Midwifery retention and coverage and impact on service utilisation in Afghanistan.

OBJECTIVE: to measure the rate of and determine factors associated with community midwifery education (CME) graduate retention in public sector health care in Afghanistan. DESIGN: cross-sectional. SETTING: performed in public health facilities of 11 Afghan provinces purposively selected by geographic location and security conditions, between October 2011 and April 2012. Facilities were selected by one of two criteria: either a registered deployment site for a CME graduate or randomly selected through population-proportionate sampling. PARTICIPANTS: facility managers and midwives employed in public facilities at the time of data collection. MEASUREMENTS: three quantitative instruments were used: a facility checklist assessed staffing and service volume, and two separate questionnaires for midwives and facility managers, which measured employment duration and perceived barriers to midwife retention. FINDINGS: at 456 surveyed facilities, 570 midwives were interviewed. Overall, 61.3% (n=209/341) of CME graduates deployed in surveyed provinces were working in public sector facilities, whereas 36.8% were working at their assigned site. Facilities without midwife staff had lower average monthly volumes of antenatal care visits (14.6 (SD ± 22.7) versus 71.5 (SD ± 72.5)), family planning visits (10.4 (SD+13.9) versus 56.8 (SD+85.0)), or facility-based deliveries (0.55 (SD ± 2.2) versus 15.7 (SD ± 18.7)). Perceived reasons for leaving employment were insecurity (civil unrest/armed conflict) (46.4%), family disagreement (28.1%), increased workload without compensation (9.9%), and lack of appropriate housing (7.8%). KEY CONCLUSIONS: CME graduate retention in public sector positions was relatively low and significantly impacted by insecurity and cultural issues related to women working outside the home. IMPLICATIONS FOR PRACTICE: culturally appropriate measures are needed to attract and retain skilled female health care providers for rural public facilities in Afghanistan and similar settings. Advocacy to encourage family and community support for midwives working in rural facilities and providing amenities such as housing, education for children, and employment for the accompanying male family member are measures most likely to improve midwife retention.

Factors influencing the retention of midwives in the public sector in Afghanistan: a qualitative assessment of midwives in eight provinces.

OBJECTIVE: to examine factors that affect retention of public sector midwives throughout their career in Afghanistan. DESIGN: qualitative assessment using semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs). SETTING: health clinics in eight provinces in Afghanistan, midwifery education schools in three provinces, and stakeholder organisations in Kabul. PARTICIPANTS: purposively sampled midwifery profession stakeholders in Kabul (n=14 IDIs); purposively selected community midwifery students in Kabul (n=3 FGDs), Parwan (n=1 FGD) and Wardak (n=1 FGD) provinces (six participants per FGD); public sector midwives, health facility managers, and community health workers from randomly selected clinics in eight provinces (n=48 IDIs); midwives who had left the public sector midwifery service (n=5 IDIs). MEASUREMENTS AND FINDINGS: several factors affect a midwife throughout her career in the public sector, including her selection as a trainee, the training itself, deployment to her pre-assigned post, and working in clinics. Overall, appropriate selection is the key to ensuring deployment and retention later on in a midwife's career. Other factors that affect retention of midwives include civil security concerns in rural areas, support of family and community, salary levels, professional development opportunities and workplace support, and inefficient human resources planning in the public sector. KEY CONCLUSIONS: Factors affecting midwife retention are linked to problems within the community midwifery education (CME) programme and those reflecting the wider Afghan context. Civil insecurity and traditional attitudes towards women were major factors identified that negatively affect midwifery retention. IMPLICATIONS FOR PRACTICE: Factors such as civil insecurity and traditional attitudes towards women require a multisectoral response and innovative strategies to reduce their impact. However, factors inherent to midwife career development also impact retention and may be more readily modified.