Saving mothers and newborns in communities: strengthening community midwives to provide high quality essential newborn and maternal care in Baluchistan, Pakistan in a financially sustainable manner.

Background: To address it's persistently high maternal mortality rate of 276/100,000 live births, the government of Pakistan created a new cadre of community based midwives (CMW). One expectation is that CMWs will improve access to maternal health services for underserved women. Recent research shows the CMWs have largely failed to establish midwifery practices, because CMW's lack of skills, both clinical and entrepreneurial and funds necessary to develop their practice infrastructure and logistics. Communities also lack trust in their competence to conduct safe births. To address these issues, the Saving Mothers and Newborn (SMNC) intervention will implement three key elements to support the CMWs to establish their private practices: (1) upgrade CMW clinical skills (2) provide business-skills training and small loans (3) generate demand for CMW services using cellular phone SMS technology and existing women's support groups.

Methods/design: This 3-year project aims to investigate whether CMWs enrolled in this initiative are providing the essential maternal and newborn health care to women and children living in districts of Quetta, and Gwadar in a financially self-sustaining manner. Specifically the research will use quasi-experimental impact assessment to document whether the SMNC initiative is having an impact on CMW services uptake, financial analysis to assess if the initiative enabled CMWs to develop financially self-sustainable practices and observation methods to assess the quality of care the CMWs are providing.

Discussion: A key element of the SMNC initiative - the provision of business skills training and loans to establish private practices - is an innovative initiative in Pakistan and little is known about its effectiveness. This research will provide emperic evidence of the effectiveness of the intervention as well as contribute to the body of evidence around potential solutions to improve sustainable coverage of high impact Maternal, Neonatal and Child Health interventions in vulnerable populations living in remote rural areas.