Misoprostol for Prevention of Postpartum Hemorrhage at Home Birth in Afghanistan: Program Expansion Experience.

INTRODUCTION: Afghanistan has a maternal mortality ratio of 400 per 100,000 live births. Hemorrhage is the leading cause of maternal death. Two-thirds of births occur at home. A pilot program conducted from 2005 to 2007 demonstrated the effectiveness of using community health workers for advance distribution of misoprostol to pregnant women for self-administration immediately following birth to prevent postpartum hemorrhage. The Ministry of Public Health requested an expansion of the pilot to study implementation on a larger scale before adopting the intervention as national policy. The purpose of this before-and-after study was to determine the effectiveness of advance distribution of misoprostol for self-administration across 20 districts in Afghanistan and identify any adverse events that occurred during expansion. METHODS: Cross-sectional household surveys were conducted pre- (n = 408) and postintervention (n = 408) to assess the effect of the program on uterotonic use among women who had recently given birth. Maternal death audits and verbal autopsies were conducted to investigate peripartum maternal deaths that occurred during implementation in the 20 districts. RESULTS: Uterotonic use among women in the sample increased from 50.3% preintervention to 74.3% postintervention. Because of a large-scale investment in Afghanistan in training and deployment of community midwives, it was assumed that all women who gave birth in facilities received a uterotonic. A significant difference in uterotonic use at home births was observed among women who lived farthest from a health facility (> 90 minutes self-reported travel time) compared to women who lived closer (88.5% vs 38.9%; P < .0001). All women who accepted misoprostol and gave birth at home used the drug. No maternal deaths were identified among those women who used misoprostol. DISCUSSION: The results of this study build on the findings of the pilot program and provide evidence on the effectiveness, primarily measured by uterotonic use, of an expansion of advance distribution of misoprostol for self-administration.

Availability and distribution of human resources for provision of comprehensive emergency obstetric and newborn care in Afghanistan: a cross-sectional study.

BACKGROUND: For over a decade, Afghanistan's Ministry of Public Health and its international development partners have invested in strengthening the national health workforce and establishing a system of primary health care facilities and hospitals to reduce the high levels of maternal and child mortality that were documented shortly after the fall of the Taliban in 2001. Significant progress has been made, but many challenges remain. The objective of this study is to assess the availability and distribution of human resources for round-the-clock comprehensive emergency obstetric and newborn care service provision in secure areas of Afghanistan in order to inform policy and program planning. METHODS: A cross-sectional assessment was conducted from December 2009 to February 2010 at the 78 accessible facilities designated to provide emergency obstetric and newborn care in Afghanistan. The availability of staff on call 24 hours a day, seven days a week; involvement of staff in essential clinical functions; turnover rates; and vacancies were documented at each facility. Descriptive statistics were used to summarize results. RESULTS: All facilities assessed had at least one midwife on staff, but most did not meet the minimum staffing requirements set in national guidelines. Given that all facilities assessed are considered referral centers for lower-level clinics, the lack of doctors at 5% of facilities, lack of anesthetists at 10% of facilities and lack of obstetrician/gynecologists at 51% of facilities raises serious concerns about the capacity of the health system to respond with lifesaving care for women with obstetric complications. CONCLUSIONS: While the government continues its efforts to increase the number of qualified female health professionals in Afghanistan after decades with little female education, innovative strategies are needed to facilitate deployment, skill-development and retention of female healthcare providers in underserved areas.

Assessing post-abortion care in health facilities in Afghanistan: a cross-sectional study.

BACKGROUND: Complications of abortion are one of the leading causes of maternal mortality worldwide, along with hemorrhage, sepsis, and hypertensive diseases of pregnancy. In Afghanistan little data exist on the capacity of the health system to provide post-abortion care (PAC). This paper presents findings from a national emergency obstetric and neonatal care needs assessment related to PAC, with the aim of providing insight into the current situation and recommendations for improvement of PAC services. METHODS: A national Emergency Obstetric and Neonatal Care Needs Assessment was conducted from December 2009 through February 2010 at 78 of the 127 facilities designated to provide emergency obstetric and neonatal care services in Afghanistan. Research tools were adapted from the Averting Maternal Death and Disability Program Needs Assessment Toolkit and national midwifery education assessment tools. Descriptive statistics were used to summarize facility characteristics, and linear regression models were used to assess the factors associated with providers' PAC knowledge and skills. RESULTS: The average number of women receiving PAC in the past year in each facility was 244, with no significant difference across facility types. All facilities had at least one staff member who provided PAC services. Overall, 70% of providers reported having been trained in PAC and 68% felt confident in their ability to perform these services. On average, providers were able to identify 66% of the most common complications of unsafe or incomplete abortion and 57% of the steps to take in examining and managing women with these complications. Providers correctly demonstrated an average of 31% of the tasks required for PAC during a simulated procedure. Training was significantly associated with PAC knowledge and skills in multivariate regression models, but other provider and facility characteristics were not. CONCLUSIONS: While designated emergency obstetric facilities in Afghanistan generally have most supplies and equipment for PAC, the capacity of healthcare providers to deliver PAC is limited. Therefore, we strongly recommend training all skilled birth attendants in PAC services. In addition, a PAC training package should be integrated into pre-service medical education.

Job satisfaction and retention of health-care providers in Afghanistan and Malawi.

BACKGROUND: This study describes job satisfaction and intention to stay on the job among primary health-care providers in countries with distinctly different human resources crises, Afghanistan and Malawi. METHODS: Using a cross-sectional design, we enrolled 87 health-care providers in 32 primary health-care facilities in Afghanistan and 360 providers in 10 regional hospitals in Malawi. The study questionnaire was used to assess job satisfaction, intention to stay on the job and five features of the workplace environment: resources, performance recognition, financial compensation, training opportunities and safety. Descriptive analyses, exploratory factor analyses for scale development, bivariate correlation analyses and bivariate and multiple linear regression analyses were conducted. RESULTS: The multivariate model for Afghanistan, with demographic, background and work environment variables, explained 23.9% of variance in job satisfaction (F(9,73) = 5.08; P < 0.01). However, none of the work environment variables were significantly related to job satisfaction. The multivariate model for intention to stay for Afghanistan explained 23.6% of variance (F(8,74) = 4.10; P < 0.01). Those with high scores for recognition were more likely to have higher intention to stay (ß = 0.328, P < 0.05). However, being paid an appropriate salary was negatively related to intent to stay (ß = -0.326, P < 0.01). For Malawi, the overall model explained only 9.8% of variance in job satisfaction (F(8,332) = 4.19; P < 0.01) and 9.1% of variance in intention to stay (F(10,330) = 3.57; P < 0.01). CONCLUSIONS: The construction of concepts of health-care worker satisfaction and intention to stay on the job are highly dependent on the local context. Although health-care workers in both Afghanistan and Malawi reported satisfaction with their jobs, the predictors of satisfaction, and the extent to which those predictors explained variations in job satisfaction and intention to stay on the job, differed substantially. These findings demonstrate the need for more detailed comparative human resources for health-care research, particularly regarding the relative importance of different determinants of job satisfaction and intention to stay in different contexts and the effectiveness of interventions designed to improve health-care worker performance and retention.

Establishing midwifery in low-resource settings: guidance from a mixed-methods evaluation of the Afghanistan midwifery education program.

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. DESIGN: 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. SETTING: 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. PARTICIPANTS: Midwives who had graduated from either IHS or CME schools. FINDINGS: 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. KEY 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.

Prevention and management of severe pre-eclampsia/eclampsia in Afghanistan.

BACKGROUND: An evidence-based strategy exists to reduce maternal morbidity and mortality associated with severe pre-eclampsia/eclampsia (PE/E), but it may be difficult to implement in low-resource settings. This study examines whether facilities that provide emergency obstetric and newborn care (EmONC) in Afghanistan have the capacity to manage severe PE/E cases. METHODS: A further analysis was conducted of the 2009-10 Afghanistan EmONC Needs Assessment. Assessors observed equipment and supplies available, and services provided at 78 of the 127 facilities offering comprehensive EmONC services and interviewed 224 providers. The providers also completed a written case scenario on severe PE/E. Descriptive statistics were used to summarize facility and provider characteristics. Student t-test, one-way ANOVA, and chi-square tests were performed to determine whether there were significant differences between facility types, doctors and midwives, and trained and untrained providers. RESULTS: The median number of severe PE/E cases in the past year was just 5 (range 0-42) at comprehensive health centers (CHCs) and district hospitals, compared with 44 (range 0-130) at provincial hospitals and 108 (range 32-540) at regional and specialized hospitals (p < 0.001). Most facilities had the drugs and supplies needed to treat severe PE/E, including the preferred anticonvulsant, magnesium sulfate (MgSO4). One-third of the smallest facilities and half of larger facilities reported administering a second-line drug, diazepam, in some cases. In the case scenario, 96% of doctors and 89% of midwives recognized that MgSO4 should be used to manage severe PE/E, but 42% of doctors and 58% of midwives also thought diazepam had a role to play. Providers who were trained on the use of MgSO4 scored significantly higher than untrained providers on six of 20 items in the case scenario. Providers at larger facilities significantly outscored those at smaller facilities on five items. There was a significant difference between doctors and midwives on only one item: continued use of anti-hypertensives after convulsions are controlled. CONCLUSIONS: Drugs and supplies needed to treat severe PE/E are widely available at EmONC facilities in Afghanistan, but providers lack knowledge in some areas, especially concerning the use of MgSO4 and diazepam. Providers who have specialized training or work at larger facilities are better at managing cases of severe PE/E. The findings suggest a need to clarify service delivery guidelines, offer refresher training, and reinforce best practices with supervision and reinforcement.

Assessing the capacity for newborn resuscitation and factors associated with providers' knowledge and skills: a cross-sectional study in Afghanistan.

BACKGROUND: Resuscitation with bag and mask is a high-impact intervention that can reduce neonatal deaths in resource-poor countries. This study assessed the capacity to perform newborn resuscitation at facilities offering comprehensive emergency obstetric and newborn care (EmONC) in Afghanistan, as well as individual and facility characteristics associated with providers' knowledge and clinical skills. METHODS: Assessors interviewed 82 doctors and 142 midwives at 78 facilities on their knowledge of newborn resuscitation and observed them perform the procedure on an anatomical model. Supplies, equipment, and infrastructure were assessed at each facility. Descriptive statistics and simple and multivariate regression analyses were performed using STATA 11.2 and SAS 9.1.3. RESULTS: Over 90% of facilities had essential equipment for newborn resuscitation, including a mucus extractor, bag, and mask. More than 80% of providers had been trained on newborn resuscitation, but midwives were more likely than doctors to receive such training as part of pre-service education (59% and 35%, respectively, p < 0.001). No significant differences were found between doctors and midwives on knowledge, clinical skills, or confidence in performing newborn resuscitation. Doctors and midwives scored 71% and 66%, respectively, on knowledge questions and 66% and 71% on the skills assessment; 75% of doctors and 83% of midwives felt very confident in their ability to perform newborn resuscitation. Training was associated with greater knowledge (p < 0.001) and clinical skills (p < 0.05) in a multivariable model that adjusted for facility type, provider type, and years of experience offering EmONC services. CONCLUSIONS: Lack of equipment and training do not pose major barriers to newborn resuscitation in Afghanistan, but providers' knowledge and skills need strengthening in some areas. Midwives proved to be as capable as doctors of performing newborn resuscitation, which validates the major investment made in midwifery education. Competency-based pre-service and in-service training, complemented by supportive supervision, is an effective way to build providers' capacity to perform newborn resuscitation. This kind of training could also help skilled birth attendants based in the community, at private clinics, or at primary care facilities save the lives of newborns.

Quality of caesarean delivery services and documentation in first-line referral facilities in Afghanistan: a chart review.

BACKGROUND: Increasing appropriate use and documentation of caesarean section (CS) has the potential to decrease maternal and perinatal mortality in settings with low CS rates. We analyzed data collected as part of a comprehensive needs assessment of emergency obstetric and newborn care (EmONC) facilities in Afghanistan to gain a greater understanding of the clinical indications, timeliness, and outcomes of CS deliveries. METHODS: Records were reviewed at 78 government health facilities expected to function as EmONC providers that were located in secure areas of the country. Information was collected on the three most recent CS deliveries in the preceding 12 months at facilities with at least one CS delivery in the preceding three months. After excluding 16 facilities with no recent CS deliveries, the sample includes 173 CS deliveries at 62 facilities. RESULTS: No CS deliveries were performed in the previous three months at 21% of facilities surveyed; all of these were lower-level facilities. Most CS deliveries (88%) were classified as emergencies, and only 12% were referrals from another facility. General anesthesia was used in 62% of cases, and spinal or epidural anesthesia in 34%. Only 28% of cases were managed with a partograph. Surgery began less than one hour after the decision for a CS delivery in just 30% of emergency cases. Among the 173 cases, 27 maternal deaths, 28 stillbirths, and 3 early neonatal deaths were documented. In cases of maternal and fetal death, the most common indications for CS delivery were placenta praevia or abruption and malpresentation. In 62% of maternal deaths, the fetus was stillborn or died shortly after birth. In 48% of stillbirths, the fetus had a normal heart rate at the last check. Information on partograph use was missing in 38% of cases, information on parity missing in 23% of cases and indications for cesareans missing in 9%. CONCLUSIONS: Timely referral within and to EmONC facilities would decrease the proportion of CS deliveries that develop to emergency status. While the substantial mortality associated with CS in Afghanistan may be partly due to women coming late for obstetric care, efforts to increase the availability and utilization of CS must also focus on improving the quality of care to reduce mortality. Key goals should be encouraging use of partographs and improving decision-making and documentation around CS deliveries.

Availability and quality of emergency obstetric and neonatal care services in Afghanistan.

OBJECTIVE: To assess the availability and utilization of emergency obstetric and neonatal care (EmONC) facilities in Afghanistan, as defined by UN indicators. METHODS: In a cross-sectional study of 78 first-line referral facilities located in secure areas of Afghanistan, EmONC service delivery was evaluated by using Averting Maternal Deaths and Disabilities (AMDD) Program assessment tools. RESULTS: Forty-two percent of peripheral facilities did not perform all 9 signal functions required of comprehensive EmONC facilities. The study facilities delivered 17% of all neonates expected in their target populations and treated 20% of women expected to experience direct complications. The population-based rate of cesarean delivery was 1%. Most maternal deaths (96%) were due to direct causes. The direct and indirect obstetric case fatality rates were 0.8% and 0.2%, respectively. CONCLUSION: Notable progress has been made in Afghanistan over the past 8 years in improving the quality, coverage, and utilization of EmONC services, but gaps remain. Re-examination of the criteria for selecting and positioning EmONC facilities is recommended, as is the provision of high-quality, essential maternal and neonatal health services at all levels of the healthcare system, linked by appropriate communication and functional referral systems.