Addressing Shortages of Skilled
Attendants
Pashtoon Azfar
Midwifery and Nursing Strategic Director
Health Services Support Project, ACCESS, Afghanistan
JHPIEGO in partnership with Save the Children, Constella Futures, The Academy for Educational Development,
The American College of Nurse-Midwives and Interchurch Medical Assistance
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
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 preservice midwifery education program
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
4
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
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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
6
Output and Achievement of MWE Programs
Currently studying
Enrolled
Graduated
Drop-outs
% Graduated
Deployed/
Employed
% Deployed/
Employment of
graduated
Currently working
(as of May, 2009)
% currently working
of graduated
Currently working
of deployed/
employed
167
1232
1103
129
90%
890
81%
754
68%
85%
CME
509
886
858
28
97%
785
91%
694
81%
88%
TOTAL
676
2118
1961
157
93%
1675
85%
1448
74%
86%
Type of Program
IHS
Accreditation Results
Progress in compliance of national midwifery education schools with accreditation
standards - Overall compliance by province
2004 - 2008
Baseline
Non-Binding
Binding
Re-Binding
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
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0%
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
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
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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.”
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