1. JHPIEGO in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and Interchurch Medical Assistance Addressing Shortages of Skilled Attendants Pashtoon Azfar Midwifery and Nursing Strategic Director Health Services Support Project, ACCESS, Afghanistan

2. Objectives of the Presentation At the end of the presentation, participants will be able to:  Describe the midwifery pre service education in Afghanistan  Discuss the midwifery school accreditation program in Afghanistan  Explain what results have been achieved and what challenges we face 2

3. Introduction  High maternal mortality  1600 MD / 100 000 LB  Low skilled birth attendance  < 10% (2003 MICS)  Shortage of skilled attendants  467 midwives in country in 2002  MoPH and stakeholders developed a pre- service midwifery education program

4. 4 Human workforce development  Policy development – creating an enabling environment and the appropriate authority and regulatory system  Planning – How many midwives do we need? Where do we need them?  Selection – Community-focused and linked to national criteria  Recruitment – Which health facilities need midwives (active or planned)?  Education – Competency-based and skill focused  Deployment – Planned from time of recruitment/selection, maintain community link during training  Supervision – Professional socialization, integration with team and actual work patterns

5. Education program  Selection  Mostly from rural areas based on MoPH policies  Collaboration with national, provincial, local health authority and communities in selection and recruitment  Education  Competency-based education curriculum re-designed  Skill focused according to definition of Basic EmOC  24 month fit-for-purpose education  Knowledge and skills of teachers and clinical preceptors updated  Accreditation system established 5

6. 6 Education program #2  Deployment  Midwives deployed to community facility they were recruited from  Working within a defined Basic Package of Health Services  Supportive supervision  Linked with provincial Afghan Midwives Association  In 6 years(2003-2009) almost 2000 new competent midwives graduated

7. Output and Achievement of MWE Programs Type of Program Currently studying Enrolled Graduated Drop-outs % Graduated Deployed/Employed % Deployed/Employment ofgraduated Currently working(as of May, 2009) % currently workingof graduated Currently workingof deployed/employed IHS 1671232110312990%89081%75468%85% CME 5098868582897%78591%69481%88% TOTAL 6762118196115793%167585%144874%86%

9. Accreditation Results

10. Assessment of maternal health utilization indicators  In provinces with midwifery schools  Increase in women accessing ANC by almost 20%  Increase in women delivering with a skilled birth attendant by 40% 10

11. 11 Challenges  Security  Retention  Supervision post-graduation – are midwives under worked? Or over burdened and not able to focus on maternal and newborn health?  Cultural, geographic isolation of women

12. Final Words  “I am happy with the midwife. Previously there was no midwife in our village and women were suffering bleeding and their children were dying. Now thanks to God, we have got a midwife and since have not seen a pregnancy death.”  “In the beginning, people thought that I might be a dayee (traditional birth attendant) and would not be effective. At present, they know me as a women’s specialist and they respect me and say that I solve their women’s problems.” 12