title: Coverage of private sector community midwife services in rural Punjab, Pakistan: development and demand.
abstract: BACKGROUND
  In 2007, the Government of Pakistan introduced a new cadre of community midwives (CMWs) to address low skilled birth attendance rates in rural areas; this workforce is located in the private-sector. There are concerns about the effectiveness of the programme for increasing skilled birth attendance as previous experience from private-sector programmes has been sub-optimal. Indonesia first promoted private sector midwifery care, but the initiative failed to provide universal coverage and reduce maternal mortality rates.
  
  
  METHODS
  A clustered, stratified survey was conducted in the districts of Jhelum and Layyah, Punjab. A total of 1,457 women who gave birth in the 2 years prior to the survey were interviewed. χ(2) analyses were performed to assess variation in coverage of maternal health services between the two districts. Logistic regression models were developed to explore whether differentials in coverage between the two districts could be explained by differential levels of development and demand for skilled birth attendance. Mean cost of childbirth care by type of provider was also calculated.
  
  
  RESULTS
  Overall, 7.9% of women surveyed reported a CMW-attended birth. Women in Jhelum were six times more likely to report a CMW-attended birth than women in Layyah. The mean cost of a CMW-attended birth compared favourably with a dai-attended birth. The CMWs were, however, having difficulty garnering community trust. The majority of women, when asked why they had not sought care from their neighbourhood CMW, cited a lack of trust in CMWs' competency and that they wanted a different provider.
  
  
  CONCLUSIONS
  The CMWs have yet to emerge as a significant maternity care provider in rural Punjab. Levels of overall community development determined uptake and hence coverage of CMW care. The CMWs were able to insert themselves into the maternal health marketplace in Jhelum because of an existing demand. A lower demand in Layyah meant there was less 'space' for the CMWs to enter the market. To ensure universal coverage, there is a need to revisit the strategy of introducing a new midwifery workforce in the private sector in contexts of low demand and marketing the benefits of skilled birth attendance.
authors.affiliation: School of Public Health, University of Alberta, 3-309 Edmonton Clinic Health Academy, 1140 - 87 Ave, Edmonton, AB, T6G 1C9, Canada. zubia.mumtaz@ualberta.ca.
authors.forename: Zubia
authors.initials: Z
authors.lastname: Mumtaz
authors.affiliation: School of Public Health, University of Alberta, 3-309 Edmonton Clinic Health Academy, 1140 - 87 Ave, Edmonton, AB, T6G 1C9, Canada. alevay@ualberta.ca.
authors.forename: Adrienne V
authors.initials: AV
authors.lastname: Levay
authors.affiliation: School of Public Health, University of Alberta, 3-309 Edmonton Clinic Health Academy, 1140 - 87 Ave, Edmonton, AB, T6G 1C9, Canada. gian.jhangri@ualberta.ca.
authors.forename: Gian S
authors.initials: GS
authors.lastname: Jhangri
authors.affiliation: Real Medicine Foundation Pakistan, Islamabad, Pakistan. afshanbhattipk@yahoo.com.
authors.forename: Afshan
authors.initials: A
authors.lastname: Bhatti
mesh_terms: D000328:Adult; D001294:Attitude to Health; D005260:Female; D006078:Government Programs; D006282:Health Personnel; D006801:Humans; D063130:Maternal Death / Q000517:prevention & control; D000068097:Maternal Health; D008427:Maternal Health Services; D008428:Maternal Mortality; D008880:Midwifery; D010154:Pakistan; D011247:Pregnancy; D017149:Private Sector; D019035:Rural Health Services; D012424:Rural Population; D011795:Surveys and Questionnaires; D035502:Trust; D000078329:Workforce