RESEARCH

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

Implantación de la atención perinatal comunitaria: resultados de un estudio piloto realizado en el Pakistán rural

Zulfiqar A Bhutta^I,1; Zahid A Memon^I; Sajid Soofi^I; Muhammad Suhail Salat^I; Simon Cousens^II & Jose Martines^III

^IDepartment of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
^IILondon School of Tropical Medicine and Hygiene, London, England
^IIIDepartment of Child and Adolescent Health, World Health Organization, Geneva, Switzerland

ABSTRACT

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.

RÉSUMÉ

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

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.

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 reduce newborn deaths in low-income communities.^2,3 Although a few, large-scale, community-based randomized trials have been carried out, understanding of how these interventions can best be delivered in public health-care systems is limited.^3–6 Consequently, there is an urgent need to evaluate the effectiveness of intervention programmes.⁷

We developed a package of interventions for improving perinatal and newborn care that could be implemented by lady health workers (LHWs), traditional birth attendants (Dais) and members of the local community in rural Pakistan. Here we present 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 neonatal 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 undertake 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 settings, staffing levels are inadequate and referral systems function poorly. Almost 70% of births take place at home, usually 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 public sector nurses and physicians place little emphasis on common early neonatal problems.

To address some of these limitations, the government of Pakistan 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 provide 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 resuscitation equipment or injectable antibiotics 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 supervision or follow-up was put in place.¹³ We developed a 3-day voluntary training programme in basic newborn care for Dais, which included basic resuscitation and immediate newborn care. Only the cost of transport and meals was reimbursed. The Dais were also encouraged to attend LHW-led community 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, adolescent girls and older women. The LHWs used standard materials, specially developed 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 intervention package was not implemented, the LHW training programme continued as usual, with regular refresher sessions, but no attempt was made to link LHWs with the Dais. Special training in basic and intermediate newborn care was offered to all public-sector rural health centre and hospital-based medical and nursing staff, irrespective of whether the intervention was implemented in their community. All health-care facilities were provided with basic and intermediate newborn care equipment courtesy of the United Nations Children's Fund (UNICEF) in Sindh.

Data collection

In total, 24 village clusters were identified from the catchment areas of primary 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 training base for the corresponding LHW. Eight clusters were randomly selected for this pilot study. A baseline household and facility survey was carried out in these eight clusters between May and June 2003 to assess their socioeconomic characteristics and baseline perinatal and neonatal mortality rates, which were based on all births and deaths in the preceding 12 months. Subsequently, the four clusters chosen 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 separate team in both the middle (June–July 2004) and at the end (August –September 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 community 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 demographic and socioeconomic characteristics of the eight village clusters and details of births and newborn deaths. On average, more households in the intervention clusters had electricity (87% versus 70% in the control clusters) 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 September 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 intervention clusters attended additional training in home-based newborn care. Of the 150 villages in the intervention clusters, 129 (86%) established community health committees and 46 (31%) set up an emergency transport and treatment fund. Four training sessions in primary- and intermediate-level newborn care were held for physicians at the health facilities in both intervention 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 attended these sessions. Of these, 64% were aged 14–30 years, 68% were married, 17% were pregnant and 11% were mothers-in-law. In almost half the sessions (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, which made it more difficult for project 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 facilities 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 examined 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 baseline 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).

In each of the four intervention clusters, stillbirth and neonatal mortality 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 neonatal 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 clusters, the pattern was less clear (Fig. 2). The stillbirth rate was largely unchanged (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 recorded in 5542 pregnancies; 5 in the 2932 pregnancies in the intervention clusters and 8 in the 2610 in the control clusters.

The survey of maternal knowledge and behaviour and care provision carried out in randomly selected villages after the intervention demonstrated important differences between intervention and control villages in terms of household behaviour and the care provided 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 villages. 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 villages who were interviewed reported that the village community health committee had played an important supportive and facilitative role during pregnancy and childbirth.

Discussion

Notwithstanding the difficulties associated with the transfer of medical personnel, our data suggest that the intervention package influenced newborn care in the home and care-seeking behaviour. However, the study had several limitations that should be recognized.

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 addition, as routine data collection by LHWs was strengthened in the intervention 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 preliminary 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-care workers (i.e. LHWs and Dais) to deliver a package of interventions.

The unchanged perinatal and neonatal mortality rates observed in control 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 differences. 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 behaviour 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 present, especially in the main Hala referral hospital and in rural health centres in the catchment area, increased substantially 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 neonatal mortality.^5,17

Feasibility of strengthening the LHW programme

The LHW programme is the mainstay 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 influence other community members.²⁰ The innovative use of information, education 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 carried out in randomly selected villages at the end of the pilot study indicated that promising changes took place in key household behaviours and practices. 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 newborn 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 referral 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 villages. The increased involvement of skilled attendants at public health facilities that was observed underscores the importance of strengthening the health-care system to complement the community-based approach.²⁴

These promising preliminary findings still have to be confirmed by a larger randomized trial, which is now underway in 16 village clusters covering a population of approximately 318 000 and whose results should be available in late 2008. If these preliminary findings are confirmed, they will indicate one way to address the challenge 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 supported by a collaborative grant from WHO and the Saving Newborn Lives (SNL) programme of Save the Children (USA), funded by the Bill & Melinda Gates Foundation.

Competing interests: None declared.

References

1. Lawn JE, Cousens S, Zupan J; Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: when? where? why? Lancet 2005;365:891-900. PMID:15752534 doi:10.1016/S0140-6736(05)71048-5        

2. Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for improving perinatal and neonatal health outcomes in developing countries: a review of the evidence. Pediatrics 2005;115 Suppl;519-617. PMID:15866863        

3. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L; Lancet Neonatal Survival Steering Team. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet 2005;365:977-88. PMID:15767001 doi:10.1016/S0140-6736(05)71088-6        

4. Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999;354:1955-61. PMID:10622298 doi:10.1016/S0140-6736(99)03046-9        

5. Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM, et al. Members of the MIRA Makwanpur trial team. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 2004;364:970-9. PMID:15364188 doi:10.1016/S0140-6736(04)17021-9        

6. Mullany LC, Darmstadt GL, Khatry SK, Katz J, LeClerq SC, Shrestha S, et al. Topical applications of chlorhexidine to the umbilical cord for prevention of omphalitis and neonatal mortality in southern Nepal: a community-based, cluster-randomised trial. Lancet 2006;367:910-8. PMID:16546539 doi:10.1016/S0140-6736(06)68381-5        

7. Bhutta ZA. Bridging the equity gap in maternal and child health. BMJ 2005;331:585-6. PMID:16155046 doi:10.1136/bmj.38603.526644.47        

8. Pakistan Demographic and Health Survey 1990/1991. National Institute of Population Studies, Islamabad, Pakistan. Columbia, MA: IRD/Macro International; 1992. Available from: http://www.measuredhs.com/pubs/pub_details.cfm?ID=77&srchTp=ctry [accessed on 11 March 2008]          .

9. Bhutta ZA, Ali N, Hyder AA, Wajid A. Perinatal and newborn care in Pakistan: seeing the unseen. In: Bhutta ZA, ed. Maternal and child health in Pakistan: challenges and opportunities. Karachi: Oxford University Press; 2004.         

10. Haines A, Sanders D, Lehmann U, Rowe AK, Lawn J, Jan S, et al. Achieving child survival goals: potential contribution of community health workers. Lancet 2007; 369(9579): 2121-31.         

11. Lady Health Worker Programme: external evaluation of the national programme for family planning and primary health care. Oxford Policy Management; 2002. p. 136. Available from: http://www.opml.co.uk/document.rm?id=690 [accessed on 11 March 2008]          .

12. Douthwaite M, Ward P. Increasing contraceptive use in rural Pakistan: an evaluation of the Lady Health Worker Programme. Health Policy Plan 2005;20:117-23. PMID:15746220 doi:10.1093/heapol/czi014        

13. Robinson WC, Shah MA, Shah NM. The family planning program in Pakistan: what went wrong? Int Fam Plan Perspect 1981;7:85-92. doi:10.2307/2948041        

14. Hayes RJ, Bennett S. Simple sample size calculation for cluster-randomized trials. Int J Epidemiol 1999;28:319-26. PMID:10342698 doi:10.1093/ije/28.2.319        

15. Pakistan Demographic and Health Survey 2006-2007 [Preliminary report]. National Institute of Population Studies, Islamabad, Pakistan. Columbia MA: IRD/Macro International; 2007. p. 25.         

16. Jokhio AH, Winter HR, Cheng KK. An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. N Engl J Med 2005;352:2091-9. PMID:15901862 doi:10.1056/NEJMsa042830        

17. Costello A, Azad K, Barnett S. An alternative strategy to reduce maternal mortality. Lancet 2006;368:1477-9. PMID:17071268 doi:10.1016/S0140-6736(06)69388-4        

18. Mumtaz Z, Salway S, Waseem M, Umer N. Gender-based barriers to primary health care provision in Pakistan: the experience of female providers. Health Policy Plan 2003;18:261-9. PMID:12917267 doi:10.1093/heapol/czg032        

19. Afsar HA, Younus M. Recommendations to strengthen the role of lady health workers in the national program for family planning and primary health care in Pakistan: the health worker's perspective. J Ayub Med Coll Abbottabad 2005;17:48-53. PMID:15929528        

20. Marsh DR, Sternin M, Khadduri R, Ihsan T, Nazir R, Bari A, et al. Identification of model newborn care practices through a positive deviance inquiry to guide behavior-change interventions in Haripur, Pakistan. Food Nutr Bull 2002;23 Suppl;109-18. PMID:12503239        

21. Wade A, Osrin D, Shrestha BP, Sen A, Morrison J, Tumbahangphe KM, et al. Behaviour change in perinatal care practices among rural women exposed to a women's group intervention in Nepal. BMC Pregnancy Childbirth 2006;6:20. PMID:16776818 doi:10.1186/1471-2393-6-20        

22. Haws R, Thomas AL, Bhutta ZA, Darmstadt GL. Impact of packaged interventions on neonatal health: a review of the evidence. Health Policy Plan 2007;22:193-215. PMID:17526641 doi:10.1093/heapol/czm009        

23. Kumar R. Training traditional birth attendants for resuscitation of newborns. Trop Doct 1995;25:29-30. PMID:7886825        

24. Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, et al. Overcoming health-system's constraints to achieve the Millennium Development Goals. Lancet 2004;364:900-6. PMID:15351199 doi:10.1016/S0140-6736(04)16987-0        

(Submitted: 9 July 2007 – Revised version received: 13 November 2007 – Accepted: 27 November 2007 – Published online: 1 April 2008)

1 Correspondence to Zulfiqar A Bhutta (e-mail: zulfiqar.bhutta@aku.edu).
doi:10.2471/BLT.07.045849