Program Evaluation of the Pre-Service Midwifery Education Program in Afghanistan

Sabera Turkmani President Afghanistan Midwives Association January 2013

Linda Bartlett, Partamin, Pashtoon Afzar, Sabera Turkmani, Nasrat Ansari, Javed Rahmanzai, Khalid Yari, Nassim Assefi, Hannah Gibson, Kavitha Viswanathan Technical support by Jhpiego, Financial support by USAID Field data collectors: AMA member midwives

Support of Midwifery Educational System

Maternal Mortality Ratio in 2002 was 1,600/100,000 Only 467 midwives available in 2003 Less then 10% births were attended by SBAs (MICS 2003) Major donors supported strengthening the Institute Health Sciences and establishing community midwifery education (CME) programs in the country to train additional midwives Develop a Basic Package of Health Services

Purpose
To improve the pre-service midwifery education program through identification of its strengths and weaknesses. Objectives To assess : How the program addressed the needs of Afghan women and their families for available quality maternal and newborn care. Estimate cost of schools and per midwife working. How program develops effective processes, for example, student recruitment. Increases the number of graduate midwives in Afghanistan and time estimated to reach national coverage with current output of midwife graduates. How program effect delivery of maternal health care services.

Methods
1. Review of midwifery education programs data: number of graduates and current students 2. Assessment of provincial level maternal health utilization: Analysis of HMIS data 3. Assessment of quality of care: Core competencies using training mannequins and simulations 4. Documentation of clinical practice of graduated midwives 5. Projection of number of midwives needed 6. Qualitative Interviews and FGDs

Review of midwifery education programs data

IHS Current enrolled students Past enrolled students Graduated Drop- outs Graduation rate (%) Graduate% IHS CME 88 98
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CME 585 1172 1149 23 98%

Total 694 2536 2367 169 93%

109 1364 1218 146 88%

Deployed % 82 89 8

Currently working % 76 84 10

Proportional 9 Difference

Utilization of midwifery services Average ANC and SBA Use by Time and Treatment Group, 2003-2008

Assessment of quality of care

Scores in 8 provinces for selected competencies
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

MROP

NBR

MVA

EC

PGR

SHK

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Badakhshan Badghis Hirat Kabul Nangarhar Paktya Parwan Saripul

Assessment of Quality of Care

Competency scores by school type
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

MROP

NB

SHK

MVA

EC

PGR

CME

IHS

Competencies in all provinces combined

SHK scores from all provinces MROP scores from all provinces
50 45 40 35 30 25 20 15 10 5 0 10 20 30 40 50 60 70 80 90 100 Percent Frequency of respondents Frequency of respondents 60 50 40 30 20 10 0 10 20 30 40 50 60 70 80 90 100 Percent

NB scores from all provinces

Frequency of respondents 30 25 20 15 10 5 0 10 20 30 40 50 60 70 80 90 100

Percent

MVA scores from all provinces

Frequency of respondents 30 Frequency of respondents 25 20 15 10 5 0 10 20 30 40 50 60 70 80 90 100 30 25 20 15 10 5 0 10 20

ECC scores from all provinces

Frequency of respondents 25 20 15 10 5 0 10 20

PGR scores from all provinces

30

40

50

60

70

80

90

100

30

40

50

60

70

80

90

100

Percent

10Percent

Percent

Monthly Averages (%) of Midwives Work Activities

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Projected Number of Midwives Needed Nationally

Estimations of the assessment in 2009 2007 Already Trained Midwives Estimated Births/Year Needs for Full Coverage @ 200 births/midwife Additional New Graduates to Meet the Goal 1,800 1,021,285 5,106 3,306 1,271,235 6,356 1,250 1,509,653 7,548 1,192 2012 2017

Actual situation Births per year 2012: 1,002,029 Number midwives needed: 5010 Number midwives: 3807 Gap: 1203
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Economic Analyses
CME 7 26 25 22 19 (73%) 303295 11922 12201 13659 IHS 2 65 60 38 41 (63%) 285144 5256 5474 7687
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Number of schools assessed Mean number of students enrolled Mean number of students graduated Mean number of students deployed Mean number of graduates working at the Eme of assessment Mean cost per batch (USD) Mean cost per enrollee Mean cost per graduate Mean cost per midwife deployed

Qualitative findings
Midwives, clients and authorities shows high general satisfaction from program Villagers refer to midwife as our own girl; she is one of the most respected women in the community and a role model for young Afghan girls. Women in the village are happy with midwives since they are female, because we cannot talk to male doctors about our problems. If we go and see a male doctor our men will kill us. These midwives are everything for us.
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Qualitative findings
Challenges cited by most respondents:
Insecurity and cultural restrictions Transportation Inadequate supplies Discrimination by doctors CME Midwives that have studied less than 12 grade cannot attain full status as civil servants Inadequate refresher training and lack of professional development opportunities Inadequate supervision of midwives especially in remote areas Inadequate working hours at BHC and CHCs (5 hours per day) One midwife per BHC and two midwives per CHC are not enough Current curriculum does not address some technical needs of the 15 midwives (mental health, pharmaceuticals, etc.)

Recommendations
Hardship allowances and performance-based Incentives for remote, insecure areas, faculty & midwives Offer refresher training for midwives Supportive supervision Increase the number midwives in BHC/CHC Increase education level to 12th Grade for CME Enrich the curriculum with the lacking technical areas increasing the course length proportionally

Update since evaluation

MoPH salary policy was revised and added additional allowances for remote facilities Curriculum revised 7 modules added, course increased from 18 months to 24 months. BPHS included two midwives per BHC Midwifery policy and strategy developed was informed by this assessment NGOs provide more consistent supervisory support to midwives AMA has embarked on an intensive advocacy activity for higher education of midwives AMA has piloted a mentorship program for supportive 17 supervision of newly graduated midwives in six provinces

Thank You!

Photos by Jhpiego sta, NGO grantees & Kate Holt

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