Mumtaz Z, Levay A, Bhatti A, Salway S
Edmonton Clinic Health Academy, School of Public Health, University of Alberta, Edmonton, AB, Canada.
BJOG. 2015 Jan;122(2):249-58. doi: 10.1111/1471-0528.13112. Epub 2014 Oct 15.
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.
Implementation research was conducted using an institutional ethnographic approach.
National programme and local community levels in Pakistan.
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.
Alignment of programme theory with real-world practice.
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.
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.
了解为何熟练接生这一公认的降低孕产妇死亡的策略在某些地区行之有效，而在巴基斯坦却成效不佳，并证明采用理论驱动方法评估孕产妇保健干预措施实施情况的价值。
采用机构民族志方法进行实施研究。
巴基斯坦的国家项目和当地社区层面。
对38名社区助产士、20名政策制定者、45名医疗服务提供者和136名社区成员进行了观察、焦点小组讨论和深入访谈。对一份关键政策文件进行了审查。整合了国家和地方层面的数据。
项目理论与实际做法的一致性。
数据揭示了项目理论、假设与实际情况之间的差距。该项目的设计未能考虑到：（1）助产士角色与贬低该角色的主导阶级和性别规范之间的不协调；（2）阻止社区助产士开展私人执业的市场和消费者行为；（3）公私部门合作的复杂性。统一部署政策未考虑现有的服务提供者密度和地理情况。
在设计孕产妇保健策略时，需要更加关注项目理论和“实际”情况，以便在不同背景下取得一致的结果。
