The HalaProject, Pakistan (2002-2005) APPENDIXA: PART 1 BACKGROUNDAccording to the World Health Organization(2008), globally, there are 4 million infant deaths a year, occurring in thefirst 28 days of life, also known as the neonatal period. Neonatal deathsaccount for up to 40% of the under-five mortality rate worldwide and most ofthese deaths occur in low-income, developing countries that have poor accessand availability to quality healthcare and education (Lawn, Cousens & Zupan,2005).
Pakistan has the third-highest neonatal mortality rate in the world atan estimated 42 per 1000 live births in 2012, which estimates to about 295 000 infantdeaths a year (The World Bank, 2014). By focusing attention on interventionsthat increase birth preparedness and newborn care, means having the ability toprevent and manage risk factors such as infection, premature birth and asphyxia,resulting in less neonatal fatalities and an overall decrease in childmortality. Demographical Information of the Setting: Pakistan Being athird-world developing country in transition, together with an ever-increasing population,Pakistan is far from capturing what is known as their demographic dividend. Thedemographic dividend can be described as the opportunity created in a countrywithin about 40 years, and is a result of the reduced number of dependentchildren in order for there to be an increase in the working force populationand per capita output as a whole. Neonatal and under-five mortality rate have adirect effect on whether Pakistan capture their demographic dividend or not, asthe more infants that die, the more people want to have more, increasing theproportion of dependent children and decreasing the working force population.Another main cause for concern as to why Pakistan have not captured theirdemographic dividend is because of the extremely low number of males andfemales that are actually completing primary education. Although the governmenthas made attempts to prioritize this, education as a whole has not contributedthe country’s stability and development the way it should.
Reducing childmortality and increasing education levels in Pakistan is therefore a must, andcontinuous planned efforts to do this will reap great rewards for the countrynow and in the future. (Sathaar, Royen& Bongaarts, 2013). Description of the Intervention The Hala Project is a 2-year program that was carriedout by the Department of Pediatrics and Child Health at Aga Khan Universitybetween the years of 2002 and 2005.
It included 315 villages in the Matiari andHala sub districts of rural Pakistan, covering a population of 138 600 people. Theywere divided randomly and equally into 24 clusters, firstly those that receivedthe intervention package as well as those who served as the control group. Thekey goal for the Hala Project was to determine the effect of a community-basedinterventions package to reduce perinatal and neonatal mortality, deliveredthrough community-based Lady Health Workers (LHWs) and Traditional BirthAttendants (TBAs). The interventions package includes training Lady HealthWorkers as well Traditional Birth Attendants in practical newborn care such asresuscitation and handling, as well as health education and communitymobilization.
It also involves community training and education in order torecruit heath volunteers as well as establish and develop community-healthcommittees. The Hala Project primarily targets expecting mothers, however, itis also targeted at women of reproductive age, adolescent girls, communityelders and local political leaders. (Bhutta, Memon, Soofi, Salat, Cousens & Martines,2008)Beneficiaries/StakeholdersThe leading agency of the investigation, theDepartment of Pediatrics and Child Health in Karachi, Pakistan, partnered withother key agencies including the London School of Tropical Medicine and Hygieneand the Government of Sindh to design and develop the Hala Project.
Implementing agencies included the Department of Health and Aga KhanUniversity. Sponsors and donors included the World Health Organization and Savethe Children, an organization funded by the Bill and Melinda Gates Foundation. Beyondthe above-mentioned agencies, and perhaps the biggest beneficiary in the HalaProject will be the people itself. This includes mothers and future mothersthat will give birth safely to children that will live, as well as infants thatwill be protected and given the proper attention and care from birth to growinto healthy and properly developed young children. (Bhutta et al, 2008).Achievements of the HalaProject and Other Similar InterventionsThe Hala Project intervention clusters brought abouta reduction in stillbirth rate, from 66 per 1000 live births at baseline to 43per 1000 live births at endline.
The neonatal mortality rate at baseline wasalso significantly reduced from 57 per 1000 live births to 41. The perinatalmortality rate declined from 101 at baseline down to 73 at endline. (Bhutta et al, 2008).A similar intervention to the Hala Project in termsof the strategies being used was also conducted in a place called Sylhet inBangladesh in 2008. This study however, slightly differed in the way theclusters were formed as some received the home-care intervention packages whileothers received community-care intervention packages and the rest served ascontrols. The study showed findings that state that the home-care interventionpackages were the most effective at reducing neonatal mortality as there was a34% decrease within that 30-month intervention period, as compared to the community-basedclusters 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 comparablenature was carried out in Uttar Pradesh, India, in 2008. It was acluster-randomized control trial, which used behavior change management as afoundation of the preventative intervention package to reduce neonatalmortality.
It was also divided into three groups, the control, the firstintervention group which received the preventativepackage of interventions for essential newborn care, and the secondintervention group which received the package of essential newborn care plususe of a liquid crystal hypothermia indicator (ThermoSpot). Findings of thestudy showed great improvements in thermal care, umbilical cord care,breastfeeding, hygienic delivery and birth preparedness in the interventiongroups 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 OutcomesThere were a number of specific goals needed to beachieved to attain the desired outcomes that Project Hala had, these include: 1) Increase% mothers who received tetanus toxoid during pregnancy. This goal was reached,increased from 66% to 79%. 2) Increase% mothers who received antenatal check-up during last pregnancy.
This goal wasreached, increased from 28% to 79%.3) Increase% mothers who delivered in a Government health facility. This goal was reached,increased from 13% to 31%.4) Increase% deliveries with presence of LHW. This goal was reached, increased from 1% to12%.5) Increase% of newborns examined by LHWs within the first 48 hours after birth. This goalwas reached, increased from 39% to 56%.6) Increase% newborns with bathing delayed beyond six hours.
This goal was reached,increased from 30% to 50%.7) Increase% mothers who fed colostrum to their newborn. This goal was reached, increasedfrom 40% to 76%.8) Increase% mothers who breastfed their infant within an hour of birth. This goal wasreached, increased from 21% to 66%.
9) Increase% mothers who breastfed their infant exclusively for first four months. Thisgoal was reached, increased from 31% to 48%.The following goals however, did not prove to bereached, but possibly with more time and effort, would have been:10) Increase % mothers who received maternal newbornhealth information during pregnancy.
11) Increase % mothers who received domiciliary visit byLHW during the last pregnancy.12) Increase % mothers who procured clean delivery kitbefore delivery.13) Increase % of newborns received post-natal visit byLHW after birth.14) Increase % mothers reported receiving support fromthe community health committee during pregnancy.
Outcomes of the Hala Project include:· Amore informed rural community on neonatal health· Establishmentof community health committees· Recruitmentof health volunteers· Continuoussharing of skills and knowledge· Ahealthy and happier rural Pakistan· Areduction in neonatal mortality rate· Areduction in child mortality as a wholeIt is safe to say that the Hala Project met all theiroutcomes to a level that was satisfactory and definitely beneficial. (Bhutta et al, 2008). PART2: Strengths, Weaknesses and Evidence-Based Recommendations Strengths versus WeaknessesFirst and foremost, the study design being a type ofrandomized control trial is advantageous as it is considered the gold standardof investigation, eliminating bias as much as possible and producingscientifically-sound results (Interactive Autism Network, 2014). Being arandomized cluster-control trial, it is highly useful when conducting grouplevel interventions like the Hala project and when individual randomization isdifficult (Leroux, 2013). Within context of the intervention itself, it wasconducted using a very large sample, which always helps to make the findingsmore generalizable to the population at large (Colorado state University,2014).
Due to the fact that the intervention was largelybased on training and empowering community members, allows for sustainabilityof the intervention for the villages after the Hala Project is complete. Allrecruitment, implementation and evaluation practices followed strict ethicalguidelines and ensured the safety of the participants involved. Majority of theimpact indicators within the study showed to be successful, this is highlyencouraging for Pakistan in terms of health and as mentioned above, evenbeneficial to factors contributing to education levels and the country’sdemographic dividend and future growth. One could say however, that the biggeststrength in the Hala Project is that it was completed with fidelity to itsoriginal design and goals, and most of all, contributes largely to achievingthe worldwide Millennium Development Goal number 4 of reducing child mortality.(Bhutta et al, 2008).Naturally, as with any intervention, also come anumber of pitfalls. A randomized control trial may be limited by ethicalconsiderations.
In this case, although randomization may have been a fairprocedure, some participants may find it unfair and even unethical that otherparticipants will be receiving a somewhat superior intervention that they willnot have the pleasure of benefiting from. The nature of this intervention alsomeans that it will be highly time-consuming as it involves measurementindicators 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 alsorequired a number of staff and facilitators as well as the high costs to carrythis out.
The intervention brought about successful and positive results andalthough it involved training, education and empowerment, there is still nevera guarantee that it will continue once the intervention has run its course.According to the article, health staff retention was also low; many medicalofficers that were present at baseline were not apart of the study in theduration of the intervention. Lastly, the number of LHW’s and TBAs differedacross the clusters and was not kept the same; this could easily be the reasonfor the differences in results and adds to the complexity of having what issuppose to be comparable groups.
(Bhutta et al, 2008).Recommendations South Asia is the region that accounts for the most neonatal fatalitiesin the world (UNICEF,2014). All three countries mentioned in this paper fallunder this region, but a big knowledge gap not mentioned within the literatureis the sociocultural aspect of the problem, specifically the fact that many ofthese countries consider boy babies to be superior to that of girl babies, andas a result, many families have reduced care-seeking for girl babies(Partnership for Maternal, Newborn and Child Health, 2011). Therefore, arecommendation for the interventions as a whole, if planning to be implementedin other similar Asian countries would be to educate participants further onthe importance of taking care of everysingle child regardless of gender and to advocate for the rights of thebaby as well. More than just the Hala Project in Pakistan, the intervention conductedin Bangladesh that was briefly spoken about above also show results of theeffectiveness of home-based care intervention packages in reducing neonatalmortality. When we look at the countries with the highest neonatal mortalityrates, we see that they lie mostly in rural, poverty stricken areas ofSouth-Asia and Sub-Saharan Africa. This being said, many, if not mostchildbirths actually occur at home rather than at a health setting, as there isalways issues of transport, access, affordability and availability. This is whyit is recommended that if an intervention of similar nature is to beimplemented in another setting of similar situation, that it focuses more onhow to deliver and take care of a newborn athome rather than focusing on trying to change what are usually veryreluctant health systems and governments.
As much training and education asthese interventions may provide to health professionals and nurses, it will notserve the highest benefit if it is experienced in only clinics and hospitalsand not in homes because it is in the homes that most of the deliveries anddeaths occur. In a study conducted in rural Zambia on the effect of trainingtraditional birth attendants to manage several perinatal conditions andneonatal mortality, similar to the Pakistan study, it was observed that out ofall the strategies used, training on the specific Neonatal Resuscitation Protocolwas the most effective at reducing mortality rather than just standard resuscitationand care methods as the Hala Project provided. Deaths due to birth asphyxia hadreduced by a staggering 63%. Due to the fact that asphyxia is one of theleading causes of neonatal death (World Health Organization, 2009). It is recommendedthat all interventions of such manner should prioritize training on theNeonatal Resuscitation Protocol, specifically modified and endorsed by theAmerican Academy of Pediatrics and American Heart Association, aimed atreducing neonatal mortality from hypothermia and asphyxia. (Gill, Mazala, Guerina & Kasimba, 2009).
In a randomized control trial done in Mumbai in 2008, on the effect ofcommunity mobilization on neonatal mortality rate, showed that althoughfeasible, cheap and simple, the strategy of forming discussion groups formothers to share knowledge on their experiences simply wont be enough to reducethe number of child deaths. Therefore, it is recommended that if suchstrategies are used in neonatal interventions, that it be used in conjunctionwith other more effective strategies like the provision of quality training byprofessionals or regular home-visits by birth assistants. This is why thesuccessful interventions are called intervention packages as they include multiple small interventions for onegreater 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, currenttraining for public sector nurses and physicians place very little emphasis onneonatal care, and even then, the amount of health professionals available forthe public is at a complete minimum.
This is why the government introduced theLady Health Workers program in 2004. This is where women from the communitywith at least 8 years of formal education, can train for 6 months and be ableto provide home-based care. It is recommended that in high infant mortalityrate countries where there is also discrepancies in healthcare to implementsuch a program into existing health systems. This way existing resources areused and the public are in trusted hands even without the presence of a doctorat all times. It also means skills and knowledge can be passed down for thehealth betterment of future generations. Conclusions Community health workers can play a vital role in delivering effectiveintervention packages for maternal and newborn care to reduce neonatalmortality. The use of Traditional Birth Attendants and Lady Health Workersproved to be an effective strategy used among many interventions of suchnature, and providing them with the essential skills to assist in reducingevents like infection, premature birth and asphyxia guarantees a result in thereduction of infants that die within he first 28 days of life.
Interventionsdealing with neonatal mortality should never be singular as literature supportsthe highest effectiveness and efficacy when a number of small interventions aregrouped into packages and delivered through community care and outreachprograms. All across the world, child mortality has been on the decline. It isup to continuous efforts such as these to ensure the number of infant deaths ayear keep reducing in numbers.