Pakistan has a high maternal mortality ratio and a low rate of skilled birth attendance (SBAs). To address these two important issues, the Pakistan Maternal Newborn and Child Health (MNCH) Programme launched the community midwives (CMW) initiative in 2007.The success of this initiative depends upon community acceptance and a CMW placement strategy that takes on board the views of the service providers and the serviced. The purpose of this study was to document the preference for birthing place and the associated reasons, of the community households for CMW assisted deliveries.
A mixed-methods national level study was conducted covering four provinces. The preferences of 1450 rural households, as to where they prefer the CMWs to conduct deliveries and why, were recorded using a quantitative method. The reasons behind particular preferences of women, community elders, CMWs and the MNCH Programme personnel were obtained through focus group discussions (FGDs) and in-depth interviews (IDIs).
Households were approached by trained female researchers from the rural districts selected through a multistage sampling technique. The respondents for the qualitative study were purposively selected with the help of the local lady health workers (LHWs).
The study found that a majority of the households preferred being serviced by CMWs at birthing stations (a room in the home of the CMW where delivery can take place) followed by a preference for having a flexibility between being serviced at the birthing station or at home, depending on the circumstances. The least favoured option was of having the delivery by the CMW at home. The major reason for preferring the birthing station was lack of facilities at home. Opting for flexibility between birthing stations and homes was based on the perception that during odd hours or when a complication occurs, the CMW could conduct the delivery at home. The stated motives for homebased CMW deliveries were mainly socio-cultural and related to stigma and privacy.
The preferences of women, community elders, and CMWs were similar to the household preferences. However, the views of the MNCH Programme personnel were in contrast to the opinions of the rest of the stakeholders, as they portrayed a preference for home-based deliveries.
Certain challenges were pointed out by the CMWs, including concerns about their introduction into the communities, their competition with the TBAs, procedural and financial issues, inadequate skillset and training, and mobility and security problems.
In order for the CMW initiative to succeed, it is imperative for the MNCH Programme to align their placement policy with the actual aspirations of the community at large and those of the CMWs. The findings of this study will provide the Programme with an important insight into the perceptions of the community, the reflection of which incorporated into the MNCH Programme's policy will go a long way in achieving the important objectives of the Programme.
Anon. Preference of birthing place: a mixed methods national study of communities, households,community midwives & MNCH programme. Human Development Research Foundation (HDRF), Islamabad, Pakistan (2012) iii + 47 pp.