Understanding variance in performance between countries, or within a country, can help identify organizations or people who have developed successful approaches to seemingly intractable problems. Reform efforts which focus on identifying these pockets of excellence and spreading lessons learned can generate rapid change. In Pakistan, working with successful community midwives using this approach is helping to make deliveries safer for more women.

In Punjab, Pakistan, many women deliver at home without a skilled birth attendant. In response to this, the Government created a cadre of community midwives who can provide skilled delivery services at home. However, many community midwives find that there is low demand for their services in the community. Increasing their utilization would help increase the skilled birth attendance rate in Punjab.


A few community midwives, however, have very high utilization. They were interviewed to identify the messages and approaches they use to drive demand for their services in the community. These interviews revealed the importance of proactive outreach and messaging during the period when a midwife is first establishing herself in the community. They helped identify practical tips that midwives use to showcase the quality of their services over traditional birth attendants.

The insights from these interviews were translated into a short in-service training for community midwives, with sessions facilitated by some of the best performing midwives who had been interviewed. The training program was built around videos of best performing community midwives describing and role-playing successful messages and approaches.

This training program was quick to create, as it relied on the practical experience of those with a proven track record of what worked rather than theory. This approach helped create a practical training that connected with the recipients.

More broadly, this approach shows that in some cases, rather than creating new structures or systems, reform can just mean finding things that already work and helping the system to do them more often.

About the Author

Fenton Whelan founded Acasus and has more than a decade of experience in public health and education development.