The infant deaths a year, occurring in the

The Hala
Project, Pakistan (2002-2005)



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According to the World Health Organization
(2008), globally, there are 4 million infant deaths a year, occurring in the
first 28 days of life, also known as the neonatal period. Neonatal deaths
account for up to 40% of the under-five mortality rate worldwide and most of
these deaths occur in low-income, developing countries that have poor access
and availability to quality healthcare and education (Lawn, Cousens & Zupan,
2005). Pakistan has the third-highest neonatal mortality rate in the world at
an estimated 42 per 1000 live births in 2012, which estimates to about 295 000 infant
deaths a year (The World Bank, 2014). By focusing attention on interventions
that increase birth preparedness and newborn care, means having the ability to
prevent and manage risk factors such as infection, premature birth and asphyxia,
resulting in less neonatal fatalities and an overall decrease in child


Demographical Information of the Setting: Pakistan


Being a
third-world developing country in transition, together with an ever-increasing population,
Pakistan is far from capturing what is known as their demographic dividend. The
demographic dividend can be described as the opportunity created in a country
within about 40 years, and is a result of the reduced number of dependent
children in order for there to be an increase in the working force population
and per capita output as a whole. Neonatal and under-five mortality rate have a
direct effect on whether Pakistan capture their demographic dividend or not, as
the more infants that die, the more people want to have more, increasing the
proportion of dependent children and decreasing the working force population.
Another main cause for concern as to why Pakistan have not captured their
demographic dividend is because of the extremely low number of males and
females that are actually completing primary education. Although the government
has made attempts to prioritize this, education as a whole has not contributed
the country’s stability and development the way it should. Reducing child
mortality and increasing education levels in Pakistan is therefore a must, and
continuous planned efforts to do this will reap great rewards for the country
now and in the future.


(Sathaar, Royen
& Bongaarts, 2013).


Description of the Intervention


The Hala Project is a 2-year program that was carried
out by the Department of Pediatrics and Child Health at Aga Khan University
between the years of 2002 and 2005. It included 315 villages in the Matiari and
Hala sub districts of rural Pakistan, covering a population of 138 600 people. They
were divided randomly and equally into 24 clusters, firstly those that received
the intervention package as well as those who served as the control group. The
key goal for the Hala Project was to determine the effect of a community-based
interventions package to reduce perinatal and neonatal mortality, delivered
through community-based Lady Health Workers (LHWs) and Traditional Birth
Attendants (TBAs). The interventions package includes training Lady Health
Workers as well Traditional Birth Attendants in practical newborn care such as
resuscitation and handling, as well as health education and community
mobilization. It also involves community training and education in order to
recruit heath volunteers as well as establish and develop community-health
committees. The Hala Project primarily targets expecting mothers, however, it
is also targeted at women of reproductive age, adolescent girls, community
elders and local political leaders.

(Bhutta, Memon, Soofi, Salat, Cousens & Martines,


The leading agency of the investigation, the
Department of Pediatrics and Child Health in Karachi, Pakistan, partnered with
other key agencies including the London School of Tropical Medicine and Hygiene
and the Government of Sindh to design and develop the Hala Project.
Implementing agencies included the Department of Health and Aga Khan
University. Sponsors and donors included the World Health Organization and Save
the Children, an organization funded by the Bill and Melinda Gates Foundation. Beyond
the above-mentioned agencies, and perhaps the biggest beneficiary in the Hala
Project will be the people itself. This includes mothers and future mothers
that will give birth safely to children that will live, as well as infants that
will be protected and given the proper attention and care from birth to grow
into healthy and properly developed young children.

(Bhutta et al, 2008).

Achievements of the Hala
Project and Other Similar Interventions

The Hala Project intervention clusters brought about
a reduction in stillbirth rate, from 66 per 1000 live births at baseline to 43
per 1000 live births at endline. The neonatal mortality rate at baseline was
also significantly reduced from 57 per 1000 live births to 41. The perinatal
mortality rate declined from 101 at baseline down to 73 at endline.

(Bhutta et al, 2008).

A similar intervention to the Hala Project in terms
of the strategies being used was also conducted in a place called Sylhet in
Bangladesh in 2008. This study however, slightly differed in the way the
clusters were formed as some received the home-care intervention packages while
others received community-care intervention packages and the rest served as
controls. The study showed findings that state that the home-care intervention
packages were the most effective at reducing neonatal mortality as there was a
34% decrease within that 30-month intervention period, as compared to the community-based
clusters who showed no significant reduction in neonatal mortality.

(Baqui, Arifeen, Darmstadt, Ahmed, Williams, Seraji, Mannan, Rahman,
Shah, Saha, Syed, Winch, Lefevre, Santosham & Black, 2008)


Another highly successful intervention of comparable
nature was carried out in Uttar Pradesh, India, in 2008. It was a
cluster-randomized control trial, which used behavior change management as a
foundation of the preventative intervention package to reduce neonatal
mortality. It was also divided into three groups, the control, the first
intervention group which received the preventative
package of interventions for essential newborn care, and the second
intervention group which received the package of essential newborn care plus
use of a liquid crystal hypothermia indicator (ThermoSpot). Findings of the
study showed great improvements in thermal care, umbilical cord care,
breastfeeding, hygienic delivery and birth preparedness in the intervention
groups compared to controls. Neonatal mortality rate decreased as much as 54%
in the preventative package arm and 52% in the ThermoSpot arm.

(Kumar, Mohanty, Kumar, Misra, Santosham, Awasthi, Baqui, Singh,
Ahuja,  Malik, Ahmed, Black, Bhandari
& Darmstadt, 2008).


Goals and Outcomes

There were a number of specific goals needed to be
achieved to attain the desired outcomes that Project Hala had, these include:

% mothers who received tetanus toxoid during pregnancy. This goal was reached,
increased from 66% to 79%.

% mothers who received antenatal check-up during last pregnancy. This goal was
reached, increased from 28% to 79%.

% mothers who delivered in a Government health facility. This goal was reached,
increased from 13% to 31%.

% deliveries with presence of LHW. This goal was reached, increased from 1% to

% of newborns examined by LHWs within the first 48 hours after birth. This goal
was reached, increased from 39% to 56%.

% newborns with bathing delayed beyond six hours. This goal was reached,
increased from 30% to 50%.

% mothers who fed colostrum to their newborn. This goal was reached, increased
from 40% to 76%.

% mothers who breastfed their infant within an hour of birth. This goal was
reached, increased from 21% to 66%.

% mothers who breastfed their infant exclusively for first four months. This
goal was reached, increased from 31% to 48%.

The following goals however, did not prove to be
reached, but possibly with more time and effort, would have been:

10) Increase % mothers who received maternal newborn
health information during pregnancy.

11) Increase % mothers who received domiciliary visit by
LHW during the last pregnancy.

12) Increase % mothers who procured clean delivery kit
before delivery.

13) Increase % of newborns received post-natal visit by
LHW after birth.

14) Increase % mothers reported receiving support from
the community health committee during pregnancy.

Outcomes of the Hala Project include:

more informed rural community on neonatal health

of community health committees

of health volunteers

sharing of skills and knowledge

healthy and happier rural Pakistan

reduction in neonatal mortality rate

reduction in child mortality as a whole

It is safe to say that the Hala Project met all their
outcomes to a level that was satisfactory and definitely beneficial.


(Bhutta et al, 2008).






2: Strengths, Weaknesses and Evidence-Based Recommendations


Strengths versus Weaknesses

First and foremost, the study design being a type of
randomized control trial is advantageous as it is considered the gold standard
of investigation, eliminating bias as much as possible and producing
scientifically-sound results (Interactive Autism Network, 2014). Being a
randomized cluster-control trial, it is highly useful when conducting group
level interventions like the Hala project and when individual randomization is
difficult (Leroux, 2013). Within context of the intervention itself, it was
conducted using a very large sample, which always helps to make the findings
more generalizable to the population at large (Colorado state University,

Due to the fact that the intervention was largely
based on training and empowering community members, allows for sustainability
of the intervention for the villages after the Hala Project is complete. All
recruitment, implementation and evaluation practices followed strict ethical
guidelines and ensured the safety of the participants involved. Majority of the
impact indicators within the study showed to be successful, this is highly
encouraging for Pakistan in terms of health and as mentioned above, even
beneficial to factors contributing to education levels and the country’s
demographic dividend and future growth. One could say however, that the biggest
strength in the Hala Project is that it was completed with fidelity to its
original design and goals, and most of all, contributes largely to achieving
the worldwide Millennium Development Goal number 4 of reducing child mortality.

(Bhutta et al, 2008).

Naturally, as with any intervention, also come a
number of pitfalls. A randomized control trial may be limited by ethical
considerations. In this case, although randomization may have been a fair
procedure, some participants may find it unfair and even unethical that other
participants will be receiving a somewhat superior intervention that they will
not have the pleasure of benefiting from. The nature of this intervention also
means that it will be highly time-consuming as it involves measurement
indicators surrounding pregnancy and birth, aspects that take months at a time.
Due to the fact that it is such a large-scale intervention, means it also
required a number of staff and facilitators as well as the high costs to carry
this out. The intervention brought about successful and positive results and
although it involved training, education and empowerment, there is still never
a guarantee that it will continue once the intervention has run its course.
According to the article, health staff retention was also low; many medical
officers that were present at baseline were not apart of the study in the
duration of the intervention. Lastly, the number of LHW’s and TBAs differed
across the clusters and was not kept the same; this could easily be the reason
for the differences in results and adds to the complexity of having what is
suppose to be comparable groups.

(Bhutta et al, 2008).



South Asia is the region that accounts for the most neonatal fatalities
in the world (UNICEF,2014). All three countries mentioned in this paper fall
under this region, but a big knowledge gap not mentioned within the literature
is the sociocultural aspect of the problem, specifically the fact that many of
these countries consider boy babies to be superior to that of girl babies, and
as a result, many families have reduced care-seeking for girl babies
(Partnership for Maternal, Newborn and Child Health, 2011). Therefore, a
recommendation for the interventions as a whole, if planning to be implemented
in other similar Asian countries would be to educate participants further on
the importance of taking care of every
single child regardless of gender and to advocate for the rights of the
baby as well.


More than just the Hala Project in Pakistan, the intervention conducted
in Bangladesh that was briefly spoken about above also show results of the
effectiveness of home-based care intervention packages in reducing neonatal
mortality. When we look at the countries with the highest neonatal mortality
rates, we see that they lie mostly in rural, poverty stricken areas of
South-Asia and Sub-Saharan Africa. This being said, many, if not most
childbirths actually occur at home rather than at a health setting, as there is
always issues of transport, access, affordability and availability. This is why
it is recommended that if an intervention of similar nature is to be
implemented in another setting of similar situation, that it focuses more on
how to deliver and take care of a newborn at
home rather than focusing on trying to change what are usually very
reluctant health systems and governments. As much training and education as
these interventions may provide to health professionals and nurses, it will not
serve the highest benefit if it is experienced in only clinics and hospitals
and not in homes because it is in the homes that most of the deliveries and
deaths occur.


In a study conducted in rural Zambia on the effect of training
traditional birth attendants to manage several perinatal conditions and
neonatal mortality, similar to the Pakistan study, it was observed that out of
all the strategies used, training on the specific Neonatal Resuscitation Protocol
was the most effective at reducing mortality rather than just standard resuscitation
and care methods as the Hala Project provided. Deaths due to birth asphyxia had
reduced by a staggering 63%. Due to the fact that asphyxia is one of the
leading causes of neonatal death (World Health Organization, 2009). It is recommended
that all interventions of such manner should prioritize training on the
Neonatal Resuscitation Protocol, specifically modified and endorsed by the
American Academy of Pediatrics and American Heart Association, aimed at
reducing neonatal mortality from hypothermia and asphyxia.


(Gill, Mazala, Guerina & Kasimba, 2009).


In a randomized control trial done in Mumbai in 2008, on the effect of
community mobilization on neonatal mortality rate, showed that although
feasible, cheap and simple, the strategy of forming discussion groups for
mothers to share knowledge on their experiences simply wont be enough to reduce
the number of child deaths. Therefore, it is recommended that if such
strategies are used in neonatal interventions, that it be used in conjunction
with other more effective strategies like the provision of quality training by
professionals or regular home-visits by birth assistants. This is why the
successful interventions are called intervention packages as they include multiple small interventions for one
greater good; reducing neonatal/child mortality.


(More, Bapat,
Das,  Alcock, Patil,  Porel, Vaidya, Fernandez, Wasundhara Joshi
& Osrin, 2012).


According to Bhutta et al (2008), in many parts of South Asia, current
training for public sector nurses and physicians place very little emphasis on
neonatal care, and even then, the amount of health professionals available for
the public is at a complete minimum. This is why the government introduced the
Lady Health Workers program in 2004. This is where women from the community
with at least 8 years of formal education, can train for 6 months and be able
to provide home-based care. It is recommended that in high infant mortality
rate countries where there is also discrepancies in healthcare to implement
such a program into existing health systems. This way existing resources are
used and the public are in trusted hands even without the presence of a doctor
at all times. It also means skills and knowledge can be passed down for the
health betterment of future generations.





Community health workers can play a vital role in delivering effective
intervention packages for maternal and newborn care to reduce neonatal
mortality. The use of Traditional Birth Attendants and Lady Health Workers
proved to be an effective strategy used among many interventions of such
nature, and providing them with the essential skills to assist in reducing
events like infection, premature birth and asphyxia guarantees a result in the
reduction of infants that die within he first 28 days of life. Interventions
dealing with neonatal mortality should never be singular as literature supports
the highest effectiveness and efficacy when a number of small interventions are
grouped into packages and delivered through community care and outreach
programs. All across the world, child mortality has been on the decline. It is
up to continuous efforts such as these to ensure the number of infant deaths a
year keep reducing in numbers.





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