Devpro Resource Centre
Afghanistan’s community midwives
|A woman health worker at Faizabad Hospital in Badakshan Province.|
Context and challenge: Insufficient resources, poor maternal health outcomes, political instability
Decades of conflict and instability have disrupted Afghanistan’s basic health infrastructure and undermined provision of maternal health services. Limited access to quality emergency obstetric care, particularly in rural areas, insufficient access to information about maternal health and safe delivery, and the scarcity of qualified female health workers, reflecting the strong cultural preference for female workers to attend to women’s health needs, are some of the main structural factors underlying the poor health outcomes among Afghan women. The unequal status of women and barriers to their access to basic and maternal health services have compounded this problem.
Inter-agency estimates from 2005 indicate the maternal mortality ratio for Afghan women was among the highest in the world, standing at 1,800 deaths per 100,000 live births. In that same year, women in Afghanistan faced a lifetime risk of death from causes related to pregnancy or childbirth of 1 in 8. Compare this with a rate of 1 in 8,000 for industrialized countries on average. The country’s neonatal mortality rate is also among the world’s highest, at 60 per 1,000 live births in the year 2004.
National averages can mask large geographical disparities, and there is an urban bias in access to health care, although 77 per cent of the country’s population lives in rural areas. Mothers in the urban centre fare significantly better than those in the remote reaches of rugged geography. In 2002, women of childbearing age who died of maternal causes ranged from 16 per cent in the capital city of Kabul to 64 per cent in Ragh district of the north-eastern mountainous province of Badakhshan.
Improving maternal health in Afghanistan necessitates addressing the country’s particular health challenges – including insufficient resources, an extremely high maternal mortality rate and a scarcity of health personnel to address maternal health issues. In particular, the country is desperately in need of skilled female health personnel to provide midwifery services.
The World Health Organization recommends one midwife to care for every 175 women during pregnancy, childbirth and the post-natal period each year. On the basis of this ratio, and given the country’s estimated number of births, Afghanistan currently requires 4,546 midwives to cover 90 per cent of pregnancies. In contrast, it only had 467 trained midwives in 2002, and fewer than half of the facilities had any female staff. In Nooristan, a rural province in the north-east, the ratio of male-to-female health staff was as high as 43 to 1.
Action: Midwives reaching out to women in their communities
|Dr. Karima Noori conducts a midwifery training course at Faizabad Hospital in Badakshan Province.|
To meet the country’s need for skilled female attendants, since 2002 the Ministry of Public Health has chosen to focus on the rapid mobilization of midwives, especially in rural areas. The objective is to create a cadre of professional midwives in keeping with the international definition of a midwife and skilled birth attendant, and recognized by the country’s National Midwifery Education Accreditation Board, established in 2005.
The Government’s efforts to strengthen and expand midwifery education involve two types of training programmes. One is a traditional three-year programme administered by the Institute of Health Sciences; candidates are selected through a competitive process, tend to be from urban areas and are deployed to provincial or district-level facilities. The second training programme, the Community Midwifery Education Programme, addresses the urban biases of both the demand and supply sides of the country’s health-care system. It is not a midwifery school in the traditional sense but a more flexible time-bound programme that commences and terminates based on specific needs of the community. It is shorter in term, at 18 months as opposed to three years and is strongly vocationally based. It is hoped that these factors will make it accessible to a wider pool of candidates.
More notably, while trainees at the existing midwifery training programmes of the country’s Institute of Health Sciences were overwhelmingly urban and unlikely to practice their skills in remote rural areas, the Community Midwifery Education Programme seeks candidates from districts that face a gap in maternal health service delivery. These candidates are also endorsed by the community they are expected to serve and commit to returning to work in their district.
Both training programmes, which are largely similar in curriculum, receive support from national and international non-governmental organizations including the European Commission, the United States Agency for International Development and the World Bank, and multilateral partners such as UNICEF, the United Nations Population Fund and the World Health Organization.
To ensure that Afghanistan’s midwives are skilled, supported and motivated, the process of forming a professional association of midwives began in 2004. The Afghan Midwives Association was inaugurated in 2005 with assistance from various local and international supporters.
Impact: Safe motherhood through community-based midwifery training
|© UNICEF Afghanistan/2008/Ahmadzai|
|Community midwifery training in Wardak province.|
Together with other initiatives by the Afghanistan government—including the provision of a special allowance to women health care providers working in remote rural areas, improvements in the transportation and communication system in the country and a push to have more women enrolled in and graduating from medical schools—the Community Midwifery Education Programme has shown encouraging signs of effectiveness.
- Between 2002 and mid-2008, the number of midwives available in Afghanistan increased from 467 to 2,167.
- The percentage of facilities having female skilled health personnel (doctors, nurses or midwives) increased from 39 per cent in 2004 to 76 per cent in 2006.
- The number of deliveries attended by skilled workers has risen from roughly 6 per cent in 2003 to 19.9 per cent in 2006.
Opportunities: Support for midwives
Although much more needs to be done for Afghanistan’s mothers and children, the establishment, strengthening and expansion of its network of community midwives represent a significant step forward in reducing maternal deaths. Midwifery training was severely set back during the Taliban’s command, and the quality of care offered by existing midwives varied greatly. The Community Midwifery Education Programme and the professionalization of the country’s midwives are beginning to reverse this deficit. Already, based on the early successes of the training programme, the Ministry of Public Health has recommended its replication in the training of other cadres of health professionals. The road ahead lies in continued support to the programme and in minimizing gender-based barriers to accessing adequate health care for Afghanistan’s mothers.
8 December 2008
To learn more
‘Afghanistan's midwives tackle maternal and infant health,’ Lancet, Volume 370, Issue 9595, 13-19 October 2007. | website
Currie Sheena, Pashtoon Azfar and Rebecca C. Fowler, ‘A Bold New Beginning for Midwifery in Afghanistan’, Midwifery, vol. 23, no. 3, September 2007.
International Confederation of Midwives | website
UNICEF Afghanistan Country Office | website
WHO, Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA, and The World Bank, 2007. | PDF