Afghan Health Providers’ Response to a Leading Cause of Deaths in Pregnant Women
A leading cause of women dying in childbirth in the developing world is a pregnancy-related blood pressure condition known as pre-eclampsia/eclampsia. Symptoms of the potentially life-threatening condition of pre-eclampsia are elevated levels of protein in a pregnant woman’s urine and high blood pressure after 20 weeks. If undiagnosed and unmanaged, pre-eclampsia can rapidly progress to eclampsia (convulsions/fits)—the deadliest form of the condition. In Afghanistan, health statistics show that 20 percent of maternal deaths are the result of hypertensive conditions.
Midwives in Afghanistan who have been trained by Jhpiego have learned to screen for pre-eclampsia/eclampsia during prenatal visits and treat it appropriately. In an effort to ensure that Afghan midwives and their physician colleagues are delivering appropriate care, Jhpiego did an analysis of health care facilities that provide emergency obstetric and newborn care and their response to pre-eclampsia/eclampsia. Jhpiego-supported staff interviewed 224 health care providers at 78 facilities and found that all of the facilities had the proper equipment—blood pressure cuffs and stethoscopes—and three-fifths had urine test strips to check for high levels of protein in a pregnant woman’s urine. In addition, from 76.7 percent to 96 percent of these facilities had a complete IV set to maintain fluid balance and administer antihypertensives and magnesium sulfate, which has been shown to reduce the risk of death from eclampsia by 45 percent.
As to the competency of health care providers, the analysis showed that 96 percent of doctors and 89 percent of midwives recognized that magnesium sulfate should be used to manage severe pre-eclampsia/eclampsia, but 42 percent of doctors and 58 percent of midwives also thought another drug, diazepam, had a role to play in treating these women. Diazepam is recommended when magnesium sulfate is not available. While supplies of anticonvulsant drugs were available at the facilities, the drugs weren’t always used, according to the analysis.
These findings suggest a need to clarify service delivery guidelines, offer refresher training and bolster best practices with supervision and reinforcement for health care providers, especially for those working in facilities with fewer women presenting with symptoms of pre-eclampsia/eclampsia.
According to the journal article on the analysis results mentioned above, “The study findings will be used to help inform continuing education and reinforcement efforts in Afghanistan and also to standardize supplies and equipment across different facility levels. More broadly, they can contribute to the development of effective strategies for translating health worker knowledge into practice in low-income countries.”
As we come to the end of another successful year we wanted to take a moment to say THANK YOU to all of you who have helped us to save the lives of women and babies in Afghanistan through our project Educate a Midwife – Save Women in Afghanistan.
Because of donors like you, Jhpiego has supported midwifery training programs across Afghanistan and helped to ensure that more mothers are alive today caring for their children and families.
We also wanted to remind you of the many ways your donations have made an impact. Since Jhpiego began working in Afghanistan:
The percentage of women giving birth in health facilities has increased from 19% to 32.4%.
Community health workers have educated more than 1,000 pregnant women living in remote areas on how to use misoprostol – a lifesaving drug that prevents mothers from bleeding to death after birth.
Mothers are surviving! There has been a significant drop in maternal deaths across the country – from 1,400 for every 100,000 live births to 327 for every 100,000 live births.
And while there is still much work to be done, we have people like you to thank for the remarkable progress we have made so far.
So, again and with all our hearts, THANK YOU! You are helping to keep mothers and babies alive and families together through your kindness.
Mothers in Afghanistan are alive today because of women like Marzia Resolu…
Marzia is among the 3,000 midwives who have been educated and trained through the national midwifery education system established by the government of Afghanistan with support from U.S. Agency forInternational Development (USAID) and Jhpiego.
During the years of Taliban rule, maternal mortality in Afghanistan was the second highest in the world, and women routinely died in pregnancy and childbirth. Maternal and newborn services and skilled care were nearly non-existent. The consequences for the women of Afghanistan were significant. The presence of a skilled health careprovider during birth is the single most important intervention to keep a pregnant woman and her newborn alive and healthy.
With community midwifery schools re-established and skilled midwives returning to the workforce, Afghanistan’s maternal death rate has declined significantly.
“Previously there was no midwife in our village and women were suffering bleeding and their children were dying. Now, thanks to God, we have got a midwife and since have not seen a pregnancy death.”
A Jhpiego-supported study found that the numbers of women receiving prenatal care services was greater in provinces that had community midwifery schools than in those without them. In those same provinces, more women gave birth in a health facility where complications could be addressed swiftly and properly.
“People in the village are happy with them since they are female, because we cannot talk to male doctors about our problem. If we go and see a male doctor, our men will kill us. These midwives are everything for us.”
A teacher, Marzia returned to school at age 26 to become a skilled midwife. Marzia, and others like her, will go to great lengths to ensure their patients receive the care they need – these midwives often walk or travel by donkey for hours to make home visits, working nights and long hours.
“I know that there is a great need for midwives in the region as many women have problems in childbirth because there are very few facilities and the insecurity makes it very hard for people to travel to hospital when they need to,” said Marzia. “I am very happy that I will be able to go back to my community . . . and help my people.
The demand for skilled midwives, however, remains high. An additional 5,000 educated and trained midwives are needed to ensure women living across this mountainous and rugged country receive the skilled care they need to survive childbirth. As international funding has declined, community midwifery schools have closed. When the Jhpiego-led Health Services Support Project ended in the fall of 2012, there were 32 schools. That number has since dropped to 22.
Continued strengthening of midwifery education and training in Afghanistan is essential to saving the lives of women and newborns in this country. Your support has made a great impact on the lives of women and their babies throughout Afghanistan. Working together, we will save the lives of many, many more.
Source material: EVALUATION OFTHE PRE-SERVICE MIDWIFERY EDUCATION PROGRAM IN AFGHANISTAN, March 2011, Health Services Support Project (HSSP)
In the tiny village of Katasank in central Afghanistan, Ozara Husseini is a lifeline for pregnant women and mothers. She is neither a doctor nor a midwife. And yet, Ozara is often the first person to whom women turn when they have a question about their health. A community health worker who is studying to be a teacher, Ozara knows the importance of education and gives women in her village of 200 the information they need to safely space their pregnancies.
"I really believe in family planning,” says the 20-something who has been a community health worker since she was a young teen. “It is the only thing that is going to improve the economic situation of women throughout Afghanistan. Most women I visit in this community are very willing to accept family planning and want to use it -- either to not have any more children or to be able to have space between their children.”
As a maternal health issue, postpartum family planning is crucial because pregnancies during the first year after childbirth hold the greatest risk for the mother and her baby. Healthy birth spacing allows women to properly care for themselves, their babies and family, helping to reduce maternal and newborn deaths.
Community health workers are often the first contact for information on hygiene, nutrition, safe birthing practices and family planning methods. Ozara visits women in their homes, using illustrated flipcharts to educate women on family health issues. She explains that spacing pregnancies three years apart benefits both mother and newborn.
When patients are ill or in need of specialized maternal health services, she refers them to the Community Health Center in the nearby town of Foladi where two midwives work.
“Women get married very young here,” says Ozara. “Some women will have up to three children before they are 20 years old. There are a lot of cultural barriers here to using family planning - a lot of people believe that the birth of children is the will of God and we shouldn't interfere with this. Some decision makers of the family don't allow the women to use birth control - but often the women will do it in secret because they know that it is the only way that they are going to be able to look after their existing children properly. I explain all types of family planning - the (intrauterine device), pill, condoms and an injection that the women have to go to the health center for. It is up to families to decide for themselves.
“I have noticed,” she added, “an improvement in the economic situation of families who are able to decide when they will have their next child because they can plan for it.”
Community health workers are an integral part of the Afghan government’s community-based health system. In partnership with the Ministry of Public Health and with the support of U.S. Agnecy for International Development, Jhpiego has worked to ensure women and families gain access to quality health services.
A rebuilt midwifery education system has graduated 3,000 skilled midwives who are working in communities throughout the country. In addition, Jhpiego has helped educate and train community health workers like Ozara in delivering basic health information, family planning counseling, gender equity issues and prevention of postpartum hemorrhage in women who can’t reach a health facility and must give birth at home. Postpartum hemorrhage or severe bleeding after birth -- is leading cause of maternal deaths worldwide.
Community health workers like Ozara have educated more than 10,000 pregnant women living in remote areas on self-administration of misoprostol, a potentially lifesaving drug to prevent postpartum hemorrhage when giving birth at home.
Shahrbanoo, a young midwife working in Bamyan Province in Afghanistan, is a graduate of the community midwifery education system, which was established by the Afghan government with support from USAID and Jhpiego. More than 3,000 skilled midwives have graduated from accredited schools in this system and are working today to save the lives of mothers and newborns. A significant reduction in maternal deaths in Afghanistan reported in 2010 has been attributed to these new midwives who bring skilled care to women where they live. Midwifery school graduates have an education and a job to help them provide for their families.
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