93546 Knowledge Brief Health, Nutrition and Population Global Practice COMMUNITY MIDWIFERY EDUCATION PROGRAM IN AFGHANISTAN Sayed Ghulam, Khalil Ahmad Mohmand and Sameh El-Saharty November 2014 Introduction KEY MESSAGES: Afghanistan’s health services in the immediate post • In 2002, maternal mortality ratio was conflict period were in a deplorable and chaotic state. In the second highest in the world. 2002, its maternal mortality ratio was the second highest • In 2003, most Afghan women delivered in the world, reflecting a lack of access and utilization of reproductive health services and skilled care during at home, and fewer than 10 percent of pregnancy, childbirth, and the first month after delivery. births were attended by a skilled These services are key to saving women at risk of dying provider. due to pregnancy and childbirth complications. • One barrier to expansion of services In a society where women seek care only from female was the lack of qualified female health providers, one barrier to expansion of services was the workers, which is critical in a society lack of qualified female health workers to deploy to where women seek care only from remote health facilities to make up for the shortfall of female providers. female staff. Some 77 percent of the population was living in rural areas, where women are usually excluded from • In 2003, the Community Midwifery access to skilled and emergency health care. In 2003 for Education Program was created. example, most Afghan women delivered at home, and fewer than 10 percent of births were attended by a skilled • The program’s success is attributed provider. to strong engagement of different stakeholders; equity; and strengthened Very few midwives trained in Kabul or other big cities human resources for health. were willing to work in rural areas where the needs were much higher. Moreover, there were no education facilities • Between 2003 and 2013, the number of and too few female school graduates who could be midwives increased from 467 to 2,245 trained in the provinces. Given the dire situation, the midwives. shortage of midwives had to be remedied urgently. The Community Midwifery Education (CME) Program was • Stakeholders believe that midwives created. have greatly helped to reduce maternal mortality, which fell from 1,600 in 2002 to 327 in 2010. Page 1 HNPGP Knowledge Brief  The CME Program The program aimed not only to train more midwives, but people’s rights to use resources equally in rural and also to ensure both their initial deployment in remote remote areas. It also focused on women by providing health facilities as well as good retention rates. These opportunities for women in rural areas to receive an aims were realized through the creation of a new health education and earn a living, and by offering basic health cadre known as “community midwives.” The pr ogram services to women who had no access. itself consists of closely interlinked stages (Box 1). Third, human resources increased rapidly. In 2003 there were only 467 midwives in the country (Bartlett et al. Three Marks of Success 2011); by April 2013 (according to the NMEAB), 2,245 The program’s success is attributed to strong students had graduated as community midwives. engagement of different stakeholders, equity, and strengthened human resources for health. Their training and deployment helped improve access to and use of reproductive health services. For instance, in First, the need for this program was communicated across provinces with midwifery schools that had graduated a wide spectrum of stakeholders — from those engaged students by June 2006, ANC rates increased faster than in policy to those involved in implementation, from donors in provinces without midwifery schools or which had not to communities. graduated students by June 2006. Similarly, provinces that graduated midwives before June 2006 reported a Second, for equity, it encouraged community involvement larger increase in the use of skilled birth attendants in all stages. It emphasized equality by providing (SBAs) than in provinces without midwives (Figure 1). resources to remote rural communities and respecting BOX 1: FIVES STAGES OF THE CME PROGRAM Recruitment: Candidates for the program are Phase 1 covers management of normal pregnancy, recruited from provinces and rural areas, according to labor, postnatal, and newborn care. Phase 2 builds the the country’s human resources workforce planning student’s skills in management of complications of needs. Ideally they should have a “commitment letter” pregnancy and childbirth. Phase 3 addresses other from their family and community indicating that they reproductive health topics, with a focus on family are going to work in an identified health facility with a planning as well as the management of service provision midwife shortage. Students are selected jointly by the and professional issues. local Ministry of Public Health (MoPH) authority, the implementing agency, and the community. Accreditation: Administered by the National Midwifery Education Accreditation Board (NMEAB), accreditation Admission: This is based on national admission has played a large role in improving the quality of policy and criteria. All candidates should meet the midwifery graduates and the quality of care provided by admissions criteria, including age and years of midwives in general. schooling and they must pass the entrance exam. Deployment and Retention: Admission guidelines aim Training and Curriculum: Originally, the program to ensure that students are recruited from areas where standardized curriculum of 2003 required 18 months’ they can be deployed, supported, and supervised after training, but with the experience of running the completing the program. Although there are no national program for a few years, the stakeholders lengthened data on retention of community midwives in the public the training to two years. Training is divided into three sector or their deployment, based on an assessment of phases. A series of learning modules in phases 1 11 provinces the overall retention rates of CME-graduate through 3 contain theoretical content and clinical skills midwives in the public sector is 61.3 percent, with 36.8 considered necessary to prepare midwives to provide percent working at their original deployment sites. comprehensive maternal, newborn, and infant care. Page 2 HNPGP Knowledge Brief  Stakeholders’ Perspectives Stakeholders consider Afghanistan’s progress in access and utilization of health care and reproductive health services as one of the greatest health achievements of the last decade. Notably, midwives have helped to fill the shortage of professional human resources in health, especially for midwives and female health workers in rural and remote areas. Stakeholders also believe that midwives have greatly helped to reduce maternal mortality, which fell from 1,600 in 2002 to 327 in 2010. They also acknowledge that deployed midwives address the communities’ needs for health services. The communities themselves believe that people now have easy access to services, and more women are visiting and using the health facilities. The role of community midwives as change agents is well recognized among health sector stakeholders, including the communities. Midwives facilitate behavior change at the family and community levels. Health-seeking behavior has picked up, and more people (especially women) are visiting health facilities. People’s knowledge of health services, particularly reproductive health, has improved, as have their attitudes and practices. Finally, graduated midwives themselves have also seen huge changes in their own personal and social lives, and most are satisfied with their earnings and social status in their communities as health service providers. Community midwives undoubtedly played a key role in expanding and improving access to health services. ANC Some of these views are given in stakeholders’ own utilization, for example, appears to have more than tripled words in Box 2. during the period 2003 to 2010. The increased access to services was especially marked in rural Afghanistan (Afghanistan, APHI/MoPH 2010). Challenges A frequent difficulty has been selecting students for CME, jeopardizing later stages, including training, deployment, and retention. Various problems include influence peddling by local authorities, including by force, as well as the lack of eligible students in some targeted communities. Accreditation of the CME schools is sometimes an issue, especially in provinces where security is a problem, as is the limited number of National Midwifery Education Accreditation Board (NMEAB) assessors. The deployment and retention of midwives working at their original deployment sites is too low at less than two out of five. Finally, the lack of a national tracking system for CME graduated midwives should be rectified. Page 3 HNPGP Knowledge Brief  “ Sustainability and Scaling Up The CME Program — through selecting women from local communities, providing training, and deploying them back BOX 2: IN THEIR OWN WORDS … to their communities — sustains impact. Trained midwives are community resources who can have long-lasting and “A lot of women come to the health facility sustainable impact through their services to the because a midwife is hired in our health facility” — community. The MoPH considers the program a a health worker in a Basic Package of Health successful intervention and believes that there is great Services (BPHS) health facility, December potential to replicate this model to train other health 2012. professionals and reduce the shortage of other human resources for health. The MoPH has already started the “Now about 80 percent of patients are visiting our Community Health Nursing Education (CHNE) based on midwife, few go to the doctor, because most of the the successful experiences and lessons learned from the patients are female” — a health worker, CME Program. December 2012. References “After deployment of our midwife, people’s 1. Afghanistan, APHI/MoPH (Afghan Public Health Institute, Ministry thinking has changed, all mothers are visiting the of Public Health). 2010. Afghanistan Mortality Survey. Kabul. clinic and the midwife is at their service day and night, during official and unofficial times” — 2. Bartlett, L., A. LeFevre, H. Gibson, J. Rahmanzai, K. Viswanathan, male representative of a health committee, K. Yari, L. Steinhardt, M. Azimy, N. Ansari, N. Assefi, P. Manalai, P. December 2012. Azfar, R. Callaghan, and S. Turkmani. 2011. Evaluation of the Pre- Service Midwifery Education Program in Afghanistan. Kabul: “After I started to work in this health facility, the Jhpiego/ Health Services Support Project. data for antenatal care, deliveries, and postnatal care improved; night duty became regular and registration improved” — a community midwife in a BPHS facility, December 2012. This HNP Knowledge Brief highlights the key findings from the HNP Discussion paper “Community Midwifery ” Education Program in Afghanistan ” written by Khalil Ahmad Mohmand, published in August 2013. The Health, Nutrition and Population Knowledge Briefs of the World Bank are quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4