Challenges to community midwives in the provision of maternal services to rural communities of Pakistan

Abstract

Background

In 2006, the Government of Pakistan introduced community midwives to provide maternal care services to rural communities. Despite huge investments, evidence from several rural regions of Pakistan suggests that the utilization of maternal care through community midwives is very low and the maternal health indicators have not shown significant improvements. A qualitative study was conducted in Thatta, a rural district of Pakistan to explore the challenges faced by community midwives in the provision of skilled care.

Methods

We used an exploratory qualitative study design by conducting in-depth interviews using a semi-structured interview guide and a purposive sampling approach. The data was collected using the four domains of the community midwifery model. Interviews were conducted with officials from the health department, three categories of midwives including (i) midwifery students; (ii) trained and working community midwives; and (iii) trained and non-working community midwives. We also carried out interviews with community women. A total of 25 interviews were conducted. A thematic analysis approach was used for analysis.

Results

Based on the four domains of the community midwifery model that guided our data collection, two overarching themes were identified: (I) Social and cultural challenges faced by CMWs including the young age of midwives, and community women’s varied preferences for their delivery and childbirth processes were major challenges for community midwives (II) Support and acceptance including nonacceptance of community midwives’ services by doctors, other healthcare providers, and community women were identified as significant barriers to community midwives services.

Conclusion

The study provides key insights to program implementers to work on strategies and interventions to resolve the challenges faced by community midwives and to help achieve the aim of increasing skilled birth attendants in rural regions of Pakistan.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-13585-w.

Background

It is estimated that globally around 830 women die every day due to preventable causes related to pregnancy and childbirth [1]. Around 73 low and middle income countries (LMICs) account for 92% of maternal and newborn mortalities including India and Pakistan [2]. Pakistan is among the top 10 countries contributing 59% of maternal deaths globally [3]. The lifetime risk of death due to pregnancy-related causes in high-income countries is 1 in 4,085 women; 1 in 61 women in LMICs including countries in South Africa and South Asia; and in Pakistani women, it is substantially higher which is 1 in 80 women [3, 4].

During the last decades, the Government of Pakistan has introduced multiple healthcare interventions to address the high rates of maternal mortality [5]. These interventions included strengthening of health facilities such as improving their infrastructures and health workforces, capacity building of healthcare workers to provide basic and comprehensive obstetrics emergency services especially to those working in rural areas, and community mobilization by involving religious and community leaders in health and social activities [6]. The introduction of these interventions and efforts has decreased the rate of maternal mortality in Pakistan from a rate of 423.9 deaths per 100,000 live births in 1990 to 154 deaths per 100,000 live births in 2020 [7]. However, the slow progress and the low skilled birth attendance in rural areas of the country prompted further ongoing measures [8].

Evidence from Pakistan suggest that in urban areas 81% of childbirth deliveries takes place in a health facility, while in rural areas, only 50% women deliver at health facilities [9]. This urban-rural difference within Pakistan is even greater in the province of Sindh with 42% of childbirth deliveries have been reported to take place at homes in rural areas while 28% in urban areas [9]. In Thatta, which is our study site, maternal health is offered at primary and secondary level health care of the public healthcare system. The first level healthcare includes primary health facilities that involves basic health units (BHUs), and rural health centers (RHCs). The secondary level includes district hospitals that provide 24 h health services [9].

The key factor for high maternal death rates especially in rural areas of Pakistan is the lack of skilled birth attendants at a primary level to provide timely intervention to pregnant and postnatal women before they aggravate and become life-threatening [10]. Therefore, the Government of Pakistan introduced community midwives (CMWs) for rural communities during the last decades [11]. CMW program is one of the extensive community-based programs covering more than 20% of the population mainly the rural population in Pakistan [12].

There are midwifery schools established in all provinces of Pakistan to train CMWs which helps in the growth of the midwifery workforce [13]. The program is comprehensively designed to increase skill birth attendance and district health officials regulate supervision and monitoring of CMWs [12]. CMWs training includes theory classes followed by clinical component. CMWs are trained to attend normal childbirths, and identify and refer high risk pregnancies to a higher level of care. The first cohort completed their training in 2008 and were deployed to their catchment areas to establish private practices, each serving a population of 10,000 [14].

Despite huge investments in training and deployment of CMWs, evidence from several rural regions of Pakistan suggests that maternal care through CMWs is very low and the maternal health indicators have not shown significant improvements in last two decades [15, 16]. There is inadequate evidence available on the challenges faced by CMWs working in rural areas that hinder utilization of their services. There is also lack of evidence on what strategies have been taken by the government to increase their retention. Therefore, a qualitative study was conducted in a rural district (Thatta) of Pakistan to explore challenges to CMWs in providing their services. This paper seeks to explain the barriers and constraints faced by CMWs in the delivery of maternal care to rural communities.

Materials and methods

Study setting

The study site selected was district Thatta of Province Sindh, which is a rural district with a total population of 979,817 [17]. Only 17% of the women residing in district Thatta are literate, and approximately 40% of childbirths in the district take place at home [18]. We purposively selected this district as it reports the highest maternal and neonatal mortality in the province of Sindh [18]. Reports from 2012 to 2013 show that only 20.8% of pregnant women from the district received maternal healthcare services from all levels of healthcare including public and private, as well as primary and secondary level of healthcare [19]. Thus, the midwifery school was established in the year 2013 to train CMWs and increase the provision of primary level maternal and neonatal services in the district [19].

The midwifery school trains more than 30 CMWs each year. However, the district data displays that out of 150 deployed and registered CMWs, only 17 CMWs are present in the district to provide care to women and their children, indicating that only 11% are working and performing their services. Identifying the challenges of CMWs’ of district Thatta and their impact on non-retention and non-availability is important to inform suitable policy recommendations.

Study design and participants

A qualitative exploratory study was carried out. We focused on the perspectives of health officials, CMWs, midwifery students, and community women of district Thatta to explore challenges faced by CMWs in the provision of skilled care services.

In-depth interviews (IDIs) were conducted with officials from the health department who were involved in CMWs training and deployment (n = 5). Interviews with health officials and program implementers were to understand CMWs challenges from the administrative viewpoint and know the available guidelines for the provision of maternal care services.

Interviews were also conducted with three categories of CMWs including, (i) midwifery students who were currently enrolled in the community midwifery program in Thatta (n = 5); (ii) trained community midwives providing services in district Thatta (n = 5); (iii) trained community midwives who were not continuing their midwifery profession (n = 5). The purpose of interviews with midwifery students was to explore any challenges encountered during their training such as classroom and clinical training that could affect their on-field services, and their potential fears that could help program managers to strengthen their training. The interviews with working and non-working midwives were conducted to understand the pragmatic barriers to providing services. We also carried out interviews with community women (n = 5) from the areas of district Thatta where CMWs birthing stations and clinics were available. Those community women who had at least one past pregnancy were invited for the interviews to explore their preference for antenatal, delivery, and postnatal services. The interviews with community women helped us to understand their perceptions from the consumers’ viewpoint and their opinions on whether or not they prefer to get maternal services from midwives and why.

Ethical approval

Ethical approval for this study was obtained from the Aga Khan University Ethical Review Committee (2020-3391-11138). As the study was conducted during the time of lockdown because of COVID-19, the participants were interviewed on telephonic call. Study participants were asked to provide verbal consent (supplemental file 1) witnessed and signed by individuals outside of the research team. The consent was audio-recorded before participation in the study while ensuring complete anonymity and confidentiality. Verbal consent was translated into local languages (Urdu and Sindhi). All details related to the study were well explained to participants including the purpose of the study, possible risks and discomforts, possible benefits, the confidentiality of information, and the withdrawal procedure. Participants’ anonymity was assured, and no identifying characteristics were specified on the transcript. Identity of the participant was kept anonymous and participants were assigned a study number. Audio recordings were stored in an external hard drive in a safe cabinet and were destroyed after one year as per the institutional policy from where ethical approval was obtained.

Data collection and reflexivity

Semi-structured interview guides were developed by the research team. The CMW model (Fig. 1) was used to develop the interview guides. The detailed interview guides are provided as Supplemental file 2. Interview guides were prepared in the English language and translated into local languages Urdu and Sindhi to capture the perceptions of the study participants. The interviews were conducted in Urdu and Sindhi languages by the investigating team as preferred by the participants. The data was collected from August 2020 to December 2020. The study team members (BK, AF, FA, SS) have expertise in carrying out qualitative data collection and analysis. The team member (MR) has experience of working with midwives and midwifery leaders.

Fig. 1.

Community midwifery model

We included domains from the community midwifery model [20] that were specific to our research questions to develop our interview guide. The several specific questions derived from the selected domains were: (1) Affordability for CMWs services: such as CMWs fee for services, and community women’s affordability to utilize services (2) Community’s acceptance and support: such as the facilitators and barriers to CMWs services, women preference for maternal and neonatal services (3) Linkages between CMWs and facilities: such as linkages with referral health facilities (4) Dynamics between CMWs and other health care providers: such as their relationships with doctors and other healthcare workers working in their area, and any government initiatives taken to strengthen these relationships.

All interviews were scheduled according to participants’ preference of time and were audio-recorded following verbal consent from study participants. The purpose of the study was well-informed to all participants through an official letter sent by the Aga Khan University in advance of their interviews. Each interview lasted between 45 and 60 min. The lead author was fluent in local languages and carried out all the interviews. The data collection was carried out until data saturation was achieved and no new information emerged. We defined saturation as the amount of data needed until no new information and meaningful conclusions were drawn out on the research questions [21].

Data analysis

The data were transcribed into Sindhi and Urdu languages and later translated into English language and analyzed manually using a rapid analysis and a team-based approach [22]. The research team conducted multiple reflexive and iterative reviews of the transcripts and tapes to familiarize themselves with the data. The analysis began soon after the first interview and continued until we gathered information from all participants. This allowed for rigorous probing during interviews to collect maximum data about the topic.

An audit trail was used to document our decision-making process. Data were searched for information relating to the four specific domains of the framework (CMW model) that guided data coding, data analysis, and reporting of the findings. A qualitative thematic analysis approach was used to analyze our results.

A codebook was developed and additional codes on the referral system and social challenges that were not part of the CMW model, yet provided important information, were added to the codebook where possible. The researchers from the investigating team (BK, SS, AF, FA) participated in refining the codebook to reach a final consensus and resolve any discrepancies to improve the credibility and reliability of the data. This paper follows the guidelines as stated in the COREQ checklist (Supplemental file 3).

Results

A total of 25 interviews were conducted. Tables 1, 2, 3 and 4 describe the demographic details of the study participants.

Table 1.

Characteristics of health officials

Health officials	N = 5
Association with CMW program
Less than 5 years	2
5 to 10 years	2
More than 10 years	1
Supervision
District level	3
Provincial level	1
National level	1
Role
Training of CMWs	2
Supervision of CMWs	2
Program manager/implementer	1

Table 2.

Demographic details of midwifery students

Midwifery students	N = 5
Age
16–25	4
26–35	1
Education
Higher secondary (12 years of study)	5
Marital status
Unmarried	4
Married	1

Table 3.

Demographic details of working and non-working groups of midwives

Midwives	N = 10
Age
21–25	2
26–30	1
31–35	4
36–40	3
Education
High school	5
Undergraduate	2
Graduate	3
Midwifery course
12 months diploma	3
18 months diploma	7
Workplace:
Non-Governmental Organizations	4
Private organizations	5
Health facilities	1
Working experience as midwife
Less than 5 years	2
Less than 10 years	5
More than 10 years	2
Marital status
Unmarried	2
Married	8

Table 4.

Demographic details of community women

Community-women	N = 5
Age
16–30	1
31–45	3
> 45	1
Education None	2
Primary	1
College	2
Antenatal visits for recent pregnancy
Less than 3	3
3 to 8	2
Facility approach during recent childbirth
None (home birth)	1
CMWs birthing units	1
BHU, RHC (other primary facilities)	1
Secondary and tertiary care hospitals	2

All the study participants were contacted by the research team using a purposive sampling approach. All those who were approached provided an agreement to participate in the study. Based on the data collection, two overarching themes were identified: (I) social and cultural challenges faced by CMWs, and (II) support and acceptance. The themes and subthemes, and illustrative quotes are presented in Table 5.

Table 5.

Themes and subthemes

Themes	Subthemes	Illustrative Quotes
Social and cultural challenges faced by CMWs	Cultural acceptability of CMWs	“Midwives are young girls” “As midwives provide services to their local communities, they have to face many cultural challenges”
	Preferences for delivery and childbirth	“Dais (TBAs) in our areas are easily approachable” “Most people don’t go to hospital due to privacy”
Support and acceptance	Relationships with other HCPs	“They think us as dais (unskilled birth attendant)”
	Non-recognition of CMWs	“TBAs are very common here as they are easily available”

Social and cultural challenges faced by CMWs

Cultural acceptability of CMWs

Community women considered CMWs as not having enough experience because of their young age. They considered them naive to deal with reproductive health matters, which is considered as something related to being married or to an older age group.

Midwives are young girls. They are not competent for services. They go and study, but they don’t have practical skills to perform deliveries (Community woman)

The young midwives were deemed as not having sufficient exposure to perform deliveries and childbirth procedures which limited their acceptability. This challenge was discussed by one of the health officials of the district:

The young age of community midwives is not acceptable by communities. They think that unmarried girls and young girls do not have any experience to deal with these matters. Of course, experience is always given importance in comparison to education in any of the fields (Health official)

Midwifery students stated that they are provided rigorous training to perform field services. However, community people don’t recognize their skills and expertise when they are assigned to their clinical placements or clinics.

When we are assigned at our clinical placement to learn and perform deliveries, we are supervised by senior nurses and staff. We also do independent deliveries and get certified to perform deliveries, but there are very less people who trust on CMWs skills to perform deliveries. They trust on local women/daais, but not us, who are certified to do this work (Midwifery student)

No matter how efficiently we provide services to community women, they still would acknowledge doctors. They do know that we also take two years full training to become a midwife(Working midwife)

When asked from students that what motivated them to become a midwife despite of challenges in the profession, they shared that they were forcibly doing this, as midwifery is a female-oriented profession and their families wouldn’t allow them to go into any other field where they have to interact with any male members.

As far as my preference for this profession is considered, yes, I want to become a midwife, but this was put into my mind to opt for this profession because midwives usually don’t interact with male members of society. They are supposed to only interact with women (Midwifery student)

The non-acceptance of CMWs families to establishing birthing stations at homes, family’s restrictions to allow CMWs to work in hospitals because of female mobility issues, and the reservations of CMWs to allowing males (husbands of pregnant women) at their birthing stations to accompany their wives as their attendants were some of the important impeding factors identified for CMWs services.

The people in our village and our family don’t allow us to work in a male-dominated area because of security issues and our cultural norms (Non-working CMW)

I have seen that CMWs don’t allow husbands in their clinics to come with their wives, this might be the major reason that our community women prefer to have home births so that they don’t have to go anywhere. I hope that the conservations of our society could change so they can work easily in our communities (Health official)

Moreover, CMWs’ counseling and educational services over sensitive issues like abortion and family planning were disregarded by the community people. They are trained to provide education and awareness to their communities on these important issues, and the educational sessions on family planning were mandated by the Government of Pakistan for safe motherhood. However, communities’ resistance to education and counseling services was faced by CMWs.

Community midwives are mandated to provide community education on a diverse range of topics such as family planning, abortion, nutrition, postnatal care, lactation, and many other important topics, but we have seen that they are mainly involved in antenatal clinics and deliveries. This aspect is missing in their services because of community’s non-acceptance (Health official)

Working as a midwife is a challenge itself, acceptance among the community is the major challenge and this is when we give counseling on family planning or abortion. It’s because we’ve taboos associated with these topics (Working Midwife)

Community women’s varied preferences

Some CMWs reflected that they face challenges in convincing women to refer them to a better-equipped health facility in cases of high-risk pregnancies or when they suffer from pregnancy complications. One CMW mentioned:

It is very difficult to explain to them about the referral. They say that if we had to go there why we have visited you and what are you here for (Working midwife)

Another reason for refusing referral according to midwives’ viewpoints is the lack of privacy in labor rooms of hospitals as cited by one of the CMWs:

In our area, there is one big hospital that is civil hospital Thatta where multiple patients deliver in a single labor room. Most women do not prefer to go to hospitals because of that (Working midwife)

Contradictory to this, community women showed up their interest in having childbirth at home instead of covering the distance to reach any health facility such as a midwife’s birthing station or a hospital’s labor room. They voiced their concerns regarding the non-availability of transportation and increased costs to reach to other facilities. They preferred a birth attendant, usually a traditional birth attendant (non-skilled birth attendant) also referred as “Daai” in local language, who is easily available in their neighborhood and provides home services at low costs. A community woman, mother of 3 children, who never visited a CMW stated the following:

Dais (TBAs) in our areas are easily approachable and we don’t have to pay anything to reach any other facility. They charge very less in comparison to anyone else (Community woman)

Support and acceptance

Relationships with other healthcare providers

Most of the respondents acknowledged that CMWs strive to maintain a positive relationship with every healthcare provider working in the community and especially with doctors such as obstetricians. However, their efforts are not acknowledged by the doctors, and they consider CMWs ‘unskilled birth attendants (Dais)’, and not trained professionals. Doctors also misinform community people about their services as acknowledged:

Women Medical Officers misguide people against CMWs if they refer any complicated case to doctors. The referred woman when is delivered by the doctor, the whole credit is taken by the doctor, and they provoke patients about complications done by CMWs. When the same patient goes back to her home, she gives that message to everyone in the community that CMWs are uneducated and non-qualified to conduct deliveries (Health official)

At doctors level, we are nothing. They think of us as dais (unskilled birth attendants). Some of them support us and they think that there is someone who has the knowledge, but some say to their clients to visit them and not us as they think we are dais and they think that we have not much knowledge about reproductive health (Non-working midwife)

Preference for deliveries by TBAs was also acknowledged by community women as they provide affordable and accessible services and conduct deliveries at home- an environment familiar to the woman. TBAs are easily available and are high in numbers in district Thatta. CMWs reported that they maintain good relations with TBAs, and they provide a monetary share to TBAs if they refer any pregnant woman to them for delivery.

CMWs try to maintain linkages with TBAs. Now they have even started providing them some share if they refer any patient to CMWs for delivery (Health official)

CMWs stated that they also try to build linkages with health facilities and other health care providers working in the district to establish their work, for example with sonologists and laboratories to refer their clients for essential services.

We have good linkages with Sonographers and laboratories to referring patients for services (Working midwife)

Lady health workers (LHWs) are an important part of the rural healthcare system of Pakistan, and they play a vital role in maternal and child health in rural communities by coordinating efforts with community midwives, and by ensuring that all mothers and children receive adequate care [23]. Every CMW in district Thatta is consigned to five LHWs of the specific area. LHWs identify and register individuals and households in the area and refer clients to nearby CMWs for antenatal and postnatal care, delivery and childbirth, and other maternal services to increase skilled birth attendance in rural areas. However, the coordination between LHWs and CMWs continued to be discordant. This is because LHWs are ineligible and non-licensed to provide maternal and newborn services and the professional rivalry creates challenges for CMWs to coordinate with LHWs.

Under one CMW, there are 5 LHWs to support each other. The registration of pregnant women is carried out by the LHWs. They register each person in the village, the children, the adults, and everyone. The bad luck is that we couldn’t strengthen the coordination between CMWs and LHWs (Health official)

Non-recognition of CMWs

Thatta is divided into urban and rural geographical zones. The urban zone of Thatta has an increased number of doctors, midwives, and healthcare providers [24]. The increasing availability and accessibility to doctors and already established CMWs create challenges for newly deployed CMWs.

I live in a town where every second person has done midwifery and MBBS. They are available in every street. We cannot establish a good setup here because there are a lot of people in this profession (Non-working CMW)

We have an admission committee to enroll girls to CMWs program from those areas where there is the unavailability of birthing stations, but we still need to strengthen this as we see that there are many gaps (Health official)

CMWs’ deployment in areas with increased dispersion of TBAs’ is a barrier to their services. There is a higher preference of community women for TBAs over CMWs as they believe that young, unmarried, and inexperienced CMWs cannot provide efficient maternal services compared to an experienced TBA who provides low-cost services.

TBAs are very common here as they are easily available, and they are very experienced to conduct deliveries in our village (Community woman)

The strategies to increase skill birth attendance through CMWs is still lacking as people still prefer TBAs over CMWs (District Health officer)

Discussion

The present study helped to explore challenges to community midwives’ services in one of the rural districts of Pakistan. Program implementers, managers, government health officials, and policy makers need to intervene to address these challenges faced by CMWs.

Most of the girls get enrolled in the program at the ages of 18 to 20 years and are certified to provide services after the successful completion of two years. The young age of a midwife to establish her own birthing station is not acceptable by communities. The maternal and neonatal services provided by young and unmarried girls is a hindering factor to gain the trust of the community, as they perceive them to be inexperienced and uninformed about reproductive health matters. Similar findings on the lack of community trust for CMWs services have also been identified for CMWs working in different parts of the province of Sindh [25]. Besides, these findings have been also reported from regions outside Pakistan such as Nigeria and Niger on the non-acceptance of midwifery personnel due to their typically young age [26, 27].

The social and cultural system is a major factor that hinders CMWs services in rural areas. CMWs find challenging to talk to community people about important yet sensitive maternal health matters such as abortions and family planning, which are not given importance, especially in rural areas. Moreover, females are not permitted to work due to the patriarchal system followed in rural areas of Pakistan. CMWs encounter challenges to establish birthing stations at their homes, and if they remain successful in establishing them, they resist allowing male attendants to their clinics due to cultural limitations. The social and cultural barriers make it difficult for CMWs to work in their communities. These findings have been reported from several other parts of Pakistan where CMWs face cultural barriers [28–30].

Community midwives are recognized as the frontline primary healthcare workers available in their communities who are responsible and accountable for pregnant women’s health. They are also accountable to refer complicated cases and patients with high-risk pregnancies to a higher level of care. Yet, they struggle referring patients to higher-level facilities that add an extra burden to them. This similar finding has been reported in other countries such as Kenya, and Afghanistan where CMWs face similar challenges with the referral of their clients due to financial constraints, patients’ fears related to referral, and patients’ non-compliance with referrals [31, 32]. Moreover, CMWs also find it difficult to convince community women for delivering at their birthing stations. This is because of the lack of community’s affordability to pay for services and transport issues. Due to availability of TBAs in rural areas, women prefer TBAs services over CMWs due to less charges and their trust on experienced TBAs.

Besides, lack of healthcare providers’ support for CMWs services was recognized a hindering factor to function in their communities. CMWs struggle to gain their status in rural communities where doctors and traditional birth attendants (unskilled birth attendants) are recognized to provide services at facilities and homes. The non-coordination between CMWs and doctors is a significator factor impeding CMW’s services in the district. Doctors consider them unskilled professionals and they convey this perception to communities which affects the utilization of CMWs services by their communities. The non-coordination between CMWs and doctors is not only a problem in rural areas of Pakistan but this problem exists across the world even in high-income countries [33, 34]. Despite much progress in the legitimization of the midwifery profession in many high-income countries, these countries also face disagreements among maternity care professionals for midwifery autonomy and scope of their practice [34]. Maternity care and services require close cooperation between obstetricians, midwives, physicians, and nurses.

The functioning of CMWs in the district depends on coordination with LHWs for the referral of pregnant women to CMWs. The provincial government and health officials have been working to strengthen coordination between CMWs and LHWs. However, the lack of coordination between LHWs and CMWs impedes their services. This lack of coordination between the two cadres is presumed due to the professional rivalry between two cadres. Yet, professional jealousy is a typical phenomenon in healthcare. Interprofessional coordination is essential in creating a collaborative culture in maternity care [35].

It has been identified that district Thatta is divided into rural and urban zones and most of the girls were enrolled from the urban regions where there was already a high saturation of healthcare providers such as medical doctors, CMWs, and lady health visitors. The rural regions of the district still suffer from issues of non-availability of birthing stations and even if CMWs were available in those regions, they were not functional due to the increased approach of the community towards TBAs based on their preference for home births. This demonstrates a lack of planning of program implementers to execute CMW program in rural communities for the purpose the program was evolved. A similar finding has been reported in a study carried out on capturing the views of MNCH program specialists who provided their insights on the malfunctioning of various vertical programs after the devolution of the federal government to provincial governments in Pakistan [35]. Moreover, a finding from another study shows that in urban areas of district Thatta, out of pocket spending (use of private health care) was 1.4 times higher than rural areas [36]. This shows that there is an increased poverty in rural areas of Thatta and therefore women prefer to utilize services of TBAs (unskilled birth attendants) who charge less fee for services than CMWs (skilled birth attendants).

Ideally, devolution (transfer of power from central to local governments) provides increased opportunities for provinces to introduce and prioritize health policies. Countries like Indonesia and Kenya provide useful examples of improved health systems following devolution [37, 38]. The health services delivery and health governance in these countries have improved after the power was delegated to local governments from the federal government [38]. Devolution has transformed the power and decision-making authorities at the subnational level and has provided increased opportunities to prioritize preventive health services rather than curative health services [38]. However, the reform in Pakistan faced a number of challenges due to a lack of defined national and provincial policies and unorganized provincial health strategies [35].

Our study has several strengths. First, the exploratory design of this study helped us to understand the challenges of CMWs working in a rural district of Pakistan from the perspectives of health officials, midwifery students, community midwives, and community women. This helped in achieving the rigor of the study by enhancing the credibility of the findings from different data sources. Second, the use of CMW model guided the researchers’ focus to developing data collection tool.

The study also has some limitations. First, the data collection was done through telephonic interviews because of lockdown due to COVID-19 infection, and the facial expressions and physical observations were therefore missed during the data collection. This also limited us to capturing data from the participants who had no access to mobile phones. Secondly, the study focused only on the perspective of the participants who are a direct or indirect part of the MNCH or CMW program. The interviews with doctors, LHWs, and TBAs of the rural areas would have provided more insights and understanding of the current processes to strengthen the findings. Furthermore, there might have been other MNCH interventions in district Thatta that we have not reported and that might have influenced the findings of our study.

Conclusion

The study findings provided an extensive understanding of the factors influencing CMWs services in district Thatta. The CMW program has been engrossed in the health system of Pakistan but has not been fully functional especially in rural communities. The study provides key insights to program implementers to work on strategies and interventions to resolve the challenges of CMWs to help achieve the aim of introducing the CMW program in Pakistan.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

BK is a student of the MSc Health Policy and Management Program at Aga Khan University, Community Health Sciences Department, Karachi, Pakistan. The manuscript has been prepared from her thesis work. The thesis has been supervised by SS. The thesis committee members AF & FA supported the conduct of this research. This qualitative study was conceptualized by BK and SS. BK conducted the study and prepared the first draft of the manuscript. SS, AF, FA, and MR provided facilitation during the data collection. SS and AF guided the development of interview guides. SS, AF, FA, and MR reviewed the manuscript several times and provided feedback. All authors have reviewed and approved the final version of the manuscript.

Funding

The paper is from the first author’s thesis work. The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Data availability

The datasets were collected and analyzed and can be made available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval to conduct the study was given by the Aga Khan University Ethical Review Committee (2020-3391-11138). Participants provided informed consent to indicate their willingness to participate. Voluntary participation and the right to ask any questions and to decline participation at any time were emphasized during the data collection. All methods were performed in accordance with the guidelines of Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.