“With Women” Midwives for Afghanistan

Reproductive Health Workforce Development in Afghanistan 2002 - 2009

Jeffrey Smith, MD, MPHAsia Regional Technical DirectorJhpiego

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Presentation Outline

Review the reproductive health situation in Afghanistan Discuss the human resource constraints Describe some key considerations in workforce

development/task shifting in reproductive health Present the results of interventions in Afghanistan

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RH Situation 2002

High maternal and newborn mortality (MMR 1600 / 100 000 LB)

Few RH providers 40% facilities with female staff 467 midwives in country Non-uniformity of qualification Out of date skills

No functional schools for training midwives – schools closed by Taliban

RH de-emphasized in medical curriculum Disarray of system for supporting human

resources for health STRATEGY: support the education and

deployment of large numbers of midwives rather than doctors

Task Shifting

Putting clinical capability in hands of appropriate peripheral workers so that key components of health care can be diffused to greatest number of people.

Should not be a temporary fix!

But a professional focus!

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What works, who works, and where?

Health Center Intrapartum Care Strategy Training of Midwives Staffing of Health Centers Health system linkages

Capability in Basic EmOC Clarity about “skilled attendant” Policy support for clinical authority Educational system to achieve

competency and capability

Lancet 2006 Maternal Survival Series

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Workforce Assessment & Planning

Array of semi trained, partially skilled workers

NEEDHAVE

Core group of leaders and academics

Group of managers and teachers

Bulk of personnel should be service

providers

Cries of crisis: “Something is better than nothing”

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Normatizing the Health Workforce

Re-establish health system accountability

Census of health workers Including where they work

Testing: knowledge + skills Phased (re)deployment

Registration and licensure Upgrade programs Education programs

Set selected practical policies Immediate need and long term

view Emergency Development

Staff functioning as midwives

QualifiedAlmost

qualifiedUnqualified

License and Deploy

Upgrade Standardize and Retain

Retrain to qualification,

Redeploy

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Importance of Standardization

Single, standard approach to upgrading RH workforce may be more efficient, especially in post-conflict settings

Fragile health systems don’t have resources to compare and contrast different, non-uniform approaches at macro level

Uniformity of professional and community expectation, supervision, supply, etc.

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Policy and Structure

Basic Package of Health Services Maternal Health / RH Service delivery guidelines

Guide for re-establishing services and in-service training/pre-service education

National MW education policy Midwifery job description Single, unified national midwifery curriculum Assessment materials and criteria

of students graduation and licensure of clinical facilities quality of care and clinical certification of schools school accreditation

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Standardization in Action

Standard curriculum and detailed teaching resources

National accreditation system Based on “recipe” for

establishing and running a midwifery school

Structured technical assistance framework

Increased local capacity and improved ability to support training programs and schools in remote or insecure areas

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Keep it clinical

Ensure that the focus remains on clinical skill development

MW program in Afghanistan was SHORTENED from 3 years to 2 and unnecessary topics were removed Semester 1: Normal

Pregnancy Semester 2: Complications Semester 3: Family Planning,

RH and Child Care

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Keep it local

Retention, deployment, selection and education all related: local control increases

local commitment

Train midwives where they are needed

Focus on local, “micro-deployment”

Caveat: ensure adequate educational and clinical capacity

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Results 2002 – 2009

5 midwifery schools re-opened and 26 new midwifery schools established

Midwifery deployment 1961 new midwives 85% deployed 86% working as midwives

Health centers with 1+ female health worker: 25% 83%

Health centers staffed with 1+ midwife: <10% 61% Standardized system to improve quality in midwifery

services and education

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Working as Midwives, 2009

Pro

gram

Cu

rrently stu

dy

ing

En

rolle

d

Grad

uated

Dro

p-o

uts

% G

radu

ated

Dep

loyed

/E

mp

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d

% D

eplo

yed/ E

mp

loym

ent o

f grad

uate

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Cu

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orkin

g (a

s of M

ay, 200

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% cu

rrently w

orkin

g o

f gra

du

ated

Cu

rrently w

orkin

g o

f dep

loye

d/

emp

loye

d

IHS 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%Local CME schools have greater success than regional IHS programs.

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Deliveries by Skilled Attendants Selected Provinces/Districts

Tarkhar: from 12%

to 21%

Herat: from 13%

to 27%

Examples of increase in skilled birth

attendant coverage at

birth:

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Professionalization of Midwifery Afghan Midwives Association

Founded in 2005 Provincial branch in most

provinces Roles:

Advocacy Professional development Networking and support

Has raised personal and professional stature of midwifery “This is the first time I have

ever belonged to anything other than my own family. I feel proud to be a midwife.”

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Reflection on “Gender”

Task shifting should not become

Clinical Shortcutting

Shortcuts in medical education vs. Shortcuts in midwifery education

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Conclusions

Vibrant maternal health / reproductive health workforce must be composed substantially of midwives

Midwives must be empowered professionally and deployed rationally

Consistency in the service delivery and educational system is essential for midwives to have skills and retain skills

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Acknowledgements

Ministry of Public Health, Afghanistan

Donors – USAID, World Bank and European Commission

Non Governmental Organization partners, WHO, UNICEF, and many other supporters of midwifery

Staff and students of all midwifery schools

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Thank you

Questions? Comments? Observations?