Zubia Mumtaz | October 2015
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Presentation at the Global Maternal Newborn Health Conference, October 21, 2015

Background: Skilled birth attendance is acknowledged as a key strategy to reduce maternal deaths. This intervention has, however, had mixed results in different programmatic contexts. Some countries, like Sri-Lanka, successfully reduced its maternal mortality rate, while others, like Indonesia, failed to achieve similar success. Pakistan launched a community midwife program in 2008. Evidence suggests this program is functioning sub-optimally. The objective of this study is to understand why an intervention that has been effective in some settings is failing in Pakistan and to demonstrate the value of a theory-driven approach to evaluating implementation of maternal healthcare interventions.

Methodology: Implementation research was conducted. Using an institutional ethnographic approach, data were generated at national program and local community levels. Observations, focus group discussions, and in-depth interviews were conducted with 36 CMWs, 20 policymakers, 45 health care providers and 136 community members. A critical policy document review was also conducted. This national and local level data were brought together to examine how the program theory aligned with real-world practice.

Results: Data revealed gaps between program theory, assumptions and reality on the ground. The design of the program failed to take into account: 1) the incongruity between the role of the midwife and the dominant class and gendered norms that devalue the role of a midwife; 2) market and consumer behaviour that prevented CMWs from establishing private practices; 3) level of infrastructural development. Uniform deployment policies failed to consider existing provider density and geography.

Conclusions: The data demonstrate the need for greater attention to program theory during design and early implementation of the interventions. By not articulating its program theory, the project failed to incorporate the ‘real-world’ setting into its processes that were essential for the program to meet its goals.