title: Development of the community midwifery education initiative and its influence on women's health and empowerment in Afghanistan: a case study.
abstract: BACKGROUND
  Political transition in Afghanistan enabled reconstruction of the destroyed health system. Maternal health was prioritised due to political will and historically high mortality. However, severe shortages of skilled birth attendants--particularly in rural areas--hampered safe motherhood initiatives. The Community Midwifery Education (CME) programme began training rural midwives in 2002, scaling-up nationally in 2005.
  
  
  METHODS
  This case study analyses CME development and implementation to help determine successes and challenges. Data were collected through documentary review and key informant interviews. Content analysis was informed by Walt and Gilson's policy triangle framework.
  
  
  RESULTS
  The CME programme has contributed to consistently positive indicators, including up to a 1273/100,000 reduction in maternal mortality ratios, up to a 28% increase in skilled deliveries, and a six-fold increase in qualified midwives since 2002. Begun as a small pilot, CME has gained support of international donors, the Afghan government, and civil society.
  
  
  CONCLUSIONS
  CME is considered by stakeholders to be a positive model for promoting women's education, employment, and health. However, its future is threatened by insecurity, corruption, lack of regulation, and funding uncertainties. Strategic planning and resource mobilisation are required for it to achieve its potential of transforming maternal healthcare in Afghanistan.
authors.affiliation: Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine (LSHTM), Tavistock Place, London, UK. elizabeth.speakman@lshtm.ac.uk.
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Speakman
authors.forename: Ahmad
authors.initials: A
authors.lastname: Shafi
authors.forename: Egbert
authors.initials: E
authors.lastname: Sondorp
authors.forename: Nooria
authors.initials: N
authors.lastname: Atta
authors.forename: Natasha
authors.initials: N
authors.lastname: Howard
mesh_terms: D000346:Afghanistan; D036861:Delivery, Obstetric / Q000193:education*; D005260:Female; D006280:Health Workforce; D006801:Humans; D007224:Infant Care; D007231:Infant, Newborn; D008427:Maternal Health Services; D008428:Maternal Mortality; D008880:Midwifery / Q000193:education*; D011181:Postnatal Care; D011209:Power, Psychological; D011247:Pregnancy; D011295:Prenatal Care; D016730:Program Development; D060728:Reproductive Health / Q000193:education*; D016387:Women's Health