title: Good on paper: the gap between programme theory and real-world context in Pakistan's Community Midwife programme.
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.
  
  
  METHODS
  Implementation research was conducted using an institutional ethnographic approach.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
authors.affiliation: Edmonton Clinic Health Academy, School of Public Health, University of Alberta, Edmonton, AB, Canada.
authors.forename: Z
authors.initials: Z
authors.lastname: Mumtaz
authors.forename: A
authors.initials: A
authors.lastname: Levay
authors.forename: A
authors.initials: A
authors.lastname: Bhatti
authors.forename: S
authors.initials: S
authors.lastname: Salway
mesh_terms: D001291:Attitude of Health Personnel; D002391:Catchment Area, Health; D002983:Clinical Competence; D003150:Community Health Workers / Q000458:organization & administration; D004465:Economic Competition; D005260:Female; D017144:Focus Groups; D006801:Humans; D007407:Interviews as Topic; D008880:Midwifery / Q000193:education / Q000458:organization & administration* / Q000592:standards; D010154:Pakistan; D010465:Perception; D010560:Personnel Selection; D011203:Poverty; D011331:Private Practice / Q000191:economics; D024382:Professional Role; D016730:Program Development; D012017:Referral and Consultation; D019035:Rural Health Services / Q000458:organization & administration*; D012923:Social Class; D066262:Social Norms; D014186:Transportation
keywords: Community Midwife; Pakistan; implementation research; maternal health services; programme theory; skilled birth attendants