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Objective  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.    Design  Implementation research was conducted using an institutional ethnographic approach.    Setting and population  National programme and local community levels in Pakistan.    Methods  Observations, focus group discussions, and in‐depth interviews were conducted with 38 Community Midwives ( CMW s), 20 policymakers, 45 healthcare providers and 136 community members. A critical policy document review was conducted. National and local level data were brought together.    Main outcomes  Alignment of programme theory with real‐world practice.    Results  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  CMW s from establishing private practices; (3) the complexity of public–private sector cooperation. Uniform deployment policies failed to consider existing provider density and geography.    Conclusions  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.

Good on paper: the gap between programme theory and real‐world context in Pakistan's Community Midwife programme