Establishing midwifery in low-resource settings: Guidance from a mixed-methods evaluation of the Afghanistan midwifery education program

Zainullah, Partamin; Ansari, Nasratullah; Yari, Khalid; M, Azimi; Turkmani, Sabera; Azfar, Pashtoon; LeFevre, Amnesty; Mungia, Jaime; Gubin, Rehana; Kim, Young Mi; Bartlett, Linda

doi:10.1016/j.midw.2013.10.026

Cited by 28 publications

(42 citation statements)

References 9 publications

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“…However, our findings showed an increase in the proportion of women who gave birth in a facility after the intervention. The MoPH has undertaken a large‐scale effort to expand the number of community midwives; therefore, we do not attribute the increase in facility‐based births to the misoprostol intervention alone. Nevertheless, the intervention did not dissuade women from receiving skilled birth attendance, which is in line with what other programs have also demonstrated …”

Section: Discussionsupporting

confidence: 87%

Misoprostol for Prevention of Postpartum Hemorrhage at Home Birth in Afghanistan: Program Expansion Experience

Haver¹,

Ansari²,

Zainullah³

et al. 2016

J Midwife Womens Health

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Introduction Afghanistan has a maternal mortality ratio of 400 per 100,000 live births. Hemorrhage is the leading cause of maternal death. Two‐thirds of births occur at home. A pilot program conducted from 2005 to 2007 demonstrated the effectiveness of using community health workers for advance distribution of misoprostol to pregnant women for self‐administration immediately following birth to prevent postpartum hemorrhage. The Ministry of Public Health requested an expansion of the pilot to study implementation on a larger scale before adopting the intervention as national policy. The purpose of this before‐and‐after study was to determine the effectiveness of advance distribution of misoprostol for self‐administration across 20 districts in Afghanistan and identify any adverse events that occurred during expansion. Methods Cross‐sectional household surveys were conducted pre‐ (n = 408) and postintervention (n = 408) to assess the effect of the program on uterotonic use among women who had recently given birth. Maternal death audits and verbal autopsies were conducted to investigate peripartum maternal deaths that occurred during implementation in the 20 districts. Results Uterotonic use among women in the sample increased from 50.3% preintervention to 74.3% postintervention. Because of a large‐scale investment in Afghanistan in training and deployment of community midwives, it was assumed that all women who gave birth in facilities received a uterotonic. A significant difference in uterotonic use at home births was observed among women who lived farthest from a health facility (> 90 minutes self‐reported travel time) compared to women who lived closer (88.5% vs 38.9%; P < .0001). All women who accepted misoprostol and gave birth at home used the drug. No maternal deaths were identified among those women who used misoprostol. Discussion The results of this study build on the findings of the pilot program and provide evidence on the effectiveness, primarily measured by uterotonic use, of an expansion of advance distribution of misoprostol for self‐administration.

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Section: Discussionsupporting

confidence: 87%

Misoprostol for Prevention of Postpartum Hemorrhage at Home Birth in Afghanistan: Program Expansion Experience

Haver¹,

Ansari²,

Zainullah³

et al. 2016

J Midwife Womens Health

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“…These include establishing midwifery schools to increase the number of skilled birth attendants, upgrading primary care facilities to include obstetrician‐gynecologists and surgical theaters in areas without a district hospital, and establishment of maternity waiting homes to provide accommodation and clinical services to women from remote areas. Funding mechanisms, including both demand‐side (conditional cash transfers) and supply‐side (provider or facility incentives) financing mechanisms have also been piloted …”

Section: Methodsmentioning

confidence: 99%

Bypassing Primary Care Facilities for Childbirth: Findings from a Multilevel Analysis of Skilled Birth Attendance Determinants in Afghanistan

Tappis

Koblinsky

Doocy

et al. 2016

J Midwife Womens Health

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Assumptions that women who give birth with a skilled attendant do so at the closest health facility may mask the importance of supply-side determinants of skilled birth attendance. More research based on actual utilization patterns, not assumed catchment areas, is needed to truly understand the factors influencing care-seeking decisions in both emergency and nonemergency situations and to adapt strategies to reduce preventable mortality and morbidity in Afghanistan.

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“…While most CHWs are illiterate, they receive pictographic training manuals and continuous professional development in the form of a three-day refresher-training every six months (24). With regard to community midwives, 9th grade rural female students are hand-picked by their communities to attend community midwifery schools; community leaders formalize the nomination through a signed letter of support (8,17). Similarly, most CHNs are recruited from, trained and deployed back in provinces where over 80% of the population is rural-residing (21).…”

Section: Strategic Rural Recruitment and Deploymentmentioning

confidence: 99%

Addressing health workforce shortages and maldistribution in Afghanistan

Safi¹,

Naeem²,

Khalil³

et al. 2018

East Mediterr Health J

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Background: Afghanistan has the second lowest health workforce density and the highest level of rural residing population in the Eastern Mediterranean Region. Ongoing insecurity, cultural, socioeconomic and regulatory barriers have also contributed to gender and geographic imbalances. Afghanistan has introduced a number of interventions to tackle its health worker shortage and maldistribution. Aims: This review provides an overview of interventions introduced to address the critical shortage and maldistribution of health workers in rural and remote Afghanistan. Methods: A review of literature (including published peer-reviewed, grey literature, and national and international technical reports and documents) was conducted. Results: The attraction and retention of health workforce in rural and remote areas require using a bundle of interventions to overcome these complex multidimensional challenges. Afghanistan expanded training institutions in remote provinces and introduced new cadres of community-based health practitioners. Targeted recruitment and deployment to rural areas, financial incentives and family support were other cited approaches. These interventions have increased the availability of health workers in rural areas, resulting in improved service delivery and health outcomes. Despite these efforts, challenges still persist including: limited female health worker mobility, retention of volunteer community-based health workforce, competition from the private sector and challenges of expanding scopes of practice of new cadres. Conclusions: Afghanistan made notable progress but must continue its efforts in addressing its critical health worker shortage and maldistribution through the production, deployment and retention of a "fit-for-purpose" gender-balanced, rural workforce with adequate skill mix. Limited literature inhibits evaluating progress and further studies are needed.

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Establishing midwifery in low-resource settings: Guidance from a mixed-methods evaluation of the Afghanistan midwifery education program

Cited by 28 publications

References 9 publications

Misoprostol for Prevention of Postpartum Hemorrhage at Home Birth in Afghanistan: Program Expansion Experience

Misoprostol for Prevention of Postpartum Hemorrhage at Home Birth in Afghanistan: Program Expansion Experience

Bypassing Primary Care Facilities for Childbirth: Findings from a Multilevel Analysis of Skilled Birth Attendance Determinants in Afghanistan

Addressing health workforce shortages and maldistribution in Afghanistan

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