title: Establishing midwifery in low-resource settings: guidance from a mixed-methods evaluation of the Afghanistan midwifery education program.
abstract: BACKGROUND
  The shortage of skilled birth attendants has been a key factor in the high maternal and newborn mortality in Afghanistan. Efforts to strengthen pre-service midwifery education in Afghanistan have increased the number of midwives from 467 in 2002 to 2954 in 2010.
  
  
  OBJECTIVE
  We analyzed the costs and graduate performance outcomes of the two types of pre-service midwifery education programs in Afghanistan that were either established or strengthened between 2002 and 2010 to guide future program implementation and share lessons learned.
  
  
  METHODS
  We performed a mixed-methods evaluation of selected midwifery schools between June 2008 and November 2010. This paper focuses on the evaluation's quantitative methods, which included (a) an assessment of a sample of midwifery school graduates (n=138) to measure their competencies in six clinical skills; (b) prospective documentation of the actual clinical practices of a subsample of these graduates (n=26); and (c) a costing analysis to estimate the resources required to educate students enrolled in these programs.
  
  
  METHODS
  For the clinical competency assessment and clinical practices components, two Institutes for Health Sciences (IHS) schools and six Community Midwifery Education (CME) schools; for the costing analysis, a different set of nine schools (two IHS, seven CME), all of which were funded by the US Agency for International Development.
  
  
  METHODS
  Midwives who had graduated from either IHS or CME schools.
  
  
  RESULTS
  CME graduates (n=101) achieved an overall mean competency score of 63.2% (59.9-66.6%) on the clinical competency assessment compared to 57.3% (49.9-64.7%) for IHS graduates (n=37). Reproductive health activities accounted for 76% of midwives' time over an average of three months. Approximately 1% of childbirths required referral or resulted in maternal death. On the basis of known costs for the programs, the estimated cost of graduating a class with 25 students averaged US$298,939, or US$10,784 per graduate.
  
  
  CONCLUSIONS
  The pre-service midwifery education experience of Afghanistan can serve as a model to rapidly increase the number of skilled birth attendants. In such settings, it is important to ensure the provision of continued practice opportunities and refresher trainings after graduation to aid skill retention, a co-operative and supportive work environment that will use midwives for the reproductive health skills for which they were trained, and selection mechanisms that can identify the most promising students and post-graduation deployment options to maximise the return on the substantial educational investment.
authors.affiliation: Jhpiego, House #107, Street 3, Ansari Watt, Shar-e-Naw, District 4, Kabul, Afghanistan. Electronic address: partamin@jhpiego.org.
authors.forename: Partamin
authors.initials: P
authors.lastname: Zainullah
authors.affiliation: Jhpiego, House #107, Street 3, Ansari Watt, Shar-e-Naw, District 4, Kabul, Afghanistan. Electronic address: Nasrat.Ansari@jhpiego.org.
authors.forename: Nasratullah
authors.initials: N
authors.lastname: Ansari
authors.affiliation: UNICEF, Jalalabad Road, Paktiakot, UN Compound, Kabul, Afghanistan. Electronic address: kyari@unicef.org.
authors.forename: Khalid
authors.initials: K
authors.lastname: Yari
authors.affiliation: MSH, House @ 24, Ayubkhan Mena, Darulaman Road, Kabul, Afghanistan. Electronic address: mazimi@msh.org.
authors.forename: Mahmood
authors.initials: M
authors.lastname: Azimi
authors.affiliation: Jhpiego, House #107, Street 3, Ansari Watt, Shar-e-Naw, District 4, Kabul, Afghanistan. Electronic address: sabera_t@hotmail.com.
authors.forename: Sabera
authors.initials: S
authors.lastname: Turkmani
authors.affiliation: International Confederation of Midwives, GK2 E Block 62, New Delhi, India. Electronic address: icmazfarp@gmail.com.
authors.forename: Pashtoon
authors.initials: P
authors.lastname: Azfar
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD 21205, USA. Electronic address: alefevre@jhsph.edu.
authors.forename: Amnesty
authors.initials: A
authors.lastname: LeFevre
authors.affiliation: Jhpiego, 1615 Thames Street, Baltimore, MD 21231, USA. Electronic address: Jaime.Mungia@jhpiego.org.
authors.forename: Jaime
authors.initials: J
authors.lastname: Mungia
authors.affiliation: Jhpiego, 1615 Thames Street, Baltimore, MD 21231, USA. Electronic address: Rehana.Gubin@jhpiego.org.
authors.forename: Rehana
authors.initials: R
authors.lastname: Gubin
authors.affiliation: Jhpiego, 1615 Thames Street, Baltimore, MD 21231, USA. Electronic address: Young-Mi.Kim@jhpiego.org.
authors.forename: Young-Mi
authors.initials: YM
authors.lastname: Kim
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD 21205, USA. Electronic address: lbartlet@jhsph.edu.
authors.forename: Linda
authors.initials: L
authors.lastname: Bartlett
mesh_terms: D000346:Afghanistan; D003479:Curriculum / Q000592:standards*; D005260:Female; D006801:Humans; D008880:Midwifery / Q000193:education* / Q000379:methods / Q000592:standards*; D011247:Pregnancy; D011446:Prospective Studies
keywords: Afghanistan; Midwifery; Pre-service education