title: 'Midwives are the backbone of our health system': lessons from Afghanistan to guide expansion of midwifery in challenging settings.
abstract: BACKGROUND
  over the last decade Afghanistan has made large investments in scaling up the number of midwives to address access to skilled care and the high burden of maternal and newborn mortality.
  
  
  OBJECTIVE
  at the request of the Ministry of Public Health (MOPH) an evaluation was undertaken to improve the pre-service midwifery education programme through identification of its strengths and weaknesses. The qualitative component of the evaluation specifically examined: (1) programme strengths; (2) programme weaknesses; (3) perceptions of the programme's community impact; (4) barriers to provision of care and challenges to impact; (5) perceptions of the recently graduated midwife's field experience, and (6) recommendations for programme improvement.
  
  
  METHODS
  the evaluation used a mixed methods approach that included qualitative and quantitative components. This paper focuses on the qualitative components which included in-depth interviews with 138 graduated midwives and 20 key informants as well as 24 focus group discussions with women.
  
  
  METHODS
  eight provinces in Afghanistan with functioning and accredited midwifery schools between June 2008 and November 2010.
  
  
  METHODS
  midwives graduated from one of the two national midwifery programmes: Institute of Health Sciences and Community Midwifery Education. Key informants comprised of stakeholders and female residents of the midwives catchment areas.
  
  
  RESULTS
  midwives described overall satisfaction with the quality of their education. Midwives and stakeholders perceived that women were more likely to use maternal and child health services in communities where midwives had been deployed. Strengths included evidence-based content, standardised materials, clinical training, and supportive learning environment. Self-reported aspects of the quality education in respect to midwives empowerment included feeling competent and confident as demonstrated by respect shown by co-workers. Weaknesses of the programme included perceived low educational requirement to enter the programme and readiness of programmes to commence education. Insecurity and geographical remoteness are perceived as challenges with clients' access to care and the ability of midwives to make home visits.
  
  
  CONCLUSIONS
  the depth of midwives' contribution in Afghanistan - from increased maternal health care service utilisation to changing community's perceptions of women's education and professional independence - is overwhelmingly positive. Lessons learned can serve as a model to other low resource, post-conflict settings that are striving to increase the workforce of skilled providers.
authors.affiliation: Jhpiego/Afghanistan, an affiliate of Johns Hopkins University, Shar-I-Nau, Kabul, Afghanistan.
authors.forename: Sabera
authors.initials: S
authors.lastname: Turkmani
authors.forename: Sheena
authors.initials: S
authors.lastname: Currie
authors.forename: Jaime
authors.initials: J
authors.lastname: Mungia
authors.forename: Nassim
authors.initials: N
authors.lastname: Assefi
authors.forename: Ahmed
authors.initials: A
authors.lastname: Javed Rahmanzai
authors.forename: Pashtun
authors.initials: P
authors.lastname: Azfar
authors.forename: Linda
authors.initials: L
authors.lastname: Bartlett
mesh_terms: D000328:Adult; D000346:Afghanistan; D003479:Curriculum / Q000592:standards; D004506:Education, Nursing / Q000379:methods / Q000458:organization & administration / Q000592:standards; D005260:Female; D017144:Focus Groups; D006078:Government Programs; D006297:Health Services Accessibility / Q000592:standards; D006801:Humans; D007223:Infant; D008427:Maternal Health Services / Q000379:methods / Q000458:organization & administration; D008880:Midwifery / Q000193:education / Q000592:standards; D020380:Needs Assessment; D018743:Perinatal Care / Q000379:methods / Q000458:organization & administration; D011247:Pregnancy; D036301:Qualitative Research; D058996:Quality Improvement
keywords: Afghanistan; Midwives; Pre-service education; Skilled birth attendant (SBA)