Theory-Driven Evaluation of Community Midwifery Programmes and Their Impact on Maternal and Newborn Outcomes in Plateau State

Background: Community midwifery programmes have been deployed in Plateau State, North Central Nigeria, to address gaps in skilled birth attendance, yet their impact has not been evaluated through a theory-driven lens that identifies effective mechanisms and contexts. Aim: This study conducted a theory-driven evaluation of community midwifery programmes and their impact on maternal and newborn outcomes in Plateau State. Methods: A realist evaluation design employed a systematic document analysis to develop an initial programme theory, followed by mixed-methods data collection including record reviews of 1,200 birth outcomes, surveys of 150 community midwives, and 30 stakeholder interviews. Realist synthesis identified context-mechanism-outcome configurations. Results: Programmes generated positive outcomes when community midwives were embedded in trusted community structures, had reliable drug supply chains, and received supportive clinical supervision. Outcomes deteriorated in contexts characterised by insecurity, poor transportation, and absent referral networks. Skilled birth attendance increased by 18 percentage points in programme communities. Conclusion: Community midwifery effectiveness is context-dependent and mechanism-specific. Findings offer transferable implementation lessons for scaling midwifery programmes in comparable Nigerian contexts. Keywords: community midwifery, theory-driven evaluation, realist evaluation, Plateau State, maternal outcomes.