Can CMWs sustain quality services and high coverage as private providers in Chitral? A three-year prospective qualitative study

Background: The maternal and neonatal mortality rates of Chitral district of Pakistan are among the highest in the country. One of the factors that found to have positive impact on maternal and newborn health indicators is the availability of quality skill birth attendance because the majority of the poor women cannot access facility-based maternity care. Therefore, in 2006, the Government of Pakistan (GOP) has initiated a program to train and deploy Community Midwives (CMWs) to support safe pregnancies and births. The Aga Khan Health Service’ Pakistan, initiated the Chitral Child Survival Program (CCSP) in partnership with the National Maternal Neonatal and Child Health program. The CCSP was an intervention package deploying 28 CMWs in remote villages of the district and supported by several strategies to ensure successful transition of these CMWs in remote settings. Aim: This study aims to assess the effectiveness of CCSP’s package of interventions and to identify the push (facilitating) and pull (hindering) factors that may have an impact on the CMW’s service utilization. Methods: A three-year longitudinal prospective qualitative design, using individual in-depth CMWs and focus group interviews of key informants conducted in Chitral district of Khyber Pakhtunkhwa province, Pakistan in localities where the CMWs were deployed. Using purposive sampling, 27 CMWs (all part of CCSP), key informants and other stakeholders were recruited. Data analysis was done concurrently with data collection by the researcher, using Creswell’s six steps. Findings: The major themes emerging from this study are: Safe and competent care in isolated villages, community’s support and satisfaction from the CMW work, Supportive supervision, dynamics of CMWs with other healthcare professionals, CMW’s referral systems and its challenges, CMW remuneration and fee for service, and Sustainability of the CMW services Recommendations: Continued support, ongoing in-service education of CMWs and constant engagement of the community, certainly plays a crucial role. The GoP could consider incorporating CMWs in the service structure with a salary based on their scope of practice. This may ensure the sustainability of the CMW model and would allow community to access the MNCH services provided by them.