Addressing Maternal Mortality in Afghanistan

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1 case study Addressing Maternal Mortality in Afghanistan Utilisation and perception of Community midwives in three provinces December 2010

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3 Addressing Maternal Mortality in Afghanistan Utilisation and perception of Community midwives in three provinces December 2010 Acknowledgements Dr Kylea Laina Liese from the Yale School of Nursing was the principal investigator for this research, which was commissioned by Merlin. She received help and support from the following individuals and organisations during the research process: Dr. Qadir (Merlin Afghanistan) Claire Manera (Merlin Afghanistan) Dr. Hashimi (Merlin Afghanistan) Dr. Nadeem (Merlin Afghanistan) Dr. Maung (Merlin Afghanistan) Dr. Fayqa (Merlin Afghanistan) CAF in Takhar Sarah Robinson (Stanford University, Department of Anthropology) This publication is provided on behalf of the Health and Policy Department, Merlin, and is based on the report of Dr Liese s findings with additional contributions by Dr Sarah Neal. Photography: Dr Kylea Liese (pages 6, 11, 13, 16 and 17) Published by Merlin, 207 Old Street, London, EC1V 9NR First published 2010 Merlin 2010

4 Acronyms Definitions ANC BPHS CAF CM CME IHS MMR MoPH TBA USAID WHO Antenatal Care Basic Package of Health Services Care of Afghan Families Community midwife Community Midwife Education Institute of Health Sciences Maternal Mortality Ratio Ministry of Public Health Traditional Birth Attendant United States Agency for International Development World Health Organisation Antenatal: The time period from conception until the onset of labour, about 40 weeks. Lifetime risk of maternal death: the probability that a woman will die from complications of pregnancy and childbirth over her lifetime, usually expressed in terms of odds; it takes into account both the maternal mortality ratio and the total fertility rate. Maternal death: The death of a woman while pregnant or within 42 days of termination of the pregnancy from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Maternal mortality ratio (MMR): The number of maternal deaths during a given time period per 100,000 live births during the same time period. Millennium Development Goals (MDGs): The MDGs are eight international development goals (each with specific targets and indicators) that all United Nations member states have agreed to achieve by the year They are based on The United Nations Millennium Declaration signed in 2000 which commits world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women. Neonatal period: The first 28 days of an infant s life. The terms neonate and newborn are often used interchangeably. Neonatal mortality rate (NMR): The number of neonatal deaths per 1,000 live births during a fixed period. Postnatal / postpartum care: Care provided to a woman during the period of six weeks after birth by for reasons related to the birth. Skilled birth attendant: An accredited health professional such as a midwife, doctor or nurse who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period and in the identification, management and referral of complications in women and newborns.

5 Case study: Addressing maternal mortality in afghanistan 3 Executive Summary Maternal mortality in Afghanistan is the highest in the world, and the development of effective health services for mothers and babies is a major challenge in a context of extreme poverty, gender inequality, geographical inaccessibility and infrastructure constraints. The Community Midwife Education Programme is a cornerstone of the Ministry of Public Health s strategy to address maternal health and aims to train community midwives (CMs) for deployment within rural areas. CMs are chosen by their own communities, and undertake an 18 month training course before returning to their homes to provide clinic-based reproductive health care. The acceptability of this model of care to women and other opinion-leaders within the community is crucial to its success. This study examines community perceptions of the skills and roles of these midwives in three provinces where Merlin is currently working (Takhar, Kunduz, and Badakhshan). It documents how women make use of the services CMs offer, and also outlines the barriers that women face in accessing care. The study also investigates the experiences of the CMs themselves, and their level of job satisfaction in their new roles. The findings suggest that women and the broader community find the model of care provided by CMs to be culturally acceptable, and understand the benefits of skilled care at delivery. They also acknowledge and value the skills that the CM possesses in a range of reproductive health areas, including management of post-natal complications and provision of family planning. Despite promising signs of progress, uptake of care by CMs at delivery is still relatively low, with most women giving birth at home with a family member or traditional birth attendant. However, young women are more likely to give birth in facilities with CMs than older women, suggesting that over time the need to seek care at delivery will be increasingly seen as a priority. There is some evidence that the presence of CMs has changed women s utilisation patterns for care during delivery, but further work is needed to investigate this issue. The disparity in women s positive attitude towards the advantages of facility-based births attended by CMs and their actual practice is mostly the result of transport difficulties, which present a huge barrier to women and their families when seeking care. Consequently any further measures to increase coverage of care during delivery will need to address these constraints.

6 CASE STUDY: Addressing maternal mortality in afghanistan 4 Introduction Each year around a third of a million women die as a result of pregnancy and childbirth. 1 Over 99% of these deaths occur in developing countries. Recent UN estimates 1 suggest that progress is being made in reducing these deaths but the picture is very mixed, with some countries and regions having made impressive gains while others show a much more negative pattern of limited improvement and stagnation. Progress tends to be poorest in fragile states such as Afghanistan, which now has the highest maternal mortality ratio in the world. Reducing maternal deaths within a fragile or post-conflict environment where infrastructure is weak is extremely challenging, and specific dimensions of the Afghan context including insecurity, social and cultural factors and geographical barriers impose particular constraints. It is widely acknowledged that a pre-requisite for reducing maternal mortality is the development of a cadre of health workers equipped with the skills to provide care for women before, during and after childbirth. In Afghanistan a national programme to train and deploy large numbers of community midwives (CMs) is a cornerstone of their strategy for reducing maternal deaths. In 2007 Merlin carried out a study to capture lessons learnt from the initial round of Community Midwife Education (CME) training in Takhar province. 2 This study follows on from this earlier piece of work, and examines how communities perceive the skills and value of CMs, and how care-seeking behaviour has been influenced by their deployment. It also highlights the barriers women face in accessing care during delivery, and outlines areas for further action. Background Afghanistan: key facts Population: 29,121,286 GDP: $366 (Current US $) Urban population: 24% Total fertility rate: 5.5 children Literacy total population: 28% male: 43% female: 13% Life expectancy at birth: 44.6 years Maternal mortality ratio: 1400 per 100,000 live births Under 5 mortality rate: 257 per 1000 live births Neonatal mortality rate: 50 per 1000 live births Sources: World Bank and WHO databases (most recent available estimate for all indicators)

7 Case study: Addressing maternal mortality in afghanistan 5 Lifetime risk of dying from pregnancy-related causes Legend Lifetime risk of dying from pregnancy related causes Afghanistan: 1 in 11 More than 1 in 20 1 in 20-1 in 49 1 in 50-1 in in 500 to 1 in 1,999 1 in 2,000 to 1 in 4,999 Less than 1 in 5,000 No data Data source: WHO, UNICEF, UNFPA, and World Bank (2010). Trends in Maternal Mortality Maternal health in Afghanistan Afghanistan has the highest maternal mortality ratio in the world (1400 per 100,000 live births), 1 and little progress has been made to reduce this figure since A woman in Afghanistan still faces a 1 in 11 chance of dying as a result of pregnancy or childbirth during her lifetime. Neonatal mortality, which is intrinsically linked with maternal health, is also unacceptably high at 50 per 1000 live births. Maternal mortality ratio (MMR) Progress in maternal mortality since Afghanistan Least developed countries Year Afghanistan s extremely high maternal mortality is underpinned by gender inequality, high fertility, limited female education and extreme inaccessibility to quality health services. The shortage of female health workers leaves most women without the option of skilled care at birth. As a result, an estimated 81% of women deliver at home with only the assistance of family members or local traditional birth attendant. 3 In much of the country a lack of transportation and mountainous, unreliable and insecure roads prevent women from reaching health facilities in time for interventions to save their lives in the event of an obstetric emergency. Even when care is available, it is culturally unacceptable for most Afghan women to be seen by a male physician. Source: WHO, UNICEF, UNFPA, and World Bank (2010) Trends in Maternal Mortality : estimates developed by WHO, UNICEF, UNFPA and the World Bank.

8 CASE STUDY: Addressing maternal mortality in afghanistan 6 Improving access to health care in Afghanistan: The Basic Package of Health Services Improving access to health care in this context is extremely challenging. The Afghanistan Ministry of Public Health (MoPH) has been working alongside the global health community to address these issues within a nationally integrated system of public health. A Basic Package of Health Services (BPHS) has been implemented, and is delivered through contracts with international, national and government bodies, focusing on providing cost-effective and widely distributed basic healthcare interventions. Widely regarded as a potential model for other post-conflict states, the arrangement ensures delivery of the most important interventions needed to reduce child and maternal mortality in even the most remote areas of the country, under the stewardship of the MoPH. Results have been impressive: in just six years the proportion of Afghans with access to basic health services (maximum of two hours walk) increased from 9% to nearly 85%. 4 Thousands of community health workers have also been trained to diagnose and treat common diseases and deliver health promotion activities.

9 Case study: Addressing maternal mortality in afghanistan 7 The Community Midwifery Education (CME) Programme The development of health workers to provide skilled care at delivery has proved more challenging. As a response to the obvious need for skilled birth attendants, two pre-service education programmes have been developed to train new midwives. The Institutes of Health Sciences (IHS) programme is designed for midwives who practice largely in provincial, regional and national/ specialty hospitals i, whereas the CME programme is tailored to develop community midwives for deployment within rural communities. Community midwives (CMs) are women who are selected by established religious and/or social leaders and/or elders in their respective communities. Those selected attend midwifery training school for 18 months and are contractually obliged to return to their villages to practice for a minimum of three years of service. The training provides skills in clinic-based antenatal, labour and postpartum care. Furthermore, CMs provide contraceptive services and vaccination clinics for women and their children. An important skill is their ability to promptly identify problems that require referral to a tertiary care centre, thereby reducing delays that often prove critical to maternal survival. Since 2002 this scheme has been extended to 22 provinces throughout Afghanistan. i IHS trained midwives have a two academic year training. The CME is accelerated to 18 months with less holiday. The role of the community in supporting and endorsing community midwives The process of acquiring the agreement of community leaders involves many hours of negotiations and discussions. However community support is a vital component to the anticipated success of the CME program in Afghanistan. The endorsement by community leaders of a young woman-turned-midwife signals their approval and paves the way for families to take advantage of her services. In many Afghan villages, the role of community midwife is one of few opportunities for women to participate as professionals in the formal sector of their own communities. As such, the potential for improving women s opportunities by expanding the CM model to other professions is substantial.

10 CASE STUDY: Addressing maternal mortality in afghanistan 8 Distribution of Midwifery Schools in Afghanistan JAWZJAN BALKH KUNDUZ TAKHAR BADAKHSHAN FARYAB SARI PUL SAMANGAN BAGHLAN HIRAT BADGHIS GHOR URUZGAN NURISTAN PARWAN KAPISA KUNAR BAMYAN LAGHMAN WARDAK KABUL NANGARHAR LOGAR PAKTYA GHAZNI KHOST FARAH ZABUL PAKTIKA CME school Hospital (IHS) midwifery school NIMROZ HILMAND KANDAHAR Source: USAID. Programme evaluation of the Pre-Service Midwifery Education Program in Afghanistan. Final phase one report.september 2009 An evaluation undertaken by USAID 5 found that as of May 2009 a total of 858 community midwives had graduated, and 91% were currently deployed and practicing. The coverage is quite substantial in some northern provinces, but remains very low in others. The USAID study also assessed a number of competencies for currently practicing graduates of the CME training in eight provinces. While it highlighted some shortcomings, it suggested that the level of competency was reasonable, and indeed was higher than for IHS graduates. Interviews with midwives and clients carried out as part of the study demonstrated high levels of satisfaction with both the training and the care provided by CMs. Merlin s community midwifery programme In 2003 Merlin partnered with a national NGO, Care of Afghan Families (CAF), to implement a training programme for community midwives in Taloqan, Takhar province as part of the national CME programme. The first round of CME training in Takhar was implemented from with funding from USAID. A further programme was started in Kunduz province in 2007, and The Aga Khan Development Network developed a further programme in Badakhshan, a province where Merlin has been active in community health programmes for many years. To date Merlin programmes in Kunduz and Taloquan have trained 65 and 94 CMs respectively the majority of whom have been successfully deployed to work in rural communities with the school in Badakhshan having trained a further 65. This innovative and challenging CME programme is a key opportunity to learn lessons around the provision of maternal care in difficult and challenging environments and thus it is important to ensure the on-going documentation and analysis of the programme approach and outcomes. An initial report in 2007 documented the experience of setting up the CME programme in Takhar and its initial results. 2 In general it suggested that the training had achieved its original objectives: the programme was successful in gaining accreditation in April of 2006 from the National Midwifery Education

11 Case study: Addressing maternal mortality in afghanistan 9 Accreditation Board as well as graduating 21 of the original 22 students and placing them in health facilities. However, the programme faced challenges in ensuring community and religious leaders supported CM candidates. Given the vital importance of community support to the viability of CM services, the programme has invested more resources to improve awareness within the communities, work more closely with religious leaders, and integrate local views and ideas into midwifery training. The programmes continue to face ongoing challenges. Much of Kunduz province is currently controlled by the Taliban which has significant security implications. Meanwhile, Badakhshan province is geographically challenging and isolated as a result of extremely mountainous terrain and under-developed infrastructure. These factors have led to what is believed to be the highest estimated maternal mortality ever recorded: 6500 per 100,000 live births (based on an estimate for the years ). 6 Key lessons learnt from Takhar CME programme 2007 The support of key actors such as the Provincial Public Health Director in Takhar were instrumental in the success of the programme Selection of students must be supported by the local community The development of the programme must be informed by the views and ideas of local communities, and in particular religious leaders The quality of trainers is key in ensuring good outcomes from training

12 CASE STUDY: Addressing maternal mortality in afghanistan 10 Rationale of this study Merlin s earlier study suggested that it is certainly possible to develop a training programme that provides quality midwifery training to young women identified by their communities. The USAID study also suggests that the CME has generally succeeded in providing these women with the competencies that would be internationally recognised as a pre-requisite for a skilled attendant. 5 However, in order to make a difference to maternal health outcomes, these women need to be able to practice effectively within their communities. Their new professional role must be accepted by the women and other opinion-formers in their communities, and their skills recognised as valuable. The earlier study carried out by Merlin in 2007 suggested obtaining community acceptance was initially a challenge which could potentially jeopardise the impact of the CME programme. 2 This study examines the community perceptions and utilisation of CMEs deployed within health facilities in rural areas of Takhar, Badakhshan and Kunduz provinces. It provides insights on the degree to which CMs are accepted as health professionals within their community and how women value and make use of the services they offer. It also provides important information on the barriers women face when seeking care, which is vital for developing and refining the CME programme. An important feature of this study is that it explores the experiences of the CMs. In the context of Afghanistan s extremely traditional and male-dominated rural society their training and employment is groundbreaking. Further success of the CME programme relies on these women receiving adequate support, respect and job satisfaction from both their communities and the broader health system, so their perspective is crucial when evaluating the outcome of this initiative.

13 Case study: Addressing maternal mortality in afghanistan 11 Methodology This study uses qualitative and quantitative data gathered from interviews and focus groups with women, community members and CMs. Where available, data from health information systems has also been analysed and incorporated. A total of nine health centres, three in each province, were selected from a list of graduated CM placements. These sites were chosen to give a range of differing distances from the provincial capital, as well as issues of ensuring the safety of the interviewers. All villages in the study were considered poor and rural, where the main source of employment is subsistence farming and/ or manual labour. Data collectors were midwives ii selected by health directors from Merlin and trained in qualitative research methods by an independent medical anthropologist. Health facility data were obtained through National Health Services Performance Assessment, an annual survey of health facilities. A total of 165 women between 19 and 45 years old who had given birth in the past three years were interviewed using a pre-tested semi-structured interview tool. The interviews were designed to elicit information on reproductive histories, health seeking behaviours, attitudes and experiences with CMs, perceptions of maternal risk and family planning. It also aims to explore authoritative knowledge during childbirth: i.e. the knowledge that forms the basis on which decisions are made and actions are taken. 7 Nearly all women in the study were poor and illiterate, lived in traditional homes made of mud and straw and relied on subsistence agriculture. Data collectors contacted every third house until the requisite number of interviews was met. The research and selection criteria were explained to any adult in the house and permission for the interview was sought from the woman being interviewed, as well as her husband and/or mother-in-law if they were present. The rejection rate for requests to conduct an interview was less than one per cent. ii These Afghan midwives (as opposed to community midwives or IHS midwives) received three years of comprehensive nursing and medical training and work in hospitals or community health centres.

14 CASE STUDY: Addressing maternal mortality in afghanistan 12 In addition, 45 focus groups 8-12 women were held to examine community perceptions of maternal risk and their views and perceptions of CMs. Detailed interviews were also conducted with 12 CMs at their respective clinical sites. Since men s opinions play an important role in women s reproductive choices and health, 8 data collectors sought to interview men whenever appropriate. A total of 15 husbands were interviewed, and informed and voluntary consent was obtained from all participants. Has the deployment of CMs increased the uptake of deliveries in facilities? The CME programme has been implemented during a time of significant broader change in health service development in Afghanistan. Access to health care, particularly in rural areas, has vastly increased during the last decade, and this has included care at delivery. While overall coverage for skilled care at birth remains amongst the lowest in the world, the percentage tripled in the years between 2003 and Percentage births attended by skilled attendant in Afghanistan % 8% 19% for some facilities data are incomplete or inadequate for carrying out the necessary analysis. In some communities CMs may not have been in post long enough to make a difference to health seeking behaviour, and other changes within the Afghan health system may be acting as incentives for increased use of facilities for delivery even where CMs are absent. It is therefore difficult to make any clear statements on the impact of CMs on uptake of care at facilities for delivery. Overall, the proportion of births at facilities remained low, with the majority of women still giving birth at home with either a family member or traditional birth attendant. However, there are hopeful signs that a shift in behaviour is taking place in communities with a CM: n Around 30% of women interviewed had had at least one birth with a CM. This is much higher than the national average of 13% estimated in a 2004 survey. 9 A number of these women stated that they had given birth at home for previous pregnancies, but the arrival of a CM had prompted them to seek skilled care. n Young women were more likely to use CMs than older women. This suggests that over time use of CMs could increase, with prioritisation and normalisation of skilled care at delivery becoming greater. n Available data from some individual communities showed markedly increased uptake following deployment of a CM. For instance the village of Khaja Ghar saw a four-fold rise in institutional deliveries when the midwife arrived. Perhaps the most telling sign of the positive impact of the CM in this village is the subsequent decline in institutional delivers in 2006, which occurred while the CM was on maternity leave. When she returned to her duties in 2007, numbers rose again. Source: WHO Afghanistan Country Profile (estimates based on national surveys) The USAID study shows a small increase in skilled deliveries in provinces with CMs compared with those without. 5 However, while the rate of institutional deliveries had risen markedly in Kunduz, Badakhshan and Takhar provinces since 2004, this study was not able to demonstrate a significantly greater increase in institutional delivery among communities where a CM had been deployed compared with communities with no CM. This was partly due to data limitations: Number of institutional deliveries Institutional deliveries in Khaja Ghar, Takhar Arrival of CM Year CM on maternity leave

15 Case study: Addressing maternal mortality in afghanistan 13 Understanding of the importance and benefits of care at delivery While the first CME case study found the community s acceptance of CMs to be a challenge to CM utilization, 2 this study showed widespread community support. Only 9% of women reported that delivering at home was preferential to delivering with the CM. In fact, most women, even many who delivered at home, described the clinic as better safer and more comfortable. Women articulated that the difference between delivering at home with a traditional birth attendant (TBA) was that CMs were professionals who could provide medical treatment, while TBAs were mostly knowledgeable older women, able to provide support and occasional herbal remedies for common complaints. As one woman explained: Of course the clinic is more comfortable. The clinic is clean and the midwife gives us injections and syrup to solve our problems. The [TBA] she is our neighbour but she doesn t know anything really. Perceptions of the risks of delivering at home were informed by the stories of neighbours and relatives who had died in childbirth. In fact, 92% of women responded that childbirth was dangerous for women. As one husband expressed it, A woman in childbirth is a human between life and death. The data suggest that younger women (less than 30 years) and older women (more than 30 years) may balance the risks differently. Older women who had previous successful homebirths, often with the assistance of a TBA, reported that while they valued the services of a CM, they did not feel they were necessary. Meanwhile, younger women prioritized delivering at the clinic. There is some suggestion that a prior successful delivery at home makes women less likely to use the services of a CM. Since men in Afghanistan have ultimate authority over their wife s health seeking behaviours, Merlin focused their community awareness and support efforts on male religious and community leaders. In this study, men did not appear to prohibit women who wished to attend the clinic from doing so. Most women reported that their husbands supported whatever decision they made regarding their health seeking behaviours. Only 16 out of 165 women reported that their husbands disapproved of delivering in the clinic. In fact, all of the men interviewed stressed that delivering at the clinic was better and safer than delivering at home. These findings suggest that investment in improving community awareness and relationships with CME may have been successful in improving people s perceptions. Some studies have found that TBAs hesitate to refer women to the clinic either because they are poorly treated by clinic staff or will not be paid for their services. 10, 11 However, of the many birth stories recounted in this study, not one featured a TBA who appeared responsible for delaying a woman in need of care. In fact, it was striking how often women reported that the TBA had made the decision to immediately transfer the woman to the clinic. Likewise, there was no evidence of animosity between CMs and TBAs. It appeared that TBAs and CMs have distinct non-competitive roles: TBAs assist women who anticipate normal uncomplicated births and CMs assist women who either require or request additional medical support for their deliveries.

16 CASE STUDY: Addressing maternal mortality in afghanistan 14 While most women reported very positive experiences of care with a CM, there were also a small number of criticisms. In particular a few women complained that the clinic was crowded and they had to wait too long, and also in one case that the midwife did not work at night. Use of the CM for managing complications Even for women who give birth at home without a CM, there appears to be strong recognition of the skills that a CM possessed in managing complications or problems. Six percent of women who delivered at home presented at the clinic with post-partum complications that were managed by the CM. Although many women who did not deliver in the clinic reported that they would go to the clinic if there were any problems with their delivery, the CM was not the first line of reference in many cases. One woman described: I was very frightened. The births of my children were very difficult. When I felt my first pain I was worried about what will happen. It took one day and one night. I asked my husband to take me to the doctor but my husband said, my mother will help you. My mother-in-law was very kind but still the baby would not come. My mother-in-law went and brought the local midwife and she gave me some medicine. By now my blood pressure was very low and I thought I would die. After two hours the child came but I was still bleeding. The next day my husband took me to the clinic and the midwife there [CM] was able to help me. She said my blood pressure was very low and she gave me injection and syrup. Narratives such as this suggest CMs can play a key role in managing post-partum maternal complications. This is a particularly important factor when it is considered that 60% of all maternal deaths occur after the birth, 12 and it has been frequently argued that the significance of post-natal care is not sufficiently acknowledged. In Afghanistan only tertiary care facilities are capable of comprehensive emergency obstetric care, which includes blood transfusions and caesarean sections. Reaching these facilities can take hours, and in some cases days, depending on road conditions, weather, security and access to transportation. Since a woman can die from post-partum haemorrhage within two hours, 12 the timing from the onset of the complication to accessing care is vital. If a CM can control post-partum bleeding at the clinic, she greatly increases a woman s chance of survival since transportation to the hospital may not be available or may take some time.

17 Case study: Addressing maternal mortality in afghanistan 15 Other roles of CMs Due to the relatively slow uptake of delivery services, CMs spend the majority of their time undertaking primary health care activities for women and their children. CMs are often responsible for vaccinating women and babies, conducting antenatal and post-natal examinations, providing nutritional support and education and distributing medications if no other female provider is available. CMs have the potential to reduce maternal mortality through the provision of family planning, and this appeared to be a key role of the CM. When asked to describe the work of CMs, many women described how they distributed birth control pills and condoms. Although women s experiences with and attitudes towards family planning varied greatly in the sample, nearly all women knew that it was available through the CM and could explain at least two methods. Barriers to uptake of institutional care for delivery There appears to be a clear disparity between women s expressed attitudes and their actions in relation to careseeking during childbirth. While the vast majority of women stated that delivery in a facility was preferable, in reality the majority still gave birth at home. This can at least partially be explained by the physical challenges many of these women face in reaching the clinic. Women and their families must weigh up their personal risk for maternal (or perinatal) death against the hazards and difficulties of getting to the clinic with limited roads and transportation. Unless women lived within the same village as the clinic, travel to the clinic was a major obstacle. Poor roads and/or a lack of transportation were highlighted in nearly every interview, even with women who delivered at the clinic with a CM. Villages are often connected by narrow dirt trails that wind through riverbeds and along steep slopes, making even How can family planning reduce maternal and newborn mortality? pregnancies in very young women and those who are over 40, which also carry higher risk for both mother and baby. Family planning is also valuable in enabling mothers to space their births: unequivocal evidence exists on the association between shorter birth intervals (less than two years) and increased child mortality, and the effect of this is strongest in the neonatal period. 13 Afghanistan has one of the highest rates of total fertility in the world, with a woman giving birth to an average of more than five children in her lifetime. Contraceptive use is low at around 16%, 14 and this is likely to be even lower in rural areas. These factors point to the role of CMs in providing family planning as a key intervention in reducing maternal mortality in these rural, isolated communities. Access to family planning reduces mortality through a number of channels. Firstly, it reduces the number of pregnancies a mother undergoes, which lessens her overall risk. Secondly, it reduces the number of unwanted pregnancies, which may limit mortality resulting from women seeking unsafe abortions. Finally, it reduces the number of higher risk pregnancies such as mothers who have already undergone a high numbers of pregnancies. Access to contraception can prevent It is difficult to ascertain whether the presence of CMs has actually changed family planning practice. Prior to the CM s arrival, the only option would have been to visit a male doctor to obtain this service, which many women would have found unacceptable. Efforts to distribute family planning commodities through community health workers had been generally of limited success. It is therefore likely that by providing a socially acceptable channel for delivering these services uptake will increase.

18 CASE STUDY: Addressing maternal mortality in afghanistan 16 a short distance to the clinic dangerous for a woman in labour and impossible during the night or winter months. As one woman pointed out: Of course the clinic is better. It is clean and the midwife there can give us injections and syrup and solve our problems. But how can I go? There is no road; there is no car; there is not even a donkey. If there were these then I would go and all women would go, but there is not, so what can we do? Although younger women were faced with the same perilous roads and unreliable transportation, they were more likely to access skilled birth attendance, especially if they had delivered at least one child in the clinic. Likewise, many older women who delivered all their children at home insisted that their daughters-in-law deliver in the clinic. This suggests that while transport is undoubtedly a problem, many families will attempt to overcome it if delivery in a facility is seen to provide a great enough benefit (or birth at home is perceived as a great enough risk). The experience of community midwives A newly qualified CM is very quickly expected to shoulder an extremely heavy burden of responsibility, and work under very challenging conditions. She may be expected to manage obstetric emergencies with no support, and transportation barriers make referral to hospital difficult, slow and in some cases, impossible. Clinics are often extremely remote, poorly staffed and lacking supplies and equipment. Although there is great prestige in being chosen by their communities to be trained in the provincial capital, there is also great constraint. Each CM student signs a contract that they will return to their community and work for a minimum of three years. However, this responsibility may conflict with more normative expectations of marriage and childrearing. In this study, all but one CM expressed high levels of satisfaction with their work. In particular, they described serving the women of their communities as a privilege

19 Case study: Addressing maternal mortality in afghanistan 17 The people were always very kind to me but still they did not come for deliveries. Then there was two childbirths and one woman who was bleeding after she had her baby. She had not delivered the placenta. She came to me at night and I took care of her and, thank God, she was better. After this happened, the next week I had so many women here it was too crowded. I would like to stay and work here for all my life. I was born here and these are my people. These women are my aunts, my sisters and my mothers. Because they selected me, I want to increase my knowledge and my service to my people. Midwife from Takhar Province and honour. When asked about the work environment of the clinic, CMs described feeling supported by the other clinic staff and confident in their own skills, knowledge and abilities. In some cases, it appeared that being from the same village in which CMs were working could, at least temporarily, be a disadvantage since they were taken less seriously than other health professionals. In a village where the CM had only been working for two months, a woman explained: Why should I go to her? Yesterday she was just my neighbour. She goes away and now she is a midwife? What does she know? I think she is still just my neighbour. However, after four to six months, most CMs saw a sudden rise in patients. This trend, which is reflected in available clinic data, suggests the impact of CMs on overall utilization rates may become more evident in the near future as CMs settle in their posts. Several midwives described the process of gaining the trust of their community in their new role. One CM in Kunduz province attributed the change to a specific event: When I first came here the people did not trust me. Maybe there were just two or three in the morning. It was like this for some time and I was discouraged. However, the respect and job satisfaction these women experience is accompanied by the stress and responsibility of caring for their clients under difficult circumstances. CMs reported that the lack of available resources regularly limited the care they were able to provide. In one case this had tragic consequences: one young CM in Kunduz cried as she explained: One lady had very serious bleeding at home. When she came to the clinic I didn t have electricity and I couldn t assist her. I tried to send her to the hospital but there was snow and no car. We couldn t do anything for her and finally she died. The way forward The findings from this study suggest that the CME programme provides a culturally acceptable model of care for women in rural Afghanistan, and efforts to involve and engage communities have been successful in ensuring support for CMs. However, utilisation of CMs is constrained by several factors, and this study suggests a number of recommendations for further programme development. Focus on transportation Transportation and poor infrastructure threatens the success of the CME programmes on two fronts: firstly it limits women s utilisation of CMs, and secondly it restricts the ability of CMs to refer serious complications in a timely manner. In the long term the building of roads to connect remote areas should be a priority for both government and nongovernment actors as isolation is a barrier to health care utilization as well as broader socio-economic development for all sectors of the community. This goal will not be reached in the foreseeable future in many areas. More

20 CASE STUDY: Addressing maternal mortality in afghanistan 18 of choosing a facility based delivery for those where the physical difficulties of reaching the clinic are not entirely insurmountable. It may also be worth focussing education on first time mothers as there is some indication that once a woman has successfully given birth at home she is less likely to do so with a CM. immediate solutions are needed for the short and medium term, and several options could be considered. Some examples that have been put forward include giving women vouchers for independent drivers, who might act as on-call ambulances. Alternatively, CMs could be trained to support home births and given access to a clinic car in order to reach women in labour. This car would then be available to refer directly to a hospital in the case of an emergency. Adjusting the catchment area for CMs and facilities may also be an important part of the solution. A further option for consideration is the building of low-cost maternity waiting homes near clinic sites. There is evidence that this model may be acceptable within the Afghan context: one maternity waiting home built beside the Feyzabod District Hospital in Badakhshan was filled to capacity before its official opening date. However, more evidence is needed for the feasibility and acceptance of these possible options, and operational research should be developed to study these issues further. It is likely a combination of measures would be needed, and reaching women in the most remote communities will remain a major challenge without major infrastructure investment. Increasing demand for services While transport is undoubtedly a major barrier to women seeking care during delivery, younger women are more likely to make the journey to a facility, which may indicate that they and their family assess the potential benefits of skilled attendance to be greater. Community education on how every birth carries risk may encourage families to place more emphasis on the importance of skilled attendance when weighing up the costs and benefits This study suggests that mothers-in-laws are critical in influencing the reproductive health of the next generation. On the whole, these women are supportive to the CMs, and could be further targeted for education on family planning, health education and the importance of skilled care at birth. Likewise, husbands should also be included in education campaigns as they may make the final decision on whether a woman delivers at home or the clinic. Building up support for institutional deliveries among the family members of young women is vital to ensuring their wishes to deliver in the clinic are realised. The need for ongoing support and evaluation Finally, it is vital that CMs are provided with consistent support and resources from clinic managers and the relevant administrative and management agencies that supply the clinic. When the performance of a CM is compromised by security concerns, limited supplies, out-of-date training or limited working hours, the community s faith in the health care system is at stake. It must be recognised that the CME programme is still at an early stage of development, and ongoing evaluation is needed to fully assess the strengths and weaknesses of the programme. It is important that relevant data are collected to assess the impact of CMs on utilisation of maternal health care, and which aspects of their role are most valued by communities. It is also important that the CMs skills are regularly evaluated and refresher training planned. During this time of transition, when such efforts have been made to improve health infrastructure and outcomes, attention should be paid to the relationship between providers and the community. Periodic evaluation of the CMs skills as well as their integration in the community should be a component of any ongoing programme of evaluation.

21 Case study: Addressing maternal mortality in afghanistan 19 Conclusion This study confirmed Afghan women s willingness to use culturally appropriate skilled attendants during childbirth. Women of all ages understood the risks of childbirth and the potential benefits of giving birth with a CM at a facility, and others with authority over decision-making such as mothers-in-law and husbands were supportive of the need to seek care during delivery. However, in reality women and their families have to weigh up the potential benefits of care during delivery with the risks and hardship of travel to the facility. Improving access to care in the short term will necessitate developing and implementing transport solutions, and in the longer term development of the rural transportation infrastructure must be seen as a priority. Currently, uptake of services remains relatively low and the majority of women give birth at home. There are, however, encouraging signs of change and it was noted that younger women were more likely to give birth in facilities than their older counterparts. This suggests a change of behaviour where skilled attendance is prioritised even in the face of significant barriers. It is hoped this shift will increase in the future, particularly as these young women themselves become mothers-in-law with authority to influence the reproductive behaviour of the next generation. The experience of the CMs themselves appears to have been overwhelmingly positive, even in the face of heavy responsibility and severe constraints. CMs fill an important place in reproductive health care in Afghanistan. Their access to medical treatment distinguishes them from TBAs with more childbirth experience. However, their ties to the community keep these services, often perceived as foreign or Western, more local and less threatening. Their education and growing expertise represent significant movement away from a society where women have limited education or professional opportunities. It is hoped that as CMs confer benefits to their community there will be other opportunities for women to be trained as local professionals, building the capacity of the community through women s education. As role models for women s education and empowerment, CMs will contribute further toward their goal of improved maternal health.

22 CASE STUDY: Addressing maternal mortality in afghanistan 20 Summary of key findings The majority of women recognise the value and benefit of skilled care during delivery, and find this model of care culturally acceptable. Mothers-in law and husband play an important role in decision-making, and are generally supportive of women using CMs at local facilities for care during birth. The community recognises the skills the CM possess in providing care before, during and after birth, as well as family planning. Their role in treating post-partum complications and providing family planning provides significant opportunities for reducing maternal deaths. Utilisation of care at delivery remains low, but there are promising signs of improvement. Young women are more likely to use a CM than older women. Geographical distance, poor roads and lack of transport presents a significant barrier to women s use of CMs during delivery, and is the main factor responsible for the disparity between women s expressed views on the value of giving birth with a skilled attendant and the actual low level of use of this service. CMs generally express high levels of job satisfaction with their roles, but also face heavy responsibilities and constraints which limit the quality of care they are able to provide.

23 References 1 WHO, UNICEF, UNFPA, and World Bank (2010) Trends in Maternal Mortality : Estimates developed by WHO, UNICEF, UNFPA and the World Bank. monitoring/ /en/index.html 2 Merlin (2007). Reducing the Burden of Maternal Mortality in Afghanistan. Merlin s Community Midwifery Education Programme in Takhar Province. 3 WHO (2008) Proportion of births attended by a skilled health worker update Acerra J, Iskyan K, Qureshi Z, Sharma R. Rebuilding the health care system in Afghanistan: an overview of primary care and emergency services. International journal of emergency medicine 2009; 2(2): USAID. Programme evaluation of the Pre-Service Midwifery Education Program in Afghanistan. Final phase one report. September Bartlett LA, Mawji S, Whitehead S, Crouse C, Dalil S, et al. (2005) Where giving birth is a forecast to death: Maternal mortality in four districts in Afghanistan, Lancet 365: Jordan, B. (1997). Authoritative Knowledge and Its Construction. In R. Davis-Floyd & C. Sargent (Eds.), Childbirth and Authoritative Knowledge. Berkeley: University of California Press 8 Dudgeon, M., & Inhorn, M. (2004). Men s influences on women s reproductive health: medical anthropological perspectives. Social Science & Medicine, 59(7), Mayhew M, Hansen PM, Peters DH, Edward A, Singh LP, Dwivedi V, Mashkoor A, Burnham G. Determinants of skilled birth attendant utilization in Afghanistan: a cross-sectional study. Am J Public Health. 2008; 98: Berry, N. (2006a). Kaqchikel Midwives, Home Births, and Emergency Obstetric Referrals in Guatemala: Contextualizing the Choice to Stay at Home. Social Science & Medicine, 62, Okafor, C., & Rizzuto, R. (1994). Women s and health-care providers views of maternal practices and services in rural Nigeria. Studies in Family Planning, Li, X., Fortney, J., Kotelchuck, M., & Glover, L. (1996). The postpartum period: the key to maternal mortality. International Journal of Gynecology and Obstetrics, 54(1), Mahy M. Childhood Mortality in the Developing World: A review of evidence from the demographic and Health Surveys. DHS Comparative Reports No.4, ORC Macro, Maryland WHO Making Pregnancy Safer: Afghanistan Country Profile.

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