Pashtoon Azfar,Sabera Turkmani, under supervision of Mrs Kyllike Christenson ,

Dr. Partamin Mr. Khalid Yari  Mr. Mahmood Azimi Dr.Wali Rasekh, MW Saliha,Hamnawazada, MW Sdiqa, MW Sharara Aman,

  1. Karolinska Institute Sweden
  2. Afghan Midwives association (AMA)
  3. JHPIEGO – Afghanistan Country Office, Kabul, Afghanistan
  4. Ministry of Public Health, Islamic Republic of Afghanistan, Kabul,
  5.  Care of Afghan Family (CAF)
  6. Agha khan Health Services (AKHS) AfghanistanCorresponding author:Pashtoon Azfar ,RNM Afghan Midwives Association (AMA) president and Midwifery advisor for Health Services Support Project (HSSP)Sabera Turkmani RM, Afghan Midwives Association officer and Midwifery program officer for Health Services Support Project (HSSP)




    The Purpose  of this study is to collect data from midwifery practices of the new graduated community midwives in 2 provinces (Takhar and Bamyan) to identify the gapes, make intervention plan to fill the gaps and, finally improve the Mother’s and family health status

    Specific objectives: 

    • To make sure all the new midwives practice according to the standards
    • To assess knowledge, skills, and confidence in current practices of Midwives after graduation.
    • To provide additional coaching in clinical skills, if needed.
    • To work with supervisors to ensure that Midwives have the support needed to apply new knowledge and skills at their job site.
    • To understand community perception of community midwives and understand how confident they are with the performance of these midwives


    38 new graduated midwives from 31 Health facilities in two provinces of Afghanistan Bamyan& Takkhar , 18 in Bamyan  and 20 in Takhar Provinces interviewed.


    Supportive supervision is conducted according to the plan, but the quality of this supervision is not good as it should be. Gaps were (lack of practices according to the standards) identified but interventions are very weak/no follow-up to make sure that gaps are filled. most of the midwives are busy with activities other than Reproductive Health .The quality of supervision needs to be supportive and strong advocacy is needed for the introduction of new midwives in the community   to enable them play a big rule on reduction of maternal and new bon mortality and morbidity and make sure of well being of mothers and their families

    The midwives who are working in the non RH area, will lose there skill as well as they can not provide quality of services because they do not have the skills’ of non RH.

    Key words:

    Midwives, Supportive Supervision, Quality of Care, Afghanistan.



    There is great need for midwifery as a profession in Afghanistan, which has the second highest maternal mortality rate globally.  However, due to thirty years of civil instability, there are few trained midwives and fewer currently working in their profession of training.  The Afghan Midwifery Association (AMA) was formed in 2005 and has taken the responsibility to improve the professional status of midwives and institute national performance standards for midwifery graduates and practicing providers, in an effort to improve reproductive health services in Afghanistan.


    In November 2007, AMA leaders attended a workshop focused on sexual and reproductive health and rights and midwifery competence in Stockholm, Sweden.  As a training course, the group developed a plan to evaluate quality of current midwifery practice and public perception of midwifery practice.  The concept paper emerging from this course was further developed into a small formal evaluation with input from the supervisor of the study, Ministry of Public Health, community midwifery programs’ implementing agencies, academic research programs, and other stakeholders.  Input was received to develop draft tools and prioritize performance indicators, with stakeholder input.  The evaluation protocol, which included in-depth interviews, chart audit, and direct observation of skills, was reviewed and approved by the Ministry of Public Health Institutional Review Board and the project self-funded by the AMA (Appendix 1).




    In 2002, Afghanistan’s interim government had just begun the long, difficult process of reconstruction. Twenty-three years of conflict nearly destroyed Afghanistan’s infrastructure, making it one of the world’s poorest and least developed countries, and its people especially women and children some of the most vulnerable to extreme poverty and destitution (UNDP, 2003).


    The country’s health indicators are appalling, including the second highest maternal mortality ratio (MMR) in the world (UNICEF, 2002), currently estimated at 1600 per 100,000 live births (Bartlett et al., 2005). Not surprisingly, the risk of death due to maternal causes increases among women living in remote regions. Bartlett et al. (2005) reported 6500 maternal deaths per 100,000 live births—the highest MMR ever reported—in the remote province of Badakshan. The neonatal mortality ratio in Afghanistan is also among the world’s highest, at an estimated 60 per 1000 live births (Lawn et al., 2005).


    Most Afghan women deliver at home, and in 2003, less than 10% of births were attended by a skilled provider (MOPH, 2003a). One Afghan woman dies every 30 mines from pregnancy-related causes, mainly hemorrhage, obstructed labor or sepsis. Given that 78% of such deaths are avoidable (Bartlett et al., 2005), rapid mobilization of female health-care providers, especially in rural areas, is essential to improving these staggering statistics. In developing a comprehensive approach to address this issue, Afghanistan’s Ministry of Public Health (MOPH), donors and international health organizations have faced many challenges. Early in their efforts, an assessment of human resources (MOPH, 2003b) identified a severe shortage of skilled health-care providers—specifically female providers, as remains the strong cultural preference in the context of health care for women. One province had only two female providers, and the total number of Afghan midwives was estimated to be 467.


    Since 1978, approximately four to five million Afghans have fled the country, including many educated health professionals. Most continue to live as refugees, mainly in Pakistan and Iran; some have returned, but they are few and based mainly in urban areas. Midwifery schools had essentially been closed from 1996 to 2002



    In 2002 an estimated 467 midwives were in Afghanistan . Midwifery schools had essentially been closed from 1996 – 2002 and the human resource need was critical, especially given the high maternal mortality and the mal-distributions of these few midwives. Even those few midwives were inadequately prepared for work and varied greatly with respect to their formal training. Results to date on the national testing and certification exams showed that the majority of midwives do not meet minimum levels of competency .


    In response to this shortage, substantial efforts have been done to educate midwives for service delivery at both hospital and health center levels. In 2002 there were nurse-midwifery programs at 6 of the country’s campuses of the Institute of Health Sciences (IHS), and one community midwife program in the country. Now there are 19 community midwife programs and a new skill-focused curriculum for the education of midwives.


    Since 2004 about 14-1600 Midwives are graduated from both Hospital Midwifery Education programs and Community Midwifery Education programs. Training of large number of the midwives itself can not solve the maternal health’s issues.  Follow-up and supportive supervision of new graduated midwives is extremely important, to make sure that they are working properly and able to put in to practice what they have learned in reproductive health areas.



    Study Sites and study population:


    The health system in Afghanistan is based on a Basic Package of Health Services. The package provides the minimum required health services to the people. The services include:


    1-      Maternal and Newborn Health

    1. Antenatal care
    2. Delivery care
    3. Postpartum care
    4. Family planning
    5. Care of the newborn

    2-      Child Health and Immunization

    1. Expanded Program on Immunization (EPI) survives
    2. Integrated Management of Childhood Illnesses (IMCI)

    3-      Public Nutrition and

    1. Prevention of malnutrition
    2. Assessment of malnutrition
    3. Treatment of malnutrition

    4-      Communicable Disease Treatment and Control

    1. Control of tuberculosis
    2. Control of malaria
    3. Control of HIV

    5-      Mental Health

    1. Mental health education and awareness
    2. Case detection
    3. Identification and treatment of mental illness

    6-      Disability Services

    1. Disability awareness, prevention, and education
    2. Assessment
    3. Referrals

    7-      Regular Supply of Essential Drugs


    In order to deliver the services in an equitable manner to the community, the service delivery is carried out through a network of facilities with focus on rural areas. The service delivery points in the BPHS include the following:

    1-      Health posts: Staffed with one male and one female community health worker, positioned in the smallest community unit (one or more villages) serving 1000 – 1500 population

    2-      Basic Health Centers: Delivers complex outpatient services to 15000 – 30000 population.

    3-      Comprehensive Health Centers: Delivers outpatient services to 30,000 – 100,000 population with a larger staff profile. The CHCs serve as the referral facilities for the BHCs in the same area.

    4-      DistrictHospital: Delivers both outpatient and inpatient services and is the first reference site for the BHC and CHC facilities in the area.


    A big challenge to realization of these essential services is lack of human resources. The shortage of qualified service providers is severing at rural communities. Female health workers are severely inadequate. The limited number of female health workers specially midwives from urban areas and prefer to work in urban areas. Midwifery services are one of the least available. In response to the sever shortage of midwives and female doctor, Ministry of Pubic health had adopted a community approach to midwifery services. The approach called Community Midwifery Education includes establishment of midwifery education facilities in the rural areas, identification and enrollment of students from communities with direct involvement of the community members and leaders, comprehensive education of the students with a full curriculum of the midwifery program and deployment of the graduated midwives in the same area.


    Two provinces selected were Bamyan and Takhar. The Community Midwifery Education (CME) school in takhar was established in  2004 The school has graduated 43midwives and currently 26 student midwives are studying in the school. The CMESchool in Bamyan was established in 2004 and has graduated 40 midwives in two batches. The school has currently enrolled 26 students. The graduated midwives have been deployed to health facilities.

    The range of the midwives are 20 -37


    The study was aimed at community midwives working in health frailties in the two



    Sub centers BasicHealthCenter Comprehensive Health center DistrictHospital Provincial hospital
    2 9 13 6 8



    A. Direct Observations:

    •           Supervisory checklist used during midwives’ practice as tool.

    B. Interview:

    •       Interview (midwives, female staff, head of the clinics.


    •        Interview with the mothers who come to receive MNH services in the clinic the tool which was used, client satisfaction questioner.



    C. Document review:

    •           Review the records of midwives’ activities (registers, patient cards).


    Tools available:

    1.         Quality Assurance tools

    2.         Supervisory check list for post graduated midwives

    3.         Client Satisfaction Questioner


    Study Conduct:


    In this study a three phase evaluation was conducted in the two respective provinces identified for the study. Due to the small scope of the project and limited resources, two community midwifery programs were chosen for evaluation.  Following considerations of safety, availability of study staff assistance, and size of midwifery workforce, the two provinces chosen for evaluation were Bamiyan and Takhar.  Study instruments were developed and field-tested, as were interview questions.  This pilot-testing resulted in three final instruments, including a professional experience checklist, client satisfaction questionnaire, and quality assurance/ direct observation tools (Appendix 2).  Following receipt of local government approval for the project, two study staff were recruited and trained in each site.  The staff were trained midwives who received further training in interview techniques, data collection sheet completion for chart auditing, and standards and scoring system for skill observation.


    Bamiyan field activities initiated in early July, 2008, and completed by end of July the same year.  Study activities were conducted in 14 different health facilities in districts of Panjab, Waras, Shibar, Yawkawlang,Kamard,Saighan and Panjab districts.


    The team conducted the study in Takhar province between mid-July, 2008, and activities were completed by mid-August.  Study activities were conducted in 20  health facilities in Taloqan, Khwajawar, Khwajabahuidin, Rustaq, Boraq, and Farqar districts.  Facilities in both provinces included the full range of government health facility, from basic health centers to provincial hospitals.




    The first phase of the evaluation involved a chart and record audit to summarize the experience of 38 practicing midwives (19/province) since their graduation from training.  There were 22 indicators retained in the final instrument (Appendix 3).  The midwives included in this phase were graduated two years before and deployed to their health centers within two to three months of graduation.  All graduates were working in reproductive health and nearly all (97%) also worked with medical issues not related to reproductive health.  Graduates had attended an average of 209 deliveries, of which 85.8% were facility-based.  The midwife was the sole attendant for most (80.9%) deliveries.  Neonatal outcomes were notable for an 83.6% live birth rate; however, there were a substantial number of deliveries (1193/7957) whose outcome was not recorded.  There were 11 maternal deaths reported, resulting in a maternal mortality ratio of 138.  Participants reported a 14% rate of complications:

    Midwives were evaluated based on their responses to complications; only 63% were deemed to have always made the appropriate clinical decision.  Most midwifery graduates were noted to be using the partograph (96%) and recording statistics for government sources (91%).


    % of MWs who are using partograph ? 96%
    % of MWs who are practicing according of their curriculum 80%
    % of staff who are aware of curriculum 77%
    % of MWs who are using of curriculum 90%
    % of MWs who are involve in HMIS record keeping ? 91%



    The second phase of the evaluation assessed client satisfaction through individual interviews, with 31 patients interviewed in two provinces.  General perceptions of care were favorable, with 50% completely and 49% somewhat satisfied with care received, based on indices of availability of care; attitude, knowledge, and communication skills of midwife; and relevance of information provided.  These levels of satisfaction remained consistent between antenatal, delivery, and post-partum care (See Figure 2).  Areas receiving low (<35% totally satisfied) satisfaction scores included: how MW handled the delivery, adequacy of general practice information, location of health facility, and marginally for perceived ability to handle complications during delivery, clarity in communication, advice provided on the importance of check-ups, conducting post-natal check-ups, and advice provided on immunization and family planning.



    Supervisors and female health staff were also interviewed for their perceptions of the performance of the midwifery graduates .generally all head of clinics were satisfied with quality of care which are providing by the midwives .they mentioned since the new midwives are deployed in the health  facility the number of deliveries increased from 2-40 deliveries overage .



    Development of tools, approval of MoPH, Training of assessors, targets achieved 100%, development of  database

    Limitations & Challenges:

    During implementation included limited resources for study staff and transportation, which curtailed sample size and distribution; distance between and accessibility of health facilities due to remote sites; and limited experience with executing evaluations of this type by AMA staff.



    • Develop a system for supportive supervision and intervention plan based on gaps identified, implementation plan, reassess
    • Strengthening of Midwifery  curriculum (adding modules on basic epidemiology )
    • Professional developments and continues education of Afghan MWs
    • Future research is needed to review maternal deaths in Afghanistan to evaluate the impact of pre service midwifery education,



    The authors wish to thank:

    Sweden International Development Agency (Sida)

    Karolinska institutet, all Supervisors’ of development project specially Mrs Kyllike Christenson our study supervisor

    Ministry of Public Health, Afghanistan

    Health Services Support Project (HSSP) specially M&E team (Mr.Khalid Yari,Mr.Mahmood Azimi,Dr. Partamin)

    Dr. Wali Rasikh head of Care of Afghan Family(CAF) in Takhar province  MW Sdiqa   MCH supervisor with CAF,MW Sharara AMA officer in Takhar, MW Saliha hamnawazada Midwifery project coordinator in Bamyan province which implemented by Agha Khan health Services (AKHS)

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>