Women’s access to skilled birth attendance in Afghanistan

Women’s access to skilled birth attendance (SBA) is of major interest and concern in Afghanistan to the public, health professionals and international partners of the vulnerable healthcare in the country. This thesis aims at understanding the situation of SBA through the research work of the author and the available evidence on the subject matter. The theoretical framework used is a modified Tanahashi model that distinguishes various layers of access to SBA including its availability, accessibility, acceptability, utilization and quality.

Chapter 1 introduces the unique situation in Afghanistan surrounding SBA necessary for developing a holistic understanding of the Afghan context. Country specific issues such exclusivity of SBA to female midwives and obstetrician/gynecologist, extreme shortage of SBA providers just a couple of decades ago and a rapid increase in the number of midwives in the period, a split healthcare provision system led by Ministry of Public Health, funded by international donors and implemented by non-governmental organizations are highlighted. Finally, the interlinking concepts of health system components, human resources for health and quality of care are described and incorporated in the final research theoretical framework of a modified Tanahashi model.

Chapter 2 describes the availability and utilization of Emergency Obstetric and Newborn Care (EmONC) in terms of the defining healthcare package of the seven Basic EmONC (BEmONC) and additional two Comprehensive EmONC (CEmONC) signal functions. The study shows how various signal functions are missing from facilities designated to provide the healthcare.

Chapter 3 explores availability and distribution of human resources for provision of CEmONC. Availability of SBA providers is explored at different facility levels and during different days, shifts, and times. The study emphasizes the need for innovative approaches for deployment, skills development, and retention of SBA providers, especially in underserved areas.

Chapter 4 is based on the study of midwifery education programs in Afghanistan established to fill the vast gap of availability of SBA in Afghanistan. The study examines two distinctive midwifery education programs established and operating in the country and summarizes lessons learned for future improvement of the systems.

Chapter 5 explores the level of trainings received by SBA providers and their level of confidence in providing the healthcare. The study documents and recommends the need for continued in-service training and hands-on practice for all SBA providers in order to ensure its effectiveness. The study specifically demonstrate that midwifes rather than medical doctors are key to reliable SBA in Afghanistan.

Chapter 6 presents the findings of a study of the quality of the educational programs in 29 public and private midwifery education programs as a prerequisite for the quality of care of their graduate SBA providers. The study documents the quality of midwifery education with respect to the necessary infrastructure and management, teachers and preceptors, clinical practice sites, curriculum, and support of students.

Chapter 7 is based on a qualitative study of women’s experience of care during facility based childbirth healthcare. The study looks at respectful maternity care from the women’s, healthcare providers’ and health managers’ perspectives and highlights key areas of improvement.

Chapter 8 synthetizes all of the findings of the research work along with the available local and international evidence into the hierarchical frame of Tanahashi model and from the perspectives of the recipient of the care, the healthcare providers and the health system. The chapter provides a list of recommendations based on the evidence compiled as the outcome of the thesis.