Feature - Afghanistan welcomes new midwifery graduates, looks forward to first Congress

[ Note: For media coverage and photos of the graduation ceremony, visit the Media Center. ]

The next generation of Afghan midwives is emerging, ready to serve and help reduce Afghanistan’s high maternal and infant death rates.

The first group of midwives to be fully trained since the fall of the Taliban graduated on 13 April 2005 at the Intercontinental Hotel in Kabul, Afghanistan. The 138 female graduates—from more than 20 provinces around Afghanistan—were from two classes that were combined during a time of curricular transition.

Speakers at the graduation included Dr. Sayed Mohammed Amin Fatimi, Afghanistan's Minister of Public Health; Ms. Guljan Jalal, Director of Student Affairs for the Institute of Health Sciences (IHS); Mr. Jim Griffin, Senior Health Advisor for USAID/Afghanistan; and Ms. Shakeela Abdali, class valedictorian.

"It is my proud privilege to stand in front of you and speak on behalf of all the graduating students," Abdali said. "We have been waiting for this day for very long.... It is our day today and we are glad that here with us comes another batch of health messengers, beholders of well-being, for whom thousands of mothers have awaited so long."

Graduates Committed to Improving Health Care

Students were trained using a new 2-year, competency-based curriculum adopted by the Ministry of Public Health (MOPH) and implemented by IHS. The Midwifery Education Program—funded by the U.S. Agency for International Development (USAID)’s Rural Expansion of Afghanistan’s Community-based Health Care (REACH) Program and the Aga Khan Development Network—includes classroom studies and clinical work at area hospitals.

The deployment of newly trained midwives to both urban and rural posts is crucial to Afghanistan’s health care system. The United Nations Children’s Fund (UNICEF) estimates that Afghanistan has the second highest maternal mortality in the world. More than 25,000 Afghan women die in childbirth each year—an estimated 1,600 maternal deaths per 100,000 live births. Newborns have a high mortality rate as well, with 165 infant deaths for every 1,000 live births.

"Fifty to 70 mothers die every day from birth complications, which is a silent tsunami for Afghanistan," said Minister of Public Health Fatimi at the graduation ceremony.

A main reason for the high mortality rate is the lack of health care professionals. Currently, only 8 percent of births are assisted by a trained professional. Under Taliban rule, women’s health care and education were neglected, and no midwives were trained between 1996 and 2003. Due to traditional and cultural restrictions, male doctors or health attendants cannot help women give birth—yet roughly 40 percent of health facilities lack skilled female birth attendants to deal with emergencies.

The new midwifery program is creating a new cadre of midwifery professionals, who can practice their obstetric skills in clinics and hospitals as well as in the home (where most births take place). Some life-threatening complications, such as hemorrhage, can turn deadly if not addressed before a woman is sent to another facility (which is often 2–12 hours away). Midwives must have the skills to manage emergencies by stabilizing the woman and starting the process of referral for emergency care.

The 138 graduates in Kabul are part of the first group to go through the program; another 90 midwives will graduate from IHS schools in Mazar-i-Sharif and Herat this month. These programs, along with pilot and remedial programs, have generated 299 new midwives—a 64 percent increase from the 467 trained midwives in Afghanistan after the Taliban fell in 2001. This is only the beginning; Afghanistan will eventually need 8,000 to 10,000 midwives, Fatimi said.

"The graduates have demonstrated their motivation and commitment to the profession of midwifery, and their success and achievements are a tribute to the many women in Afghanistan who need their help so much," said Sheena Currie, Jhpiego’s Midwifery Advisor in Kabul. "These midwives will be vital in providing the capacity that strengthens the overall quality of health care and the overall goal of health for all."

The REACH Program supports centers for midwifery education in 10 areas of the country. REACH is an ambitious 3-year health program funded by USAID and led by Management Sciences for Health (MSH). Within REACH, Jhpiego has the responsibility for supporting the program’s safe motherhood activities, including midwifery education.

First National Congress to Promote Midwives

The midwives also have the opportunity to attend the Inaugural Congress of the Afghan Midwives Association, to be held 4–5 May 2005 in Kabul. The AMA was formed in 2004 to support Afghan midwives and promote the professionalization of midwifery in the country.

"I’m very excited about the national Congress and I even can’t sleep at night very well," said Pashtoon Azfar, Faculty Development Officer for the REACH Safe Motherhood Unit and Chairperson of the AMA. "I’m excited to have all the midwives together and strong. It is my dream that all people should look for a midwife instead of a doctor because a midwife is a very wonderful care provider. Midwives should be proud and confident."

In travels throughout Afghanistan, Azfar has told midwives about the AMA and received enthusiastic support. "It’s amazing for midwives to have this support," she said. "They were so happy. They were in disbelief."

Interest in the AMA has grown steadily, as more Afghan midwives discover the organization and find in it a way to share their experiences and discuss common challenges to their daily work. In the first Congress, members will adopt a constitution and establish the structure through which the organization will begin to influence Afghanistan’s Safe Motherhood Initiative.

Challenges include elevating the status of midwives in the eyes of doctors and Ministry of Public Health officials, Azfar said. A recent example involved a hospital in Kabul, where the director asked the midwives to wear blue coats—the color coat worn by support staff—rather than the white coat worn by doctors. When Azfar discussed this with the director, they compromised by allowing the midwives to wear white coats with a blue ribbon sewn onto the top of the coat pocket.

Another challenge for the new AMA, Azfar said, will be to expand opportunities for capacity-building and continuing education—such as English and computer classes—for midwives that are more readily available to doctors. A 2004 survey of Afghan midwives showed that some midwives had not received any knowledge updates in more than 25 years. However, improvements are starting to be made through the REACH Safe Motherhood Unit.

"It’s difficult for health care providers to work and not have their knowledge updated," Azfar said. "Now I’m happy when I go to Herat, to Mazar or Badakhshan, or Takhar, and I talk about midwives and the midwifery programs. And people know about the changes that have been brought about by the Safe Motherhood team of Jhpiego and REACH."

A third issue is that some communities have low expectations or support for midwives, Azfar said. After the revolution in 1978, the national midwifery program’s infrastructure was damaged and some schools reduced programs to just 3–6 months. These schools graduated a variety of students with the title of nurse or midwife, despite their limited education. By reinstituting a 2-year curriculum and updating skills through performance and quality improvement, the stature of midwives is on the rise again. The AMA is also in the process of qualifying for membership in the International Confederation of Midwives.

"Conditions have improved and now girls want to come to midwifery programs more than nursing programs," Azfar said. "My hope and dream [for the AMA] is that I want to have a very strong association to make all the midwives really professional, and we want to have a training center to build knowledge and skills of all midwives so they can reach the top of their career. This is my dream."

Through REACH, Azfar provides technical assistance in rehabilitating Schools of Midwifery in both Kabul and other provinces. She conducts clinical and training skill courses for staff of USAID-funded nongovernmental organizations involved in midwifery education, and is helping to implement the standardized national midwifery and community midwifery curricula that REACH has developed to educate Afghan midwives in the future. For more information about Azfar, read "The Afghan Midwives Association: A traditional calling on a new path.”

About Jhpiego
For 35 years, Jhpiego, (pronounced "ja-pie-go"), has empowered front-line health workers by designing and implementing simple, low-cost, hands-on solutions that strengthen the delivery of health care services, following the household-to-hospital continuum of care. We partner with community- to national-level organizations to build sustainable, local capacity through advocacy, policy and guidelines development, and quality and performance improvement approaches.