Download Presentation - Women Deliver

Skilled Care at Birth
Experience from Afghanistan
Women Deliver Conference
June -7-9- 2010
Pashtoon Azfar, President
Afghan Midwives Association (AMA)
Presentation Outline
• Overview of the context and challenges
• Overview of the methods employed to address the challenge
– Creating the policy environment
– Establishing an accreditation system
– Estimating needs and employing a workforce planning approach
•
– Ensuring quality education
Ensuring deployment, supervision and support
• AMA and its role in:
– Strengthening Midwifery Profession
– Improving maternal Health in Afghanistan
– Results and Achievements
• Remaining challenges
• Lessons learned and recommendations
2
The challenges – after 23 years conflict
Challenging Health Indicators:
Maternal Mortality Ratio
– 1,600 / 100,000
Neonatal Mortality
– 60/1000 live births
– Less than 9% of deliveries
attended by SBA
Few female health workers
– 467 midwives in 2002
– 21% health facilities had female
staff
– Socio-cultural demand for female
providers
3
Maternal Health in Afghanistan
• Estimated 26,000
women dying from
pregnancy related
causes per year
• 1 woman dying
every 27 minutes
• 78% of deaths are
preventable
8%
9%
38%
4%
5%
10%
Haemorrhage
Obstruction
26%
PIH
Sepsis
Source: Bartlett et al
2005
Other direct
Indirect
Unclear
4
Policy Environment
• Development of Basic Package of
Health Services
• Maternal mortality reduction
strategy included improving
coverage of SBA and an
Intrapartum care strategy
• Policy statement on cessation of
TBA training issued (2003); focus
on training SBAs
• Midwifery curriculum existed;
out of date, focused on training
midwives for hospitals
5
Creating the Policy Environment
GOAL: To prepare qualified and competent midwives, to work in underserved areas of
Afghanistan
•Competency-based curriculum and
training materials developed
• midwives job description developed (2004)
•18-month competency-based curriculum re-designed
•Knowledge and skills of clinical preceptors updated
•Assessment conducted and curriculum revised
and extended to 24-months
•National program of community midwifery education
began 2004; one pilot program started in 2002
•Testing and certification process of previously
trained midwives established
•Midwifery Education Policy endorsed (2005)
6
Estimating 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
7
Selection According to Human Resource Needs
• Mostly from rural areas
• Commitment to work postgraduation in the community
where a need was identified
and where student is from
• Collaboration with national,
provincial, local health
authorities and communities in
selection and recruitment
• Follow selection policies of
MoPH
8
Deployment, Supervision & Support
•
Deployment
– Midwives deployed to community
facility that they were recruited
from
– Working within a defined Basic
Package of Health Services
– Supportive supervision
•
Supervision
–
Supervision teams established and
checklists used.
9
Quality Education
•
Education is focused on
competencies and required
clinical skills
•
Standards & accreditation to
ensure quality of teaching
•
Residential programs addressed
cultural concerns about women
being away from families &
provided supportive learning
environments with almost zero
attrition
•
Babies and toddlers stayed with
their mothers …and new babies
arrived during the training!
10
Establishing the Accreditation System to Ensure
Quality in Midwifery Education
1.
2.
3.
4.
5.
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
11
Performance Standard Example
PERFORMANCE
STANDARDS
1.
The provider asks
about and records
danger signs that
the woman may
have or has had.
SCORE
VERIFICATION CRITERIA
YES
NO
1
N/A
COMMENTS
Verify whether the provider determines if the woman has had any danger signs
during her pregnancy:

Vaginal bleeding

Respiratory difficulty

Fever, severe headache/blurred vision

Severe abdominal pain

Convulsions/loss of consciousness

Blurred vision
Assures immediate attention in the event of any of the above symptoms
N/A = Not Applicable
12
CME Paktya, Binding Assessment
13
Accreditation 2006-2009
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Binding
Ta
kh
ar
Non-binding
Pa
kt
iy
a
Kh
os
t
Baseline
Ka
nd
ah
ar
Ka
bu
l
zj
an
Ja
w
ira
t
H
ho
r
G
ya
n
Ba
m
Ba
da
kh
s
ha
n
0%
14
Re-binding (After 2 years)
15
16
Results: IHSs &CME Schools
1.
2.
3.
4.
5.
6.
7.
Badakhshan
Badghis
Baghlan
Bamyan
Daykundi
Farah
Faryab (2
schools)
8.
Ghazni
9.
Ghor
10. Helmand
11. Jawzjan
12. Khost
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27
Kunar
Kunduz
Laghman
Logar
Nangarhar (2 schools)
Nimroz
Paktika
Paktiya
Parwan
Samangan
Sari Pul
Takhar
Urozgan
Wardak
Zabul
Newly graduated community midwives in
Badakhshan province take midwifery pledge
17
Results: Institute of Health SciencesHospital Midwives
1.
2.
3.
4.
5.
Kabul
Herat
Nangarhar
Kandahar
Balkh
Students in skills lab in Takhar CME
18
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 inservice trainings
20
Output and Achievement of MWE Programs
Currently studying
Enrolled
Graduated
Drop-outs
% Graduated
Deployed/
Employed
% Deployed/
Employment of
graduated
Currently working
(as of May, 2009)
% currently working
of graduated
Currently working
of deployed/
employed
167
1232
1103
129
90%
890
81%
754
68%
85%
CME
509
886
858
28
97%
785
91%
694
81%
88%
TOTAL
676
157
93%
1675
85%
1448
74%
86%
Type of Program
IHS
2118 1961
Achievements
Before:
– 8% of births attended
by a skilled provider
in 2003
– Skilled 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
– 34 midwifery education
programs in 2010
– Competency-based
training curriculum
developed to train
hospital & community
midwives
– By May 2009, 2,200
competent midwives
have graduated, 1,675
deployed (85%)
– 59% of BPHS health
facilities (BHC, CHC, 22
DH) staffed with at
least 1 midwife
Are Women Getting the Services they
Need?
“Before there was no midwife in
our health center and we had to
travel over one hour to the
nearest town. I had all my
babies at home before because
of this. But now Midwife Hadia
is at the health centre and
because of this more women
are seeing a midwife. I will have
my next baby with Hadia in this
health center, she is very nice
and makes me feel safe”
Woman in Takhar province who was
delivered by Midwife Hadia
23
Remaining Challenges
•
Planning the HR needs for midwives
nationally – how many do we need?
•
Supervision post-graduation – are
midwives under worked? Or over
burdened and not able to focus on
maternal and newborn health?
•
Tracking deployment nationally
•
Retention for remote and insecure
areas
•
Focusing on quality of existing
programs
•
Cultural isolation of women and
female literacy rates
24
25
Lessons Learned &
Recommendations
• Increasing skilled attendance at birth requires political will and
commitment
• Focus should be on establishing and supporting a national
accreditation system and processes
• Build on previous successes and approaches
• Selection & recruitment of midwives linked to deployment is 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 continuously supported in maximizing their
potential
• A professional association, such as AMA, is important to providing
advocacy for the profession, support for the midwives, and contributes
to sustainability
• Success of community midwifery programs has created demand
26
• Professional development and CME .
Remaining Challenges
•
Planning the HR needs for midwives
nationally – how many do we need?
•
Supervision post-graduation – are
midwives under worked? Or over
burdened and not able to focus on
maternal and newborn health?
•
Tracking deployment nationally
•
Retention for remote and insecure
areas
•
Focusing on quality of existing
programs
•
Cultural isolation of women and
female literacy rates
27
Final Words
•
“I am happy with the midwife.
Previously there was no midwife in
our village and women were
suffering bleeding and their
children were dying. Now thanks to
God, we have got a midwife and
since have not seen a pregnancy
death.”
•
“In the beginning, people thought
that I might be a dayee
(traditional birth attendant) and
would not be effective. At present,
they know me as a women’s
specialist and they respect me and
say that I solve their women’s
problems.”
28
THANK YOU