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. 2015 Jan;122(2):249-58.
doi: 10.1111/1471-0528.13112. Epub 2014 Oct 15.

Good on paper: the gap between programme theory and real-world context in Pakistan's Community Midwife programme

Z Mumtaz  1 , A Levay, A Bhatti, S Salway
Affiliations
Free PMC article

Good on paper: the gap between programme theory and real-world context in Pakistan's Community Midwife programme

Z Mumtaz et al. BJOG. 2015 Jan.
Free PMC article

Abstract

Objective: To understand why skilled birth attendance-an acknowledged strategy for reducing maternal deaths-has been effective in some settings but is failing in Pakistan and to demonstrate the value of a theory-driven approach to evaluating implementation of maternal healthcare interventions.

Design: Implementation research was conducted using an institutional ethnographic approach.

Setting and population: National programme and local community levels in Pakistan.

Methods: Observations, focus group discussions, and in-depth interviews were conducted with 38 Community Midwives (CMWs), 20 policymakers, 45 healthcare providers and 136 community members. A critical policy document review was conducted. National and local level data were brought together.

Main outcomes: Alignment of programme theory with real-world practice.

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

Conclusions: Greater attention to programme theory and the 'real-world' setting during design of maternal health strategies is needed to achieve consistent results in different contexts.

Keywords: Community Midwife; Pakistan; implementation research; maternal health services; programme theory; skilled birth attendants.

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Figures

Figure 1
Figure 1
Logic model of Pakistan's CMW programme.
See this image and copyright information in PMC

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References

    1. Campbell OMR, Graham WJ. Strategies for reducing maternal mortality: getting on with what works. The Lancet. 2006;368:1284–99. - PubMed
    1. Arulkumaran S. The State of the World's Midwifery, 2011: Organization of Midwifery Services in Sri Lanka. 2011. [ http://www.unfpa.org/sowmy/resources/docs/background_papers/01_Arulkumar...]. Accessed 20 December 2013.
    1. Bureau FH, Ministry of Health, Sri Lanka. Annual Report on Family Health 2010. Columbo: Family Health Bureau; 2012.
    1. Haththotuwa R, Senanayake L, Senarath U, Attygalle D. Models of care that have reduced maternal mortality and morbidity in Sri Lanka. Int J Gynecol Obstet. 2012;119:S45–9. - PubMed
    1. Fernando D, Jayatilleka A, Karunaratna V. Pregnancy-reducing maternal deaths and disability in Sri Lanka: national strategies. Br Med Bull. 2003;67:85–98. - PubMed

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