Training Midwives in Afghanistan

Maternal and New-born Health Rates Declining – Midwife Training Urgently Needed

Dear Friends and Supporters,

Between 2000-2017, Afghanistan made significant progress with its maternal and child
health, becoming one of the countries to achieve a 50% reduction in its maternal mortality
rate. By 2019, rates of infant mortality halved from rates observed in 2000, to 47 per 1000
live births. Unfortunately, these progresses are at risk and rates have vastly declined since
the withdrawal of US troops and NATO forces from Afghanistan in 2021 and the Islamist
takeover. Today, the UN estimates that one woman from Afghanistan dies every two hours
during pregnancy or childbirth. This is the highest maternal mortality rate in Asia and
demonstrates a dire need for health care improvements.

Economic sanctions and devastation, the lack of sustained donor support for health care
and Taliban interference with basic human rights have all gravely affected quality and access
to child and maternal health care. Furthermore, many health workers have also left
Afghanistan, exacerbating an additional stress on the functioning of health system. A crucial
and lifechanging strategy for improving maternal and new-born health is midwifery
education.

Our organisation, AfD, has established a reputation in Afghanistan as a group that promotes
improved health and makes the most of medical care. Yet, in 2023, and despite positive
responses from donors and other supporters, AfD was unable to pursue our goals of training
230 midwives due to a lack of funding and inability to secure the sufficient amount of
funding to launch the training. The cost of training one midwife through our program is
250$ (for a two-week training, The training and enhancement of skills of these midwives
would greatly benefit women, with estimated 450 women per annum would benefit.
Current circumstances have demonstrated that very soon, there will be insufficient
educated girls able to enter university for midwifery training. Therefore, continued
investment in midwives' training and development should be an urgent priority at a time
when resources and skills are severely limited and generating such a devastating impact on
women and children.

Help AfD to help the families in need and save lives in Afghanistan,

Purpose: This summary has been developed to share feedback from local midwives living and working in Kabul, Afghanistan to share their personal experiences as a midwife, rural and urban midwifery needs, standards of care and findings from a basic training needs analysis.

The feedback from the midwives will help AfD to continue to improve and develop the midwifery programme and form a baseline for needs assessment. In addition to these questionnaire responses, further interviews are planned with midwives to deepen our understanding and to continue to expand and develop our AfD midwifery programme as aligned to local midwifery needs.

Summary of respondents: 9 midwives (out of 250 trained in 2022) currently working in Kabul and Bamyan provinces of Afghanistan were interviewed and completed our needs assessment questionnaire in March 2023. The average age of respondents was 27-years. 57% were unmarried and 100% were educated to graduate level, graduating from a private university in midwifery studies. Beyond basic midwifery training completed at graduate level, 57% had completed other professional development training (beyond the AfD programme) including an internship and or training hosted by their hospital. 100% of midwives said that more opportunities are needed to support their continued professional development and to support women and their maternal health more effectively.

5/9 midwives are clinic-based and paid a salary (5000-8000AFG per month). Of concern, 2 midwives are working as volunteers as they aren’t able to get a paid midwifery role due to changes implemented by de facto authorities:

‘-Most hospitals are no longer hiring interns in Kabul after the Taliban regime took over. Aryana hospital which I was working there is an example. In Bamyan there are very limited positions for midwives and challenging to get hired’

‘-We preform our tasks like official midwives do but as a volunteer we don’t receive any salary. Most patients who come from far rural areas where has been more affected by the Taliban, experience mental health problems or psychological problems. As one of these patients were crying and explaining to me her story of how poor she was and how difficult it was to have access to the hospital.’

 ‘-I have spent a large amount of money on my studies and with all the obstacles I managed to graduate but it is very disappointing, not being able to find a job. I would  like to have an official job to be able to work effectively and provide my services.’

 ‘-I believe employment opportunities for women especially in midwifery is important to gain experience and reach more women in need. In addition, hospitals have limited health care facilities, equipment and tools to women in need’

For the midwifes working in a paid role, they are registered and they are the sole income provider for their household. 5 midwives lived and worked in an urban area and 2 lived in a rural area. The numbers of women supported per month by midwives range from 21-100 women depending on community needs. Hours worked range from 16-hours per week to 35 hours a week:

 ’-I work each day from 8:30 am until 5pm, with an exception during the month of Ramadan which I can leave at 3:30pm. I also have one night shift in the clinic each week’.

Midwifery training and learning needs:  When questioned, each midwife reported a level of confidence to manage general ‘obstetric care and natural childbirth’:

‘- After 4 years of studies in midwifery and the work experience that I have, I believe I am capable of handling pregnancy related complications such as high pressure, respiratory problems and normal pregnancies. Sometimes it also depends on the type of the complication the patients experience but in general I am quite confident.’

The midwifery training curriculum:  86% of our respondents rated the AfD midwifery training as ‘excellent’. The content and delivery were well-received. However, to continue to respond to training needs and to support midwifes in their professional development to meet the maternity needs of their communities, respondents identified a need for further professional development training – focusing on a range of themes to support clinical practice as well as health promotion and prevention outreach:

‘-I would like additional trainings in consultation, nutrition (women and child) and abnormal deliveries.

Conclusions: This summary report continues to reaffirm the urgent need for investment and development of midwifery training for midwives working in Afghanistan.

The challenges experienced by the midwives are heightened because of the restrictions placed on women and girls and the rules of the de facto authorities on what women can and can’t do. The risks to maternal health and wellbeing have never been greater now for women living in Afghanistan and for women and girls in the future.

‘-Problems have always existed. Especially after the Taliban took over, the freedom of women has been limited. With all the new rules by Taliban, the free movement of women without a male guardian has created challenges for nurses. As a result, it has limited our accessibility of us to reach out to more patients in far areas’.

‘- As you have heard in the news, our access to education has been banned and we are facing a lot of problems to enrich our knowledge as a midwife and gain experience’.

Continued investment to enable ongoing training and development for midwives is an essential need and represents an opportunity to provide humanitarian intervention at a time when resources and skills are extremely stretched.

The de factor authorities recognise midwives as a profession that should be allowed to continue to practice. With this position agreed, it is essential to build on the baseline of training already developed by AfD and to expand the programme to include the areas of need identified by midwives including a specific module on ultra-sound; clinical supervision and support to manage abnormal deliveries; post-natal care for complex deliveries; as well as mental health and nutrition support.

‘Women should be supported and be given their education rights. Since women are banned from accessing education, we have faced a lot of obstacles to learn and enrich our knowledge as a midwife.’