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

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.