Challenges in delivery of skilled maternal care – experiences of community midwives in Pakistan

BACKGROUND: Maternal mortality ratio in Pakistan remains high at 276 per 100000 live births (175 in the urban areas and 319 in rural) with a mother dying as a result of giving birth every 20 minutes. Despite the intervening years since the Safe Motherhood Initiative launch and the Millennium Development Goals (MDGs), there have been few improvements in MDGs 4 and 5 in Pakistan. A key underlying reason is that only 39% of the births are attended by skilled birth attendants. Pakistan, like many other developing countries has been struggling to make improvements in maternal and neonatal health, amongst other measures, which include a nationwide health infrastructure network. Recently, government of Pakistan revised its maternal and newborn health program and introduced a new cadre of community based birth attendants, called community midwives (CMW), trained to conduct home-based deliveries. There is limited research available on field experiences of community midwives as maternal health care providers. Formative research was designed and conducted in a rural district of Pakistan with the objective of exploring role of CMWs as home based skilled service providers and the challenges they face in provision of skilled maternal care. METHODS: A qualitative research using content analysis was conducted in one rural district (Attock) of Pakistan. Focus group discussions were conducted with CMWs and other community based health workers as LHWs and LHSs, focusing on the role of CMWs in the existing primary health care infrastructure. RESULTS: Results of this study reveal that the community midwives are struggling for survival in rural areas as maternal care providers as they are inadequately trained, lack sufficient resources to deliver services in their catchment areas and lack facilitation for integration in district health system. CONCLUSIONS: CMWs face many challenges in the field related to the communities' attitude and the health system. With adequate training and facilitation by health department, CMWs have potential to play a vital role in reducing burden of maternal morbidity and in achieving significant gains in improving maternal and child health.