1. Skilled Care at Birth Experience from Afghanistan Women Deliver Conference June -7-9- 2010 Pashtoon Azfar, President Afghan Midwives Association (AMA)

2. 2 Presentation Outline Overview of the context and challenges Overview of the methods employed to address the challenge –Creating the policy environment –Establishing an accreditation system –Estimating needs and employing a workforce planning approach –Ensuring quality education Ensuring deployment, supervision and support AMA and its role in : –Strengthening Midwifery Profession –Improving maternal Health in Afghanistan –Results and Achievements Remaining challenges Lessons learned and recommendations

3. 3 The challenges – after 23 years conflict Challenging Health Indicators: Maternal Mortality Ratio –1,600 / 100,000 Neonatal Mortality –60/1000 live births –Less than 9% of deliveries attended by SBA Few female health workers –467 midwives in 2002 –21% health facilities had female staff –Socio-cultural demand for female providers

4. 4 Maternal Health in Afghanistan Estimated 26,000 women dying from pregnancy related causes per year 1 woman dying every 27 minutes 78% of deaths are preventable Source: Bartlett et al 2005

5. 5 Policy Environment Development of Basic Package of Health Services Maternal mortality reduction strategy included improving coverage of SBA and an Intrapartum care strategy Policy statement on cessation of TBA training issued (2003); focus on training SBAs Midwifery curriculum existed; out of date, focused on training midwives for hospitals

6. 6 Creating the Policy Environment GOAL: To prepare qualified and competent midwives, to work in underserved areas of Afghanistan Competency-based curriculum and training materials developed midwives job description developed (2004) 18-month competency-based curriculum re-designed Knowledge and skills of clinical preceptors updated Assessment conducted and curriculum revised and extended to 24-months National program of community midwifery education began 2004; one pilot program started in 2002 Testing and certification process of previously trained midwives established Midwifery Education Policy endorsed (2005)

7. 7 Estimating the Need for Midwives Calculation of required number of midwives based on number of health facilities (actual and planned) and population Approximately 5,000+ midwives needed to staff the expected ideal distribution of health facilities Human resource database established in Ministry of Health

8. 8 Selection According to Human Resource Needs Mostly from rural areas Commitment to work post- graduation in the community where a need was identified and where student is from Collaboration with national, provincial, local health authorities and communities in selection and recruitment Follow selection policies of MoPH

9. 9 Deployment, Supervision & Support Deployment –Midwives deployed to community facility that they were recruited from –Working within a defined Basic Package of Health Services –Supportive supervision Supervision –Supervision teams established and checklists used.

10. 10 Quality Education Education is focused on competencies and required clinical skills Standards & accreditation to ensure quality of teaching Residential programs addressed cultural concerns about women being away from families & provided supportive learning environments with almost zero attrition Babies and toddlers stayed with their mothers …and new babies arrived during the training!

11. 11 Establishing the Accreditation System to Ensure Quality in Midwifery Education 1.Unified, national system built based on education standards 2.All programs initially “encouraged” to implement standards 3.National Midwifery Education Accreditation Board established 4.Standards and accreditation became mandatory 5.Improvements extended to clinical areas

12. 12 Performance Standard Example N/A = Not Applicable

13. 13 CME Paktya, Binding Assessment

14. 14 Accreditation 2006-2009

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17. 17 Results: IHSs &CME Schools 1.Badakhshan 2.Badghis 3.Baghlan 4.Bamyan 5.Daykundi 6.Farah 7.Faryab (2 schools) 8.Ghazni 9.Ghor 10.Helmand 11.Jawzjan 12.Khost 13.Kunar 14.Kunduz 15.Laghman 16.Logar 17.Nangarhar (2 schools) 18.Nimroz 19.Paktika 20.Paktiya 21.Parwan 22.Samangan 23.Sari Pul 24.Takhar 25.Urozgan 26.Wardak 27Zabul Newly graduated community midwives in Badakhshan province take midwifery pledge

18. 18 Results: Institute of Health Sciences- Hospital Midwives 1.Kabul 2.Herat 3.Nangarhar 4.Kandahar 5.Balkh Students in skills lab in Takhar CME

19. Support to/from the Afghan Midwives Association Built capacity of AMA AMA promotes and strengthens the midwifery profession through –Organizational development and sustainability, leadership programs, advocacy, and in- service trainings

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21. 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%

22. 22 Achievements Before: –8% of births attended by a skilled provider in 2003 –Skilled ANC at 4.6% in 2003 –5 midwifery education programs in 2002 –Outdated midwifery education curriculum with a focus on training hospital midwives –467 midwives in the country in 2002 –Few female staff in health facilities After: –Birth attendance by skilled provider increased to 19% in 2006 –Skilled ANC increased to 32% in 2006 –34 midwifery education programs in 2010 –Competency-based training curriculum developed to train hospital & community midwives –By May 2009, 2,200 competent midwives have graduated, 1,675 deployed (85%) –59% of BPHS health facilities (BHC, CHC, DH) staffed with at least 1 midwife

23. 23 Are Women Getting the Services they Need? “Before there was no midwife in our health center and we had to travel over one hour to the nearest town. I had all my babies at home before because of this. But now Midwife Hadia is at the health centre and because of this more women are seeing a midwife. I will have my next baby with Hadia in this health center, she is very nice and makes me feel safe” Woman in Takhar province who was delivered by Midwife Hadia

24. 24 Remaining Challenges Planning the HR needs for midwives nationally – how many do we need? Supervision post-graduation – are midwives under worked? Or over burdened and not able to focus on maternal and newborn health? Tracking deployment nationally Retention for remote and insecure areas Focusing on quality of existing programs Cultural isolation of women and female literacy rates

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26. 26 Lessons Learned & Recommendations Increasing skilled attendance at birth requires political will and commitment Focus should be on establishing and supporting a national accreditation system and processes Build on previous successes and approaches Selection & recruitment of midwives linked to deployment is key to success; think about the quality and deployment at the beginning Involve the community and think about creative and culturally appropriate approaches to attract students and the support of the community and families Midwives must be continuously supported in maximizing their potential A professional association, such as AMA, is important to providing advocacy for the profession, support for the midwives, and contributes to sustainability Success of community midwifery programs has created demand Professional development and CME.

27. 27 Remaining Challenges Planning the HR needs for midwives nationally – how many do we need? Supervision post-graduation – are midwives under worked? Or over burdened and not able to focus on maternal and newborn health? Tracking deployment nationally Retention for remote and insecure areas Focusing on quality of existing programs Cultural isolation of women and female literacy rates

28. 28 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.” “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.”“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.”

29. THANK YOU