In the immediate postconflict period, Afghanistan’s health services were in a deplorable and chaotic state. In 2002, Afghanistan’s maternal mortality ratio, for example, was the second highest in the world.

Access and utilization of reproductive health services and skilled care during pregnancy, childbirth, and the first month after delivery are key to saving those women at risk of dying due to pregnancy and childbirth complications.

In a society where women seek care only from female providers, one barrier to expansion of services was the lack of qualified female health workers who could be deployed to remote health facilities. Very few midwives who had trained in Kabul or other big cities were willing to work in rural areas (where the needs were much higher), and there were no education facilities and too few female school graduates who could be trained in the provinces. As maternal health was one of the top priorities of the health sector, the shortage of midwives to provide reproductive health services had to be tackled urgently. Hence the Community Midwifery Education (CME) Program was created.

The program aimed not only to train more midwives, but also to ensure both their initial deployment in remote health facilities as well as good retention rates. These aims were realized through the creation of a new health cadre known as “community midwives,” along with new competency-based curricula; establishment of CME schools in each province; relaxation of the admission criteria for students (to have enough female students from each province receive training in their own province); and establishment of a strong accreditation board to ensure qualified midwives were trained by the program.

The program’s success is attributed to stakeholder strong engagement, equity, and strengthened human resource for health. This approach worked well: maternal mortality fell from 1,600 in 2002 to 327 in 2010. The midwives have helped to plug the shortfall of professional human resources in health, especially for midwives and female health workers in rural and remote areas. Since their deployment in community clinics and hospitals, midwives have seen a vast increase in the use of general health care by women in the community, with a particular rise in maternal and child health services. Largely for this reason the program should be expanded to address the continuing shortage of midwives.

The CME Program — through selecting women from local communities, providing training, and deploying them back to their communities — sustains impact. Trained midwives are community resources who can have long-lasting and sustainable impact through their services to the community. The MoPH considers the program a successful intervention and believes that there is great potential to replicate this model to train other
health professionals and tackle the shortage of other human resources for health. MoPH already started the Community Health Nursing Education Program, which is built on the successful experiences and lessons learned from the CME Program