This study explored whether community midwives (CMWs) are improving access to skilled maternity care to socially excluded women in 2 districts, Jhelum and Layyah, Pakistan. Data was collected over 9 months (2001-2012) in 3 overlapping modules (level of services provided and challenges faced by CMWs, barriers to access faced by socially excluded women, quantitative measure of social exclusion and its link to uptake of CMW care). Data was collected via interviews, observation, focus groups, a cross-sectional survey (1457 women who had given birth in the past 2 years), and was gathered from CMWs, dais (traditional brith attnedants), other healthcare providers, women (age 15-49) and their families. Results: poor socially exceluded women (quartile 1) are 7x more likely to use a TBA, 80% less likely to use a physician and 4x more likely to give birth at home compared to rich socially included women (quartile 4). Only 3% and 11.7% of births in Layyah and Jhelum, respectively, were attended by a CMW. However CMWs were providing services equally to socially excluded and included women. Conclusion: The programme was not working because of the low status of women and of midwifery, poor selection criteria and training of CMWs, and failure to incorporate the gendered and social realities of their lives into the programme. The authors identified why some CMWs were successful and used this to recommend the following: improved selection and training of CMWs, increased CMWs in rural areas rather than urban areas, provision of an escorted service to the delivery, and financial incentives to provide care to the poor.
Mumtaz, Z.; Bhatti, A.; Levay, A.; Jhangri, G.; O’Brien, B. Are community midwives addressing the inequities in access to skilled birth attendance in Punjab, Pakistan? Gender, class and social exclusion. University of Alberta, Canada; Research and Advocacy Fund, Pakistan, (2013) 78 pp.