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

7/29/2019 Program Evaluation of the Pre-Service Midwifery Education Program in Afghanistan

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Program Evaluation of the Pre-ServiceMidwifery 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


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Support of Midwifery Educational

System

Maternal Mortality Ratio in2002 was 1,600/100,000

Only 467 midwives available in2003

Less then 10% births wereattended by SBAs (MICS

2003)

Major donors supportedstrengthening the Institute

Health Sciences andestablishing community

midwifery education (CME)

programs in the country to train

additional midwives

Develop a Basic Package ofHealth Services 2


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Purpose

To improve the pre-service midwifery education program throughidentification of its strengths and weaknesses.

Objectives

To assess :

How the program addressed the needs of Afghan women and theirfamilies 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 timeestimated to reach national coverage with current output of midwife

graduates.

How program effect delivery of maternal health care services.


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Methods

1. Review of midwifery education programsdata: number of graduates and current

students

2.Assessment of provincial level maternalhealth utilization:Analysis of HMIS data

3. Assessment of quality of care: Core

competencies using training mannequins

and simulations

4. Documentation of clinical practice ofgraduated midwives

5. Projection of number of midwives

needed

6. Qualitative Interviews and FGDs


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Review of midwifery education

programs data

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IHS CME Total

Current enrolled students 109 585 694

Past enrolled students 1364 1172 2536

Graduated 1218 1149 2367

Drop- outs 146 23 169

Graduation rate (%) 88% 98% 93%

Graduate% Deployed % Currentlyworking %

IHS 88 82 76

CME 98 89 84

Proportional

Difference

9 8 10


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Utilization of midwifery services

Average ANC and SBA Use by Time and

Treatment Group, 2003-2008

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0%

10%

20%

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70%

80%

90%

100%

MROP NBR MVA EC PGR SHK

Scores in 8 provinces for selected competencies

Badakhshan Badghis Hirat Kabul Nangarhar Paktya Parwan Saripul

Assessment of quality of care


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Assessment of Quality of Care

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0%

10%

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100%

MROP NB SHK MVA EC PGR

Competency scores by school type

CME IHS


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Competencies in all provinces combined

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45

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10 20 30 40 50 60 70 80 90 100

Frequency

ofrespondents

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MROP scores from all provinces

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10 20 30 40 50 60 70 80 90 100

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ofrespondents

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NB scores from all provinces

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ofrespondents

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SHK scores from all provinces

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10 20 30 40 50 60 70 80 90 100

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ofrespondents

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MVA scores from all provinces

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Frequency

ofrespon

dents

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ECC scores from all provinces

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Frequency

ofrespon

dents

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PGR scores from all provinces


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Monthly Averages (%) of Midwives

Work Activities

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Projected Number of Midwives Needed

Nationally

2007 2012 2017

Already Trained Midwives 1,800

Estimated Births/Year 1,021,285 1,271,235 1,509,653

Needs for Full Coverage @200 births/midwife

5,106 6,356 7,548

Additional New Graduatesto Meet the Goal

3,306 1,250 1,192

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Estimations of the assessment in 2009

Actual situationBirths per year 2012: 1,002,029

Number midwives needed: 5010Number midwives: 3807

Gap: 1203


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Economic Analyses

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CME IHS

Numberofschoolsassessed 7 2

Meannumberofstudentsenrolled 26 65

Meannumberofstudentsgraduated 25 60Meannumberofstudentsdeployed 22 38

Meannumberofgraduatesworkingat

themeofassessment 19(73%) 41(63%)

Meancostperbatch(USD) 303295 285144Meancostperenrollee 11922 5256

Meancostpergraduate 12201 5474

Meancostpermidwifedeployed 13659 7687


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Qualitative findings

Villagers refer to midwife as our own

girl; she is one of the most respected

women in the community and a rolemodel for young Afghan girls.

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Midwives, clients and authorities shows high generalsatisfaction from program

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

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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 developmentopportunities

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

midwives (mental health, pharmaceuticals, etc.)


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Recommendations

Hardship allowances and performance-based Incentivesfor 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


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Update since evaluation

MoPH salary policy was revised and added additionalallowances for remote facilities

Curriculum revised 7 modules added, course increasedfrom 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 tomidwives

AMA has embarked on an intensive advocacy activity forhigher education of midwives

AMA has piloted a mentorship program for supportivesupervision of newly graduated midwives in six provinces

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ThankYou!

PhotosbyJhpiegostaff,NGOgrantees

&KateHolt

Documents

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