title: Exploring operational barriers encountered by community midwives when delivering services in two provinces of Pakistan: a qualitative study.
abstract: OBJECTIVE
  to explore barriers experienced by community midwives (CMWs) when delivering services, from their own and their managers׳ perspectives, at provincial and district level in the context of organisational factors, and to determine other factors linked with the poor performance of CMWs in the delivery of maternal, neonatal and child health (MNCH)-related services within their communities.
  
  
  METHODS
  qualitative study design using in-depth interviews (IDIs) and focus group discussions (FGDs).
  
  
  METHODS
  two districts in Khyber Pakhtunkhwa and Punjab provinces in Pakistan.
  
  
  METHODS
  41 participants were interviewed in depth; they included CMWs, lady health supervisors and managerial staff of the MNCH programme.
  
  
  METHODS
  participants were interviewed about administrative issues including financial and policy areas, training and deployment in the community, functioning in the community, and supervision and referral for emergency cases.
  
  
  RESULTS
  CMWs reported financial constraints, training needs and difficulty with building relationships in the community. They required support in terms of logistics, essential supplies, and mechanisms for referral of complicated cases to higher-level health facilities.
  
  
  CONCLUSIONS
  CMWs working in developing countries face many challenges; starting from their training, deployment in the field and delivery of services in their respective communities. Facilitating their work and efforts through improved programming of the CMW's services can overcome these challenges.
  
  
  CONCLUSIONS
  the MNCH programme, provincial government and other stakeholders need to take ownership of the CMW programme and implement it comprehensively. Long-term adequate resource allocation is needed to sustain the programme so that improvements in maternal and child health are visible.
authors.affiliation: Human Development Programme, Pakistan.
authors.forename: Shafiq
authors.initials: S
authors.lastname: Ur Rehman
authors.affiliation: Health Services Academy, Islamabad, Pakistan. Electronic address: jamil.ahmed.dr@gmail.com.
authors.forename: Jamil
authors.initials: J
authors.lastname: Ahmed
authors.affiliation: Human Development Programme, Pakistan.
authors.forename: Sher
authors.initials: S
authors.lastname: Bahadur
authors.affiliation: International Islamic University Islamabad, Islamabad, Pakistan.
authors.forename: Amber
authors.initials: A
authors.lastname: Ferdoos
authors.affiliation: Human Development Programme, Pakistan.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Shahab
authors.affiliation: Human Development Programme, Pakistan.
authors.forename: Nazish
authors.initials: N
authors.lastname: Masud
mesh_terms: D000293:Adolescent; D000328:Adult; D003153:Community Health Services / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data; D003906:Developing Countries; D005260:Female; D017144:Focus Groups; D006295:Health Resources / Q000191:economics / Q000600:supply & distribution; D006301:Health Services Needs and Demand; D006801:Humans; D008427:Maternal Health Services / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data; D008880:Midwifery / Q000191:economics / Q000379:methods*; D010154:Pakistan; D011247:Pregnancy; D036301:Qualitative Research; D019035:Rural Health Services / Q000191:economics / Q000600:supply & distribution
keywords: Barriers; Community; Maternal; Midwives; Operational; Qualitative