A cross-sectional analysis of the impact of lady health worker visits in the prenatal and postnatal period on the uptake of continuum of care interventions and childhood mortality in Pakistan

Background: Community health workers are crucial in bridging the gap between health care facilities and the general population. In Pakistan, the lady health worker (LHW) program was launched in 1994 to enhance access to essential health care services. However, the overall quality of care provided by LHWs and its impact on population-level coverage of key maternal, newborn, and child health (MNCH) interventions and mortality remain insufficiently understood. Methods: We conducted a cross-sectional analysis using data from 32 106 households with at least one woman of reproductive age across eight districts in Pakistan. Of these households, 63% were located within LHW catchment areas. We categorised households into three groups: 1) no contact with LHWs, 2) at least one contact during either pregnancy or post-delivery, and 3) at least one contact each during both pregnancy and post-delivery. Results: We observed a clear gradient in the uptake of pregnancy-related and MNCH interventions across the three groups. For instance, four antenatal care visits were reported as 25.3% in group A, 29.4% in group B, and 36.2% in group C (P < 0.001). Similar trend followed for skilled birth attendance; 54.4% group A, 58.7% group B, and 64.4% group C (P < 0.001). Measles vaccination coverage was 32.3% in group A, 35.2% in group B, and 49.7% in group C (P < 0.001). However, there was no evidence of significant differences in neonatal (P = 0.862), postnatal (P = 0.121), or child mortality (P = 0.319) across the three groups. Conclusions: Increased LHW contact enhances MNCH intervention uptake, though other mechanisms may contribute. Effectiveness depends on service quality, referral systems, and systemic barriers. Strengthening training, optimising referrals, and integrating community health initiatives are vital for sustainability. Addressing workforce shortages, gender challenges, and financial constraints is crucial. Future research should examine sociocultural and programmatic factors influencing health care access and outcomes. Registration: Clinicaltrials.gov NCT04184544.