A realist evaluation of a normal birth programme

Background. Complex programmes are characterised by multiple components, acting independently and interdependently, at multiple levels, within diverse and dynamic systems. High-quality evaluation of such programmes is imperative for optimising their development, implementation and effectiveness, but is often challenging. There is debate about whether the traditional outcome-focused approaches are feasible or appropriate for evaluations of large-scale, complex programmes as they often fall short of explaining how and why they do or do not work. Theory-driven approaches offer a more appropriate alternative as they attempt to uncover the black-box between the programme’s inputs and the resulting complex pattern of outcomes. Aim. This paper illustrates drawing upon a realist evaluation to assess a complex programme to support normal birth. Method. Firstly, the programme theories – the ideas about how the programme would bring about change – were elicited from programme developers and key stakeholders. Secondly, these initial hypotheses were tested out by collecting data on how the programme worked in different contexts, using a multiple case study design. Thirdly, the data were analysed and interpreted to refine the programme theories in light of evidence on how the programme unfolded in practice. Findings. Described in detail are the process of conducting a realist evaluation, methods used, steps in data analyses, challenges encountered and the approach adopted to overcome them. The usefulness of this approach and some limitations are discussed.