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

1. 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

2. 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

3. 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)

5. 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

6. 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 Source: Bartlett et al 2005

7. 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by a skilled provider in 2003 Skilled antenatal care (ANC) at 4.6% in 2003 5 midwifery education programs in 2002 Outdated midwifery education curriculum with a focus on training hospital midwives 467 midwives in the country in 2002 Few female staff in health facilities After: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 Progress to Date

8. Community Midwifery Education Schools • Badakshan • Bamyan • Jawzjan • Khost • Paktya • Takhar • Ghor • Wardak • Parwan • Logar • GhaniKhail • Samangan • Sari Pul • Baghdris • Farah • Kunduz • Helmand • Uruzgan • Faryab • Daikundi • Lagman • Baghlan Newly graduated community midwives in Badakhshan province take midwifery pledge.

9. Institute of Health Sciences—Hospital Midwives • Kabul • Herat • Nangarhar • Kandahar • Balkh Photo by Hannah Gibson

12. 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

13. Establishment of Accreditation System to Ensure Quality in Midwifery Education • Unified national system built, based on education standards • All programs initially “encouraged” to implement standards • National Midwifery Education Accreditation Board established • Standards and accreditation became mandatory • Improvements extended to clinical areas

14. 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

15. 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

16. 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

17. 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

18. 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.

19. AMA Inaugural Congress

20. AMA’s Progress • More than 1,100 members • 27 provincial chapters • Governing body

21. AMA’s Accomplishments to Date During the last four years, the AMA recognized midwives who made significant contributions to maternal health.

22. 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.

23. Advocacy for Safe Motherhood

24. Involving Men in Safe Motherhood

25. National Celebration of Safe Motherhood Day

26. Provincial Celebration of Safe Motherhood Day

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

28. Celebration of AMA’s 5th Annual Congress

29. Celebration of AMA’s 5th Annual Congress

30. Mother’s Memorial Quilt

31. Celebrating International Day of Midwives 2009

32. 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

33. 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

34. Thank You