed (Mantel-Haenszel risk ratio: 1.04; 95% CI: 0.84–1.30; P = 0.23) as was the neonatal mortality rate (Mantel-Haenszel risk ratio: 1.14; 95% CI: 0.91–1.44; P = 0.26). During the study, 13 maternal deaths were re- corded in 5542 pregnancies; 5 in the 2932 pregnancies in the intervention clusters and 8 in the 2610 in the con- trol clusters. The survey of maternal knowledge and behaviour and care provision car- ried out in randomly selected villages after the intervention demonstrated important differences between inter- vention and control villages in terms of household behaviour and the care pro- vided by LHWs (Table 3). These data support the information obtained from LHWs on antenatal care, breastfeeding and postnatal visits. In particular, 21 households (5.3%) in the intervention villages reported that an LHW had been present at the delivery compared with only three (1.4%) in control vil- lages. Moreover, 113 families (64.6%) in intervention villages reported that a LHW had visited them within a week of the birth, with 64 families (56.0%) being visited within the first 48 hours. Information was also available on 396 episodes of newborn illness that was recognized and treated by, or referred on by, an intervention LHW. Of these, 245 (62%) were managed successfully at home. Of the 151 sick newborns who were referred for treatment, we were able to track 109 (72%) who sought care in public sector facilities. It was not possible to track those referred to the private sector. Importantly, 150 women (38%) in the intervention vil- lages who were interviewed reported that the village community health committee had played an important supportive and facilitative role during pregnancy and childbirth. Table 2. Birth and neonatal mortality data following the intervention, June–August 2005 Characteristics Intervention village clusters Control village clusters Bhanoth Bhit Shah KK Nizamani Suhrab Pur Total Miran Pur Khyber Khandu Pir Jhando Total Pregnant women 268 510 386 314 1478 294 537 298 272 1401 Live births 508 1028 730 666 2932 532 952 668 458 2610 Stillbirths 29 46 31 26 132 41 66 31 30 168 Total births 537 1074 761 692 3064 573 1018 699 488 2778 Early neonatal deaths 18 28 18 26 90 20 39 30 24 113 Late neonatal deaths 3 12 8 8 31 5 14 13 11 43 Total neonatal deaths 21 40 26 34 121 25 53 43 35 156 Perinatal deaths 47 74 49 52 222 61 105 61 54 281 Stillbirth rate (per 1000 births)a 54.0 (-19.3) 42.8 (-23.0) 40.7 -55.0 37.6 (-22.2) 43.1 (-34.6) 71.6 (+40.9) 64.8 (+16.0) 44.4 (-27.4) 61.5 (-6.4) 60.5 (+4.1) Early neonatal mortality rate (per 1000 live births)a 35.4 (-23.7) 27.2 (-28.5) 24.7 (-62.0) 39.0 (-12.5) 30.7 (-36.2) 37.6 (-19.2) 41.0 (+14.6) 44.9 (-0.7) 52.4 (+77.8) 43.3 (+11.6) Late neonatal mortality rate (per 1000 live births)a 5.9 (6.3) 11.7 (+27) 11.0 (+82.6) 12.0 (-25.9) 10.6 (+14.9) 9.4 (-49.5) 14.7 (+19.7) 19.5 (+53.7) 24.0 (+111.8) 16.5 (+23.2) Total neonatal mortality rate (per 1000 live births)a 41.3 (-21.6) 38.9 (-17.8) 35.6 (-49.8) 51.1 (-16.1) 41.3 (-28.0) 47.0 (-27.8) 55.7 (+15.9) 64.4 (+11.2) 76.4 (+87.2) 59.8 (+14.6) Perinatal mortality rate (per 1000 births)a 87.5 (-20.6) 68.9 (-24.8) 64.39 (-56.9) 75.1 (-17.2) 72.5 (-34.6) 106.5 (+12.2) 103.1 (+15.0) 87.3 (-15.7) 110.7 (+18.7) 101.2 (+6.9) a Values in parentheses are the percentage change from baseline. Discussion Notwithstanding the difficulties as- sociated with the transfer of medical personnel, our data suggest that the intervention package influenced new- born care in the home and care-seeking behaviour. However, the study had several limitations that should be rec- ognized. Study limitations Although village clusters in this pilot study were matched for mortality, public sector health facilities and Dais available, the groups differed in some important respects. In particular, the number of LHWs per inhabitant was higher in intervention villages. In ad- dition, as routine data collection by LHWs was strengthened in the in- tervention clusters only, so as not to alter LHW behaviour in control villages, only limited data on LHW performance in control clusters were available. Although encouraging, the findings must be regarded as prelimi- nary and need to be corroborated by the planned larger effectiveness trial, whose results are expected in late 2008. Nevertheless, these data are the first on the effectiveness of using existing health- Research Community-based perinatal care in rural Pakistan 457Bulletin of the World Health Organization | June 2008, 86 (6) Zulfiqar A Bhutta et al. Table 3. Perinatal care and care provision reported after the intervention in randomly selected intervention and control villages Characteristics Sample of intervention village clusters (N = 395) Sample of control village clusters (N = 375) n % n % Antenatal check-up during last pregnancy 313 79.2 247 65.9 Proportion who received maternal and newborn health information during pregnancy 334 84.6 93 24.8 Main source of maternal and newborn health information during last pregnancy (out of 334 and 93 in intervention and control villages, respectively) LHW 288 86.2 33 35.5 Dai 10 3.0 10 10.8 Doctor 18 5.4 43 46.3 Domiciliary visit by LHW during the last pregnancy 273 69.1 21 28.4 Receipt of tetanus toxoid during pregnancy 310 78.5 246 65.6 Procurement of clean delivery kit before delivery 249 63.0 5 1.3 Delivery in government health facility 121 30.6 48 12.8 Presence of LHW during delivery 21 5.3 3 1.4 Application of traditional materials to the cord 176 44.6 300 80.0 Bathing the baby within 6 hours of birth 198 50.1 113 30.1 Colostrum administration 299 75.7 149 39.7 Breastfeeding within an hour of birth 261 66.1 79 21.1 Exclusive breastfeeding for first 4 months 190 48.1 117 31.2 Postnatal visit by LHW in the week after birth 113 64.6 39 18.1 Newborn examination within the first 48 hours after birth 64 56.0 15 38.5 Support received during pregnancy from the community health committee 150 38.0 19 5.1 LHW, lady health worker. care workers (i.e. LHWs and Dais) to deliver a package of interventions. The unchanged perinatal and neo- natal mortality rates observed in con- trol clusters are consistent with recent findings from the 2007 Demographic and Health Survey, which indicates that neonatal mortality rates in Pakistan have not changed in over a decade.15 Factors contributing to the observed effects While our results appear similar to those of Jhokio et al. in rural upper Sindh,16 there are important differ- ences. Jhokio et al. focused on training Dais and linking them with existing health system staff, which led to a reduction in perinatal mortality. Our training programme for Dais was much less intensive and our intervention focused principally on community be- haviour and LHW training. Although the overall number of skilled attendants in the area did not change during the period 2003–2005, the proportion of births at which skilled attendants within public sector facilities were pres- ent, especially in the main Hala referral hospital and in rural health centres in the catchment area, increased substan- tially in the intervention clusters. These findings support previous studies, which found that community support strategies and the creation of demand affect care-seeking behaviour and neo- natal mortality.5,17 Feasibility of strengthening the LHW programme The LHW programme is the main- stay of primary care for reproductive health services in rural Pakistan.11,12,18,19 Our preliminary findings indicate that LHWs, working with traditional birth attendants and skilled care providers, can play a major role in implementing interventions that affect maternal and newborn care. As in northern Pakistan, our findings suggest that community group counselling sessions may be a powerful, low-cost and effective means of reaching a large number of women in rural settings and may also influ- ence other community members.20 The innovative use of information, educa- tion and communication materials and docudramas was consistent with the government’s media policy for health education. The survey of maternal knowledge and behaviour and care provision car- ried out in randomly selected villages at the end of the pilot study indicated that promising changes took place in key household behaviours and prac- tices. These positive findings were also observed in Nepal where community support groups assisted by experienced community mobilizers conducted monthly group meetings in wards with an average population of 700–800.21 In contrast, our intervention was less intensive as an average of one group session took place every 3 months per 1000 population as part of a routine health programme. Conclusions Our data provide evidence that new- born outcomes can be influenced by a package of interventions implemented using a community care and outreach strategy within the existing health-care system.2,3,22 In contrast to other studies of domiciliary care,4,23 no injectable antibiotic or resuscitation equipment was provided to LHWs since a refer- ral system, though weak, did exist in the area. We did, however, strengthen training for staff working in primary and secondary health-care facilities in both intervention and control vil- lages. The increased involvement of skilled attendants at public health fa- cilities that was observed underscores the importance of strengthening the health-care system to complement the community-based approach.24 These promising preliminary find- ings still have to be confirmed by a larger randomized trial, which is now 458 Bulletin of the World Health Organization | June 2008, 86 (6) Research Community-based perinatal care in rural Pakistan Zulfiqar A Bhutta et al. underway in 16 village clusters cover- ing a population of approximately 318 000 and whose results should be available in late 2008. If these prelimi- nary findings are confirmed, they will indicate one way to address the chal- lenge of improving newborn health and survival in community settings in developing countries. ■ Acknowledgements We wish to acknowledge the input into the project provided at various stages by Dr Steve Wall, Dr Gary Darmstadt, Dr Nabeela Ali and Dr Amanullah Khan (SNL), Dr Asif Aslam (UNICEF), Dr Pariyal Channa, and several staff members of the National Programme for Primary Care of the Government of Pakistan (Dr Qazi Mujtaba Kamal, Dr Haroon Jahangir Khan and Dr Zahid Larik). The help provided by Dr Makhdoom Rafiquzzaman (former Nazim Hyderabad), Muhammad Ali Shah Jamot (Nazim Matiari), Dr Noushad Shaikh (former Health Secretary, Sindh), Dr Usman Chachar (DCO Matiari), Dr Hassan Murad Shah (former EDO Health Matiari), Dr Paryal Channa, Drs Abdul Wajid, Shabina Ariff, Jai Parkash and several members of the local government in Hala and Matiari is gratefully acknowledged. Funding: The Hala project is sup- ported by a collaborative grant from WHO and the Saving Newborn Lives (SNL) programme of Save the Chil- dren (USA), funded by the Bill & Melinda Gates Foundation. Competing interests: None declared. Résumé Mise en œuvre des soins périnatals en communauté : résultats d’une étude pilote dans le Pakistan rural Objectif L’étude pilote a examiné la faisabilité de délivrer un ensemble d’interventions communautaires visant à améliorer les soins périnatals et faisant appel à des agents de santé féminins (LHW) et à des accoucheurs traditionnels (Dais ) dans le Pakistan rural. Méthodes L’intervention a été mise en œuvre dans quatre parmi huit groupes de villages (soit au total : 315 villages et une population totale de : 138 600 habitants), les quatre autres servant de groupe de comparaison. Les LHW de groupes de villages bénéficiant de l’intervention ont reçu une formation supplémentaire axée sur les soins essentiels à la mère et au nouveau-né, ont mené des séances d’éducation communautaire en groupe et ont été encouragées à se mettre en relation avec les Dais locaux. L’intervention a été délivrée dans le cadre du programme gouvernemental LHW régulier et a été appuyée par la mise en place de comités sanitaires communautaires constitués de volontaires. Résultats Dans les villages bénéficiant de l’intervention, on a constaté une baisse notable, par rapport au niveau de référence, de la mortinatalité (de 65,9 à 43,1 pour 1000 naissances, p < 0,001) et des taux de mortalité néonatale (de 57,3 à 41,3 pour 1000 naissances vivantes, p < 0,001). La proportion d’accouchements assistés par du personnel qualifié a également augmenté dans les établissements publics, passant de 18 % au départ à 30 %, tandis que celle des naissances à domiciles diminuait de 79 à 65 %. Une enquête auprès des ménages a indiqué une plus grande fréquence de certains comportements clés (allaitement au sein précoce et exclusif, report du bain et des soins du cordon, par exemple) dans les villages concernés par l’intervention. Conclusion La réduction observée de la mortinatalité et des taux de mortalité néonatale indique que les agents de santé communautaires (à savoir les LHW et les Dais ) peuvent jouer un rôle efficace dans la mise en œuvre d’un ensemble de prestations communautaires et de proximité, entraînant une amélioration des soins pratiqués à domicile par les familles et un plus grand recours aux soins et à des prestateurs de soins qualifiés. Ces observations préliminaires doivent être confirmées par un essai suffisamment puissant. Resumen Implantación de la atención perinatal comunitaria: resultados de un estudio piloto realizado en el Pakistán rural Objetivo Se decidió investigar mediante un estudio piloto la viabilidad de la implantación efectiva de un paquete de intervenciones comunitarias de mejora de la atención perinatal basadas en el uso de trabajadoras sanitarias (lady health workers, LHW ) y parteras tradicionales (Dais ) en el Pakistán rural. Métodos La intervención se llevó a cabo en cuatro de ocho grupos de aldeas (en total: 315 aldeas y 138 600 habitantes), utilizando los otros cuatro para comparar los resultados. Las trabajadoras sanitarias de los grupos de intervención recibieron capacitación adicional centrada en servicios esenciales de atención de la madre y el recién nacido, dirigieron sesiones de grupo de educación comunitaria, y fueron alentadas a estar en contacto con las Dais locales. La intervención se llevó a cabo en el marco del programa habitual de LHW del gobierno, y para apoyarla se crearon comités voluntarios de salud comunitaria. Resultados En las aldeas de intervención se registraron reducciones considerables de las tasas de mortinatalidad (de 65,9 a 43,1 por 1000 nacimientos, P < 0,001) y de mortalidad neonatal (de 57,3 a 41,3 por 1000 nacidos vivos, P < 0,001) respecto a los valores basales. Además aumentó la proporción de partos atendidos por parteras cualificadas en centros del sector público, desde el 18% de referencia hasta un 30%, mientras que la proporción de partos domiciliarios disminuyó del 79% al 65%. Una encuesta de hogares mostró una mayor frecuencia de comportamientos cruciales (como por ejemplo la lactancia materna temprana y exclusiva, la posposición del primer baño y el manejo del cordón umbilical) en las aldeas de intervención. Conclusión La mejora observada en las tasas de mortinatalidad y mortalidad neonatal indica que los agentes de salud comunitarios (en este caso LHW y Dais ) pueden aplicar eficazmente un paquete de medidas comunitarias de extensión que propicie prácticas mejoradas de atención domiciliaria por las familias, una mayor búsqueda de atención y un mayor recurso a proveedores de atención especializados. Estas observaciones preliminares deberán ser confirmadas mediante un ensayo más robusto. Research Community-based perinatal care in rural Pakistan 459Bulletin of the World Health Organization | June 2008, 86 (6) Zulfiqar A Bhutta et al. صخلم ناتسكاب فير في ةيدايترا ةسارد جئاتن :ةدلاولاب ةطيحلما ةترفلا في ةيعمتجلما ةياعرلا قيبطت ينسحتل ةيعمتجم تلاخدت ةمزح ميدقت ىودج ةساردلا هذه تثحب :فدهلا تايادو ،تايحص تلاماع مادختساب كلذو ،ةدلاولاب ةطيحلما ةترفلا في ةياعرلا .ناتسكاب فير في ،تارهام 315( ةيورق تاعومجم نياثم ينب نم ،عبرأ في لخدتلا اذه قِّبُط :ةقيرطلا عبرلأا تاعومجلما تلّـَ ثم مانيب ،)ةمسن 138 600 ناكس ددع ليماجإب ةيرق ز َّكرت ًايفاضإ ًابيردت تايحصلا تلاماعلا ت َّقلتو .ةنراقملل تاعومجم ىرخلأا ةيعماج تاسلج نيرجأ ماك ،نادلولاو تاهملأل ةيساسلأا ةياعرلا بناوج لىع .تايلحلما تايادلا عم طارخنلاا لىع نهعيجشت متو ،ةيعمتجلما ةيعوتلل ،تايحصلا تلاماعلل يماظنلا يموكحلا جمانبرلا راطإ في لخدتلا اذه م ِّدُقو .ةيعوطت ةيعمتجم ةيحص ناجل ءاشنإ في لثتم ًماعد ى ِّقلت ماك في ًايربك ًاضافخنا تلاخدتلا هذه اهيف ترج يتلا ىرقلا تدهش :تادوجولما ةدلاو 1000 لكل 43.1 لىإ 65.9 نم ،)تيم ديلو ةدلاو( صلاملإا تلادعم لىإ 57.3نم،نادلولا تايفو تلادعمو ،)0.001 نم لقأ لماتحلاا ةبسن( ةيح تعفترا ماك .)0.001 نم لقأ لماتحلاا ةبسن( ةيح ةدلاو 1000 لكل 41.3 ةياعرلا قفارم في تارهام تادلوم يديأ لىع ترج يتلا تادلاولا ةبسن تادلاولا ةبسن تضفخنا مانيب ،%30 لىإ ،ساسأ طخك %18 نم ،ةماعلا لىعأ ارتاوت سرلأا ىوتسم لىع يرُجأ حسم رهظأو .%65 لىإ %79 نم ةيلزنلما في رخأتلاو ،هيرغ نود يدثلا نم ركبلما عاضرلإا لثم( ةيساسلأا تايكولسلل .تلاخدتلا هذه اهيف ترج يتلا ىرقلا في )هتَّسرب ةيانعلاو ديلولا ميمحت ،نادلولا تايفوو ،صلاملإا تلادعم في ظحول يذلا نسحتلا ِّينبي :جاتنتسلاا نكيم )تايادلاو تايحصلا تلاماعلا( عمتجلما ةحص لاجم في تلاماعلا نأ ةيلاصيلإاو ةيعمتجلما تامدخلا ةمزح قيبطت في لعاف رود نهل نوكي نأ في كلذكو ،تلائاعلا لبق نم ةيلزنلما ةياعرلا تاسرمام ينسحت لىإ يدؤت يتلا تامدخ نم بركأ لكشب ةدافتسلااو ةياعرلا سماتلاب قلعتلما كولسلا زيزعت نم اهديكأت لىإ ةيئدبلما تاظحلالما هذه جاتحتو .ةرهلما ةياعرلا يم ِّدقم .ةبسانلما دراولماو تايناكملإا اهل رفوتـت ةبرجت للاخ References Lawn JE, Cousens S, Zupan J; Lancet Neonatal Survival Steering Team. 4 1. million neonatal deaths: when? where? why? 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