Expanding Access to Skilled Birth Attendants: Strengthening Afghanistans Midwifery Education

Sabera Turkmani, Victoria Parsa, Pashtoon Azfar, Nasratullah Ansari, Jaime Mungia
HSSP is a USAID funded project under the ACCESS Leader Award and is led by Jhpiego with partners Save the Children and Futures Group

Ensuring that every woman and her newborn have access to quality midwifery services demands that we take bold steps.
Ban Ki-moon UN Secretary General

Afghanistan Maternal Health Situation in 2002

Maternal mortality ratio (MMR) of 1,600/100,000 8% of births attended by a skilled provider Only 21% of health facilities had female staff 467 midwives Estimated 5,000 midwives needed

Supportive Policy Environment

GOAL Increase access to and use of health services: Basic Package of Health Services developed Scale-up and strengthening of community-based health care Reproductive health strategy included improving coverage of skilled birth attendants by educating and deploying large numbers of qualified and competent midwives Focus on an intrapartum care strategy
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Key Components of Preparing Competent Midwives

Competency-based job description for midwives developed in 2004 Competency-based curriculum and training materials developed and translated in 2004 National program of community midwifery education began in 2004 Midwifery Education Policy endorsed in 2005 Accreditation process for midwifery schools to assure quality established in 2005
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Comprehensive Systems-Based Approach to Building a Qualified Workforce

Midwifery Education Accreditation

With the rapid expansion of midwifery education programs in 2003, there was a need to:
Ensure quality using educational standards based on Standards-

Based Management and Recognition (SBM-R) methodology Ensure uniformity

Afghanistan Midwifery and Nursing Education Accreditation Board (AMNEAB):

Acts as a national technical regulatory body for high-quality

midwifery and nursing educational institutes

5 Areas of Standards
Area 1: Classroom Area 2: Clinical Area 3: Infrastructure Area 4: Management Area 5: Clinical Areas Where Student Midwives Undertake Clinical Experience
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AMNEAB Methods of Accreditation

Assessments
Baseline
Within the first three months of registration

Non-binding

Within nine months after the baseline assessment Within three months of the graduation of the first batch of students; it is the accreditation assessment

Binding

Results: Expansion of Education Institutions

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Results: Accreditation Assessment Scores (20062012)

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Achievements against SBME-R standards

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Results
At the end of 2012, there were 32 midwifery schools in 34 provinces Over 3,000 midwives graduated since 2004 80% of health centers staffed with at least 1 midwife

Photo: Hannah Gibson

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Evaluation of the pre-service midwifery education program in Afghanistan (20082009):

I repaired cervical and vaginal lacerations, inserted an IUD (intra-uterine contraceptive device) that another midwife could not do, did episiotomies, removed retained placentas, did many breech deliveries, delivered twins and managed a case of shock. All have been done on my own. This is a source of pride for me. - Midwife

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10 years later.
AMNEAB continuing to monitor quality of existing and new educational programs, including community nursing education Institutionalizing midwifery education within the government MMR of 327/100,000 (AMS, 2010)
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Lessons Learned
Establishment of a standardsbased national accreditation system ensured that quality education can be achieved during a period of rapid expansion. A regional networking system has enabled the AMNEAB to provide proper technical support at the provincial level as the number of school has expanded.
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Summary
Investing in high-quality pre-service education programs CAN contribute to improved health outcomes, BUT sustained commitment and political leadership are necessary.

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