Training Midwives 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.’

Dear friends, 

The global health organizations recognize that Afghanistan should have nearly 3500 midwives trained in the next five years to cover at least 85% of pregnancies. The World Health Organization (WHO) suggests a ratio of one trained midwife per 175 pregnant women. Currently, this ratio in Afghanistan is 0.1 per 1,000 pregnant women (rather than the required 5.7 midwives).

With the take-over of the de facto authorities and the suppression of women’s rights since August 2021, women are even more marginalized. The commitment to continue to allow training for midwifery gives some hope.

Since 2014, AfD has provided gap-training to over 950 certified midwifes across the country. In 2022, AfD provided training to 180 young women (midwives) and their families despite the challenges laid by the new de facto government and broader issues such as covid, lack of employment opportunity and extreme natural disasters (i.e. draught, flooding, earthquakes). AfD training included up skilling 120 midwifes who had received basic training as well as training for 60 midwifes as midwife trainers. These trainers gained the capacity to cascade the training with a greater reach to 120 other midwifes in more remote and or isolated province areas.

During the year 2022 AfD also advanced in developing a new module which is added to our training curriculum of midwives. This module will provide the midwives with additional information about counseling for proper nutrition both, the pregnant and lactating mother and provide necessary counseling for the proper nutrition of the baby. 

This module was developed upon the need assessment which was conducted in October 2022. The study of over 50 lactating mothers showed that the tendency towards formula feeding was prevailing and majority of the mothers did not know how to better support the nipple feeding process, thus they thought that the newborns discomfort and cry is the result of hunger, and therefore, they were starting feeding with formula.

Our new module developed depicts the necessary messages, and facts that a midwife can pass to mothers and thus help them to continue breast feeding their babies, as well as have balanced nutritious food for themselves.

The AfD target for 2023 is to train a total of 250 midwives in different rural areas of the country. 

Please support us further in order to continue our training program for the midwives, and continue saving lives. 

Links:

• AfD website

 In 2001, more than 1,600 Afghan mothers were dying per 100,000 live births. Through the support of maternal health and the training of skilled midwives, the country has reduced the rate to about 640 deaths. There is clear evidence that an increased number of trained midwives is directly correlated with a decrease in maternal and child mortality. This is why AfD is dedicated to expanding the capacity of midwives across Afghanistan to drastically reduce maternal and child mortality while also addressing the current employment stress facing Afghan women.

We are happy to announce the continuation of our Midwifery training initiative. In August, AfD conducted a widely successful training session. 60 midwives received ToT training, who then (following our cascade model) trained an additional 180 midwives. We continue to partner with the Midwifery School of Geneva on production of training modules to ensure the midwives are prepared comprehensively to support mothers. As the scope of our training increases, we hope to have a lasting impact on the health and well-being of mothers across Afghanistan. 

AfD has positioned itself within the community as an organisation helping people to achieve better health and get the most out of health service delivery. Through our meetings with community elders and other stakeholders, we ensure that the credibility of the actions we perform goes back to us, but also to our donors who support us. 

Many of the participants have truly appreciated the donor contributions towards building the capacity of Afghan health care personnel. On the other hand, participants will be able to improve the knowledge of their partners and colleagues on the issues they have learned. They will introduce into their health facilities the standards for the management of diseases that they have learned to control. Their work will still be supervised and monitored by the midwives who received the ToT. Gaps and weak points will be shared with the management staff in the field so that they can be exploited in due course. Midwives are recognized as health professionals who support and provide necessary services to women during pregnancy, childbirth and the postpartum period. They are also the closest health professionals to detect complications and provide preventive measures and medical care. These services are essential especially in rural areas where female gynaecologists are rarely available. The government of Afghanistan and global health organisations are realising and confirming the fact that Afghanistan should have nearly 3500 midwives trained in the next five years to cover at least 85% of pregnancies. The World Health Organisation (WHO) suggests a ratio of one trained midwife per 175 pregnant women, currently this ratio in Afghanistan is 0.1 per 1,000 pregnant women (rather than the required 5.7 midwives). 

With the take over of the de facto authorities the roles of women in the society got limited and mostly cut. Particularly nowadays since the only area where women could have a role is the health system, this training has given hope and moral support to 180 young women and their families.

AfD continues to support initiatives regarding maternal health, however this is not without difficulty. Following the regime change in Afghanistan, the employment situation of women has become even more precarious. Midwifery remains one of the only employment possibilities for Afghan women and as most literate and educated people have left Afghanistan, the time for action is now.

In our ‘2021 Annual Report’ on Training Midwives in Afghanistan, we expressed the delays and challenges that have been caused largely by the Taliban takeover, their limiting expectations, and the changes to a functioning administrative system. These factors have created barriers in accessing healthcare, especially for females, as well as a decline in the quality of healthcare and healthcare professionals including adequately trained midwives. 

We are happy to announce that our re-registration processes have been completed, the brand new MoUs established and signed with the current authorities of the Ministry of Health - allowing AfD to take the next steps in the implementation of its health projects, particularly in providing training to midwives. A total of 20 midwives from Logar province have been nominated to receive the ToT training, who will then train an additional 80 midwives in their respective locations. The training will contain 10 modules that AfD has established through its collaboration with the Midwifery School of Geneva. We will keep you posted with the new pictures and reports about the process of the training and its outcomes.

The re-registration process as well as the demanded changes have created administrative back-ups, and left many not feeling comfortable, or even allowed to leave their homes to seek healthcare, to study, or to work. The health systems are currently facing huge unpredictability for the future. Recent reports show that medical stores have supplies of essential medicine only for the next two months. Food prices are rising, and poor nutrition prevails over the entire country among children, pregnant and lactating women.   

In Afghanistan, thousands of women die from preventable pregnancy related deaths each year at an alarming rate. Historically during Taliban controlled regimes in Afghanistan, the number of midwives being trained decrease, and maternal and child mortality rates increase. A correlation can be seen between the rates of available, adequately trained midwives and the rates of mortality.

All of these factors result in a decline in the positive growth that the Nation and AfDs’ Training Midwives in Afghanistan project was achieving such as reducing child mortality. The steps towards progress, reduced child mortality, and overall well-being for women of reproductive age are to continue to train midwives in Afghanistan, have freedom of movement, and remove the barriers to 1. Accessing Healthcare and 2. Midwifery Training.

According to the United Nations National Survey, in 2000 at the end of a 4-year Taliban rule, 100 of every 1000 Afghan babies died before their 1st birthday. Between 2001-2015 the number of deaths fell dramatically to 66-45 per 1000. Today Afghanistan is still listed as having the highest infant mortality in the world, which concludes that it is even more important now to work towards training more midwives in Afghanistan so history will not repeat itself, which is highly likely unless intervention occurs, and programs like AfDs midwifery training continues to be supported.

Action for Development continues to move forward in unprecedented times, working for the lives of children, mothers, families, and for the benefit of the citizens of Afghanistan who need our support, and who should not be affected by the on-going conflict. AfDs project, Training Midwives in Afghanistan is a stable benchmark to progress in a country whose violence interrupts the very basic human needs of women and children. 

In Afghanistan, the ongoing instability caused by the regime change is affecting every aspect of people's lives, down to their very first one. Indeed, it is estimated by UNICEF that infant mortality rate gravitates around 52 deaths per 1,000 births, and maternal mortality rate approximates 640 deaths per 100,000 live births, and these figures continue to rise as access to healthcare has become more challenging. As a result, only about half of all births in Afghanistan are attended by trained medical professionals, and rural areas have been facing a shortage of midwives and female health professionals, although they account for the majority of births and delivery supervisions. 

What are we doing to help?

Despite the complexity of the current political and social contact in Afghanistan, AFD is determined to continue supporting the training of medical personnel on the field to ensure a safe birthing experience for both mothers and infants.

This year, however, we have had to reckon with unprecedented difficulties. With the change of regime came new institutions, new ministries, and a new administrative context with which we have yet to find appropriate agreements to continue to provide quality trainings and promote the access of vulnerable populations to essential health services.

In these critical times the accessibility to health services is prohibited in some areas due to insecurity, however, some areas are still partially secure and there is a possibility to set up trainings for women, by women specialists, and we would like to use this momentum to safely train an additional 350 midwives to reach our initial goal. We have taken all the necessary measures to ensure the safety and well-being of our staff and the midwives we would like to train.

Until present, AfD received close to 25,000 USD through additional fundraising mechanisms and over 4,000 USD online through the GlobalGiving platform and generous donors like yourself.  However, we are urgently looking for additional funds to support the implementation of our midwifery training programme and other emergency services.

These sustained efforts and continuous support have enabled us to continue making a difference on the field, and to measure it, we've gathered testimonials from the midwives that we've helped train in Kabul to understand how this program helped them in their professional advancement and in making a difference in their community. 

The interview with Sherazade, who asked us to use this nickname instead of her real name amid concerns for her safety, can be found below: 

-    Hi Sherazade, thank you so much for being with us today for this interview. Could you maybe start by summarizing the role you took into this program, and for how long?

“Good morning from Kabul, I’m happy to be here! I am actually a trained midwife here at the Health Center, I started working around spring last year, so I joined about eight months ago”

-    When did you start?

“I actually started overall about a year and a half ago, as I initially joined the center as a volunteer for an entire year before being offered this position”

-    What was your first appointment? Did you get any promotion, since you started? Why? How? When?  

“I have been a midwife since the first day I joined this clinic, and I still am, but now I specialize in juvenile care and in family planning”

-    Are you happy with your job? what makes you feel happy when you attend your job? or which part of your job do you like to most?

“I adore my job! I would say the part I like the most about it is to be able to have a special relationship with my patients, which you could perhaps not have in other medical professions”.

-    Why did you join the program? What did you think it could do for you?

“I joined this health center because I wanted to specialize myself in family planning from early on, and improve my skills, learn more things, and increase the arsenal of methods I knew so I could better care for my patients.”

-    How did you learn about this Health Facility? Why did you choose this clinic specifically?

“I joined this health center specifically because it was the one providing me with the exact training that I wanted, it was a unique opportunity for me in that regard!”

-    So, which are the training have you received so far?

“I learn new things every day here, but the two main trainings I’ve received have been in certain surgical interventions, IV drip placing for instance, juvenile care in general, and as I mentioned, in family planning.”

-    What was your first day feeling when they offered you the job? Did you experience overwhelm, joy, serenity?

“I was very overwhelmed, mostly with joy! I remember exactly when they called me to offer me this position at the Health Center, I was so happy! I knew it would be a challenge, but I also knew that I was going to be helpful to my community, that meant the world to me!”

-    After you got the training, which areas do you feel you improved the most?  

“I feel that I’ve learned to use many more different methods that what I knew when I joined the facility. I've improved a lot in small surgical interventions too, especially on mothers and infants, and I can offer a more adapted care to my patients”.

-    Tell us about a day from your life that you were proud to be a midwife? 

“Honestly, I am proud to be a midwife every single day, it’s a rewarding job in itself, but being able to place and IV drip for the first time was definitely a moment to remember! It was so intimidating, and I was proud to have managed that on my own.”

-    What do you want to achieve in the future? 

“The goal for me is to help my people and my community, and to continue specializing in midwifery, improve my skillset, and make a difference in the lives of my patients, one at the time, especially in the lives of my female patients, mothers, infants and girls”.

-    Is there any moment you regretted your choice to become a midwife, did you ever experience any doubts?

“I absolutely experienced challenges, but I never regretted my choice to become a midwife, not even for a second. It is definitely challenging, it is not an easy job, but I enjoy it and I wake up every day knowing that I love it, and that I am being helpful in the community.”

-    How do you see your role as a midwife - now, under the new regime? are you able to work? are you able to move freely? What changes have you experienced since the change of regime? 

“Professionally, not so much. The job and the clinic are able to function almost normally on a daily basis. But we are people also, and we had to make a lot of personal changes since the new regime, even in a big city like Kabul, there’s a huge difference. Especially in the medical profession, face coverings are mandatory for women for example, they [The Taliban] are in the street permanently, revving their engines, driving by fast, we feel their presence constantly.”

-    How do patients experience the difference since the new regime? Has it changed your professional relationship with your patients? 

“The change has been drastic in my relationship with my patients. They are a lot more reluctant to seek our help, most of the time because they are concerned that they will not have enough money to both eat and get medicine, and they feel they might have to choose. The influx of patients that have to be treated at the clinic has also increased significantly under the new regime, even as some people and even doctors are displaced from Kabul to the countryside.

-    Thank you so much for your time Sherazade, is there anything else you’d like to share with the world? A special message? 

“Thank you for having me!

I guess if I had a message to share with the world, it would be to keep fighting. Keep fighting for us, keep fighting for the women and girls in Afghanistan and for their future. The new regime is making their lives particularly restrictive and dangerous. It is truly heartbreaking to witness on a daily basis these women and girls who cannot go to school, get an education, contribute to their community the way they feel is right or at their full potential. I’d say that now more than ever, we need your support and we need you not to give up.