Steve on Hala

New Hope for Newborns

This piece originally appeared in GLOBAL HEALTH Magazine, re-posted on HNN with permission.

New findings from rural Pakistan were recently published in The Lancet showing for the first time that government-employed community health workers can save a substantial number of newborn lives. In the last decade, there have been several landmark studies demonstrating that neonatal mortality could be greatly reduced by simple home-based interventions provided by community health workers employed by research projects. Seminal research papers published in The Lancet [1,2,3] found that ‘packages’ of newborn care by community health workers – hired by the researchers – reduced neonatal mortality by an astounding 30-60%. However, many developing countries have not made use of these results as yet, in large part because there was no evidence for existing cadres of government community health workers providing these interventions with sufficient coverage and quality to reduce neonatal mortality at scale. That evidence is now available, thanks to the research led by Dr. Zulfiqar Bhutta of Aga Khan University in Pakistan, published this week in one of the leading medical journals, The Lancet.

The study was conducted in a very poor area in rural Pakistan (Hala) where neonatal mortality rates were among the highest in the world. More than 80% of births were at home, most attended by a local woman, usually an untrained traditional birth attendant (TBA). The study utilized a national cadre of community health workers, known as Lady Health Workers (LHWs), who are trained and deployed to cover approximately 70% of Pakistan’s villages. Major tasks of LHWs have traditionally included community education around sanitation, immunization, and nutrition. But LHWs did not previously have a role in promoting newborn care and changing traditional newborn care practices. Untrained TBAs and families often unknowingly expose newborns to harmful, even life-threatening risks (eg, hypothermia, pre-lacteal delays in breastfeeding, application of harmful substances to the cord, delays in recognition and seeking care for signs of newborn illness). Yet the government’s LHW program was missing the opportunity for LHWs to address critical newborn practices that could spell life or death. The Hala trial was specifically designed to answer the question: can newborn lives be saved by training the Pakistan government’s LHWs to focus on newborn care practices?

A Lady Health Worker in Pakistan. Photo by Alixandra Fazzina for Save the Children.


The Hala researchers found that the LHW training and supervision package reduced neonatal mortality, as well as stillbirths, by 15-20%, demonstrating to governments and professionals that existing cadres of community health workers could indeed save newborn lives, albeit somewhat less than previous trials employing only project workers. Dr Bhutta estimated that almost 100,000 newborns could be saved each year in Pakistan by implementing this simple package by the current LHWs – conducting group education sessions and making home visits to pregnant women and newborns. This news is critically important because it shows that governments, and their partners, can intervene now, using existing systems and resources that are already in place.

The Hala package included only preventive components, namely messages of essential newborn care at the time of delivery and in the postnatal period. These included an emphasis on hygiene (clean cord cutting), warmth for the baby (delayed bathing), immediate and exclusive breastfeeding, and recognition and care seeking for newborn danger signs. The addition of interventions to manage or treat complications was not tested in this study; but expanding the ‘package’ to provide simple treatment at home offers considerable potential to further reduce neonatal mortality. Evidence to date suggests that where facility-based care is not an option, adding community-based management of complications such as infection, low birth weight, and birth asphyxia is life-saving as well as feasible in a number of existing health systems in developing countries.

The evidence is unequivocal: community-based care saves newborn lives, even when delivered by existing cadres of government-employed community health workers. Where access to treatment is limited, there may be potential to further increase lives saved by adding feasible interventions to manage newborn complications.

It is time to ensure that policy makers and programs hear this good news. Not only in research settings, but in real-world settings such as in Pakistan’s LHW program, we now know that community health workers – serving in existing programs – can save thousands of newborn lives each year.

1. Bang A, Bang R, Baitule S, Reddy H, and Deshmukh M. (1999) Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet, 354, 1955-1961.
2. Baqui A, Arifeen S, Darmstadt G, Winch P, Williams E, Rosecrans A, Ahmed S, Santosham M, and Black R. (2008) Effect of a package of community-based newborn care delivered by two strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet, 371, 1936-1944.
3. Kumar V, Mohanty S, Kumar A, Mishra R, Santosham M, Baqui A, Awasthi S, Singh P, Singh V, Ahuja R, Singh J, Malik G, Ahmed S, Black R, Bhandari M, Darmstadt G. (2008) Impact of community-based behavior change management on neonatal mortality: a cluster-randomized, controlled trial in Shivgarh, Uttar Pradesh, India. Lancet, 372: 1151-62.

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