Delivering High-Impact Interventions: Afghanistan’s Experience in Scaling Up Skilled Birth Attendants

Pashtoon Azfar, Jhpiego Midwifery Advisor and President of the Afghan Midwives Association

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Presentation Outline

Overview of ACCESS/HSSP Project

A glance at Afghanistan’s Health Profile

Progress to date Who helped make it happen Afghan Midwives Association

and its role in: Strengthening the midwifery

profession Improving maternal health in

Afghanistan Lessons learned and

recommendations

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ACCESS HSSP

Associate Award under ACCESS Program Jhpiego is prime with subs Futures Group and Save the

Children US July 2006 – Mar 2011, $40 million Focus is on increasing the utilization of health services at

the rural level by improving the quality of health services, increasing the number of skilled providers and generating demand for health services

Four Intermediate Results (IRs)

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A Glance at Afghanistan’s Health Profile

Challenging Health Indicators Maternal Mortality Ratio:

1,600/100,000

Neonatal Mortality 60/1,000 live births Less than 9% of deliveries

attended by a skilled birth attendant

Few female health workers 467 midwives in 2002 21% of health facilities had

female staff Socio-cultural demand for female

providers

Photo credit Med Air

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Maternal Health in Afghanistan

Estimated 26,000 women dying from pregnancy-related causes every year

1 woman dying every 27 minutes

78% of deaths are preventable

38%

26%

10%

5%

4%

9%

8%

Haemorrhage

Obstruction

PIH

Sepsis

Other direct

Indirect

Unclear

Source: Bartlett et al 2005

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Progress to Date

Before: 8% of births attended by a

skilled provider in 2003 Skilled antenatal care (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programs in 2002 Outdated midwifery education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

27 midwifery education programs in 2009

Competency-based training curriculum developed to train hospital and community midwives

To date, 1,961 competent midwives have graduated, 1,675 deployed (85%)

61% of health centers staffed with at least 1 midwife

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Community Midwifery Education Schools

1. Badakshan

2. Bamyan

3. Jawzjan

4. Khost

5. Paktya

6. Takhar

7. Ghor

8. Wardak

9. Parwan

10.Logar

11.GhaniKhail

12. Samangan

13. Sari Pul

14. Baghdris

15. Farah

16. Kunduz

17. Helmand

18. Uruzgan

19. Faryab

20. Daikundi

21. Lagman

22. Baghlan Newly graduated community midwives in

Badakhshan province take midwifery pledge.

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Institute of Health Sciences—Hospital Midwives

1. Kabul

2. Herat

3. Nangarhar

4. Kandahar

5. Balkh

Photo by Hannah Gibson

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Creating the Policy Environment

18-month competency-based curricula and training materials developed in February 2004; focus on required clinical skills

Residential program addressed cultural concerns about women being away from families

Testing and certification process of midwives trained previously was established

Knowledge and skills of teachers and clinical preceptors updated

Midwifery Education Policy endorsed 2005

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Establishment of 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

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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

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Selection of Students According to Human Resource Needs of the Country

Mostly from rural areas Commitment to work post

graduation Collaboration with

national, provincial and local health authorities, as well as communities in selection and recruitment

Follow selection policies of the Ministry of Public Health

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Deployment, Supervision and Support

Deployment Midwives deployed to community facility where they were

recruited from Working within a defined Basic Package of Health Services Supportive supervision

Supervision Supervision teams established and checklists used.

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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Who Helped to Make it Happen?

Ministry of Public Health, Afghanistan Donors—USAID, World Bank, European Commission USAID, REACH, ACCESS HSSP NGO partners implementing CME and I.H.S. schools WHO, UNICEF and other supporters of midwifery National Midwifery Education Accreditation Board Afghan Midwives Association Staff and students of all midwifery schools Jhpiego, the ACCESS Program and partners

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Afghan Midwives Association

The AMA aims to: Promote and strengthen the midwifery

profession and the role of the midwife to ensure the well-being of women and families in Afghanistan.

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AMA Inaugural Congress

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AMA’s Progress

More than 1,100 members 27 provincial chapters Governing body

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AMA’s Accomplishments to Date

During the last four years, the AMA recognized midwives who made significant contributions to maternal health.

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Advocacy for Safe Motherhood

Women are not dying of diseases we can’t treat …They are dying because societies have yet to make the decision that their lives are worth saving.”

Mahmoud Fathalla

This quotation was used as inspiration for the need to build political and social will for safe motherhood issues.

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Advocacy for Safe Motherhood

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Involving Men in Safe Motherhood

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National Celebration of Safe Motherhood Day

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Provincial Celebration of Safe Motherhood Day

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Midwives and Obstetricians Come Together to Support the Lives of Mothers and Newborns

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Celebration of AMA’s 5th Annual Congress

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Celebration of AMA’s 5th Annual Congress

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Mother’s Memorial Quilt

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Celebrating International Day of Midwives 2009

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AMA Promotes Women’s Empowerment

Women’s participation in education programs Contribute to household economy Safeguard the health and well-being of families Women in leadership roles/positions

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Lessons Learned and Recommendations

Increasing skilled attendance at birth requires political will and commitment

Focus should be on establishing and supporting a national system and processes

Build on previous successes and approaches Selection and recruitment of midwives linked to deployment are 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 continually supported in maximizing their potential A professional association, such as the AMA, is important to

providing advocacy for the profession and supporting the midwives, and contributes to sustainability

Success of community midwifery programs has created demand

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Thank You