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The National Midwifery Education Program in Afghanistan: Training Women and Saving Lives

Speaker: Linda Bartlett, Scientist, Johns Hopkins Bloomberg School of Public Health
Presider: Isobel Coleman, Senior Fellow and Director, Women and Foreign Policy Program, Council on Foreign Relations
June 8, 2011
Council on Foreign Relations

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ISOBEL COLEMAN: I'm Isobel Coleman. I'm a senior fellow here at the Council on Foreign Relations. Although I am based in New York, I live and work in New York, and come down here every now and then. I don't do that many meetings down here. I must say, it's a little strange to me to see such a small group, given how many we had signed up. But as I said to Linda, do not take it personally. And it's certainly to our benefit because we get to pick more of her brain, so to speak. And I think there will no doubt be some who are straggling in as we get going.

So this is the second meeting in a three-part series that we're doing, looking specifically at maternal health in Afghanistan. The third meeting will be in New York, not here, unfortunately for those of you who've made the first two meetings. And we are honored to have with us Dr. Linda Bartlett, who is a scientist at Johns Hopkins school of public health, a medical doctor, an epidemiologist and someone with tons of experience not only in maternal health but also in working in Afghanistan. Linda is famous for having conducted the first RAMOS study, RAMOS being reproductive age mortality study, which -- correct me if I'm wrong, but I believe you did on horseback --

LINDA BARTLETT: (Off mic) -- yeah.

COLEMAN: In the fall of -- or spring of 2002?

BARTLETT: That's correct, yeah.

COLEMAN: Spring of 2002, so a matter of months after the fall of the Taliban. They went into Afghanistan, went to some very remote areas and districts and tallied up the staggering level of maternal mortality in that country. I think it was -- in many cases, you know, surpassed anything that had been measured before. And it was very instrumental in directing a development agenda around maternal health in that country. That has been proceeding since.

Linda is involved in RAMOS II, so looking at a new study there. And I thought, Linda, maybe you could just start by talking a little bit about the state of maternal health. Let's step up a level from Afghanistan. You know, we have seen some -- I mean, maternal health is one of the MDGs; it's one of the MDGs that has had the least progress. But we did get some positive news last year that maternal mortality has declined from roughly half a million to more like 350,000 a year. What are some of the factors that are leading this positive trend? Maybe start there and then look at what are some of the obstacles to achieving the maternal mortality goal under the MDGs.

BARTLETT: OK. You're right that the more recent estimates --

MS. : Let's pull this a little closer to you.

BARTLETT: OK.

MS. : That -- (off mic).

BARTLETT: OK, good. Is that good?

So you're right that the more recent estimates both by the U.N. and IHME, which is based out of Seattle, found that there was a reduction in maternal mortality, the number of maternal deaths, from about 500,000 to about 350,000 over the past about 15-year period, I think it was.

And it was attributed to a number of different factors, that there's improving contraceptive use in countries, which reduces the number of women who have high-risk pregnancies, and birth spacing which also can reduce the -- both the infant and maternal mortality. There has been some increasing trends in women who access skilled birth attendants at delivery. And while there still is actually a human-resource crisis in the world, there has been improvements in skilled birth attendants' coverage. But there needs to be quite a bit more, and I think we're going to be talking about that later with respect to midwifery.

There's -- there also has been some demographic change with respect to education and improved employment, all those things that have contributed. So --

COLEMAN: And when -- if we look specifically at Afghanistan, I mean, the spring of 2002 is arguably one of the lowest points in modern history of a country's, you know, health situation. I mean, it really had gone through at that point decades of war and civil war. And it had started at such a low point, even before all of that happened.

There have been improvements in the health system, so to speak, of Afghanistan. I use that word cautiously, because I think it's still premature to talk about a health system in Afghanistan. But there have been improvements. What are some of the trends that you've seen that have been positive in the country that we can point to?

BARTLETT: There is -- there is actually a lot of documentation of success in the country. Contraceptive-prevalence rate increased substantially. I'd have to check the numbers, but I know skilled birth attendants increased from 5 percent to about 20 percent up until -- 2008 was the most recent number available. And use of ante-natal care increased from 5 (percent) to 35 percent. Contraceptive prevalence was, I believe, around the same amount. Do you remember Mary-Ellen (sp) by any chance? No? Well, it's about the same amount.

COLEMAN: From like 5 (percent) to 35 (percent) -- is that what you said?

BARTLETT: Yeah, something like that. Yeah. I'll get you exactly the numbers --

COLEMAN: Yeah.

BARTLETT: -- if you need them, but the SBA was 5 (percent) to 20 percent, and ANC was 5 (percent) to 35 percent. There's many more functioning health facilities. There was about 500 in 2002, and there was 1,700 identified in 2009. In those facilities, there's far less stock-outs of key medications like oxytocin for prevention and management of post-partum hemorrhage, antibiotics for treatment of post-partum sepsis, ability to provide blood transfusions. And there's good documentation of these in the literature with, you know, appropriate analyses and that kind of thing.

There's many more skilled female health providers in facilities. It was only 24 percent in 2002, and now it's over 80 percent of facilities have a skilled female health provider. I mean, that's a huge change right there just in any country, but particularly in a country like Afghanistan, where women can't see men unless it's a life-threatening emergency situation. And then -- and then they will for the most part, but even some will not. The family will choose to let her die rather than see a man.

So that's -- there are other changes; for example, many more roads; cellphone coverage is almost complete throughout the country, which may not sound like it's relevant to maternal health, but it very much is. If a family is having a problem or a midwife in a community, she can now call and talk to somebody and call for help, call for an ambulance, things like that.

COLEMAN: Tell us about the RAMOS I study. Tell -- you know, let us live a little vicariously of what it was like to do that, because it really must have been remarkable on many levels.

BARTLETT: It was.

COLEMAN: Maybe take us through a little bit of what it was actually like to do the study and some of the things that you found.

BARTLETT: It was an incredibly interesting and rewarding experience, as you can probably imagine. We were in there in January 2002, which is when the U.N. went back in after 9/11, 2001. And so we were there at the very, very beginning when things were new and fresh. And for the vast majority of people they were so happy that the changes had happened, the Taliban had been ousted, freedom was coming. So it was very positive, lots of hope, joy, very welcoming.

And so we worked with the Ministry of Health to identify four districts that would represent different situations in the country, from Urban in Kabul through semi-rural, which was in Laghman, which is actually now more rural, I would say; and Kandahar in the south; and then the rural remote was in -- which was in Badakhshan.

And finding females who were educated and who could be interviewers and supervisors and data-entry people was extremely challenging. We basically scoured the country to find about a hundred women who could work on this with us. But they were -- I mean, actually I have pictures, but I wasn't prepared to show them, because it's not supposed to be a presentation venue.

But these women were, for the most part, really motivated and passionate about what they were doing, and just openly grateful that somebody was there who cared about what happened to women because it's not, you know, something that they were used to in the more traditional parts of the country, certainly.

So each place was a very different experience. Kabul being of course a major city, but heavily, heavily damaged during the Mujaheddin civil war; and so lots of bombs out building -- bombed out buildings and streets. And people were, for the most part, poor to very poor; whereas now you can find rich to very, very poor. Much more disparity now.

And Laghman, at the time, was just this lovely peaceful place. It's a valley province, so walking along this riverside in the valley, very green and fertile and very quiet place, and now is very strongly controlled by Taliban so it's a very difficult place now to go to. And none of us Westerners are going anywhere near there, primarily because we don't want to put our teams in danger. But so things have changed with respect to how much you can move around and actually do hands-on type of work.

Kandahar was where most of the war occurred. And so people were frightened by that, and very cautious. But the Afghans have a guest culture, so if -- when we approached them, first of all, almost nobody said no, they wouldn't talk to us and let us interview them. And then once they say yes, you're their guest. And so they'll -- they, you know, are very warm and welcoming and will protect you and those kinds of things. So it was really quite universal, even in a province like Kandahar that was heavily traumatized, that we were welcomed and thanked for caring about women.

And Badakhshan of course has the most, I guess, interesting experience, and also sort of the most famous, because we recorded the highest ever maternal mortality there that had been recorded to date. And we rode horses for over two weeks, going from village to village in this environment which, for the most part, had not been touched by Western civilization. So if you're walking -- or driving through even remote areas of Africa you'll see people carrying plastic water jugs and wearing plastic shoes -- flip-flops, that's the kind of thing.

And in Badakhshan at that time, and there probably still are areas, people still made their shoes, and they make their water jugs. There wasn't a piece of plastic or metal to be seen anywhere, unless it was an actually, you know, hand-cast piece of metal. So Mary Ellen (ph) and I have talked about this, that it was really like being in a biblical era. And that's also how we equate the, you know, lack of health care for people, and the risk of maternal mortality.

COLEMAN: And so what were some of the key findings from that first study?

BARTLETT: Well, we found a substantial and a significant change -- or difference between urban to rural settings. So it literally went from Kabul, to Laghman, to Kandahar, to Badakhshan, like that, and as I said. So substantial but also statistically significant. And that helped to put focus on the public health implementation in Afghanistan on rural settings, although hopefully that would have happened anyway.

We found that, of the women who died, most women died of postpartum hemorrhage, which was -- is the most common cause of maternal mortality globally. But in Badakhshan we found that more women died of obstructed labor than any other cause, which was also a different finding. But you know, it's a finding that we believe because the validity and reliability of direct obstetric causes of death by verbal autopsy is very high.

And if a woman -- if you can imagine, if a woman gives birth and bleeds until she dies, well, she died of maternal mortality. She didn't died of anything else. And the same in Badakhshan, if a woman is in labor and died undelivered, she died of obstructed labor. And so it's not, you know, a situation, say, where a child has a fever and we don't know if they died of pneumonia, malaria, TB, meningitis or something like that. They're very clear and direct causes of death.

But that was -- it was very surprising to find the obstructed labor and shocking in many ways. Women dying of hemorrhage is a terrible thing, postpartum, but if you can imagine the stories of being in labor for 10 days and then dying undelivered, they really, really were horrific. And also an indicator of the complete lack of access to health care, because obstructed labor deaths are almost completely preventable through assisted delivery or Caesarean section.

So all those women dying of obstructed labor meant that none of them were getting to health care. And that's what our data showed as well. None of them had even attempted to reach health care because they were so remote.

We also found that the -- 75 percent of the infants who were born to women who died also died. And it was one of the first studies that documented what happened to newborns of women who died, and the risk to them as well. So the greater impact on the family than just the mother's death, risk to the infant and the other children, plus the economic impact of things like that.

COLEMAN: You know, I'm not a maternal health expert, but I'm actually surprised that that wasn't documented until 2002. That's amazing to me.

BARTLETT: There was some, but it was one of the first that measured that, you know, in a careful way, and then since there there has been more -- since then there's been more.

COLEMAN: So you have recently -- you know, the RAMOS II is under way. Maybe compare and contrast RAMOS I with RAMOS II for us, just how -- what are some of the similarities, and I think there's some stark differences too.

BARTLETT: Well, we're in the middle of data collection now in Kabul, so I don't have any data to present today. But USAID and the Ministry of Health in Afghanistan asked us to conduct a second RAMOS in the same districts, using the same methods to identify if there's a decrease in maternal mortality in the districts, and if so, why or why not.

So we're using the same methods, which is a direct household survey to identify deaths as opposed to some of the indirect estimates where they use sisterhood methods -- either indirect or direct sisterhood. We're using a direct methodology which -- (coughs) -- excuse me.

We visit almost 25,000 households and, among a lot of other data, we ask about births and deaths in the household by age and gender and with a number of careful checks behind that. Then among the women of reproductive age we have a team that goes back who are trained in verbal autopsy, and they conduct a verbal autopsy to determine cause of death. And we have also a semi-qualitative component where we talk to the family about barriers and enablers to health care access to learn about -- more about preventing maternal death.

So this time we're only going three districts, at this point. Kandahar is not accessible anymore. And we will do the qualitative component there, and documentation of what program and policy has been implemented. But we're only conducting the survey in Kabul, which is almost done; Laghman, which is about halfway done; and Badakhshan, which is starting in a couple of weeks.

In addition to the -- what I just described, which is to measure the magnitude of causes of maternal mortality, we have a large component that includes qualitative and a documentation review. And the purpose of that is to try to assess what programs and policies contributed to the decline, if indeed we find a decline. And that's to guide further programming in Afghanistan but also we think that it could also be useful to inform programming in other very-low resource or post-conflict settings.

COLEMAN: So just to understand a little bit more. Laghman you said is not heavily Taliban controlled. So how are you doing the study there?

BARTLETT: That's a good question. We're hiring people from the districts that we're collecting data in exclusively. So there's nobody working in Laghman who's not from Laghman. And in fact, we've tried to limit to staff that are from that particular district in Laghman.

But Laghman's always been a traditional conservative area. So again, finding educated women who are allowed to leave the home and work with us is not easy, but -- so through a lot of hard work, lot of connections, talking to people at UNICEF, a colleague and a friend who's from Laghman, and he, you know, reassures the community -- you know, these are good people and they're not going to do anything to you, and this kind of thing -- we've been able to get the staff that we need.

COLEMAN: And what about in Kandahar? Because you said it's off-limits. I mean, we've had this surge that was supposed to make Kandahar on-limit, you know? (Chuckles.) It's started in Marja, and now in Kandahar we've got all these troops there. Why is it off-limits? I'm just curious; I've heard varying thing -- various things -- varying things about Kandahar today. I've not been there, so --

BARTLETT: Well, where we needed to go is a rural district in Kandahar. So you can still go to Kandahar city.

COLEMAN: Yeah, but just not outside.

BARTLETT: But not a large household survey outside in one district, because we'll have teams there for a number of weeks. So if somebody wanted to target a team --

COLEMAN: It would be too risky.

BARTLETT: It would be too easy. And so the provincial public health director, who's been there for years -- he's very -- he's very bright and he's very savvy -- and he said, you know, please just don't right now, it's just too risky.

COLEMAN: So if you had to sum up what's, you know, the clear improvements -- you've mentioned some of them -- what are some of the things that have been disappointing?

BARTLETT: That's a good question. (Chuckles.) Certainly, the continuing, and, in fact, increasing in security is very disappointing and very -- it has a -- it's having a big impact on the country. Mobility is substantially lower than what it used to be for Afghans and for non-Afghans. So the Afghans even won't move around the way that they used to move around.

COLEMAN: But I mean, are they to the point where there are community clinics that they can't access because they can't walk a few miles to get there? I mean, is it that diminished mobility?

BARTLETT: I think that would be true in some areas. I haven't actually been to those particular areas myself except for Kandahar, but I would assume that that's true. Yeah.

But even general mobility like, say, some of our interviewers from Kabul going to Badakhshan -- a very small proportion will agree to do so, and the rest's just, like, no, it's just -- you know, everybody's kind of homebound, so to speak, because of the insecurity.

COLEMAN: Let's turn now to midwifery and look specifically at that program in Afghanistan. Maybe you could start by talking a little bit more generally about midwifery. And why has there been this focus on midwife training, particularly in low-resource countries like Afghanistan? Not only Afghanistan -- there are a range of countries where there's been a big push on midwifery. And then -- and then let's talk about Afghanistan.

BARTLETT: Well, as I said, there's an acknowledged health -- human resources for health crisis in the world. There's far too many (sic) physicians, nurses and midwives. And that's reflected -- well, in many indicators, but in particular -- in developing countries, less than half or about half of women deliver with a skilled birth attendant, and the rest deliver alone or with a family member or with a layperson.

Since the vast majority of maternal and newborn deaths occur around the first 24 hours of labor and delivery and postpartum, then you can probably imagine if a woman delivers at home without any assistance whatsoever, if something happens, it's very unlikely that's she's going to survive it except for the grace of God.

And so there's a big push to improve human resources for health. It's part of the move to achieve the goals -- MDG goals four and five of reducing child and maternal mortality.

Recently, there has been a lot of attention put on to midwifery. There's been a number of international statements of -- consensus statements about expanding midwifery. I think people have come to realize that midwives save lives. For the most part, midwives are women. Women in any country tend to prefer to go to women.

And to educate a midwife is much more time- and cost-effective than to educate a physician. So while a physician can do more sophisticated treatment for complications, including cesarean section -- you know, a physician who's trained in cesarean section -- but it takes about eight years to educate a physician, if not longer, and they tend to want to stay in urban areas. And that's true somewhat of midwives as well, but there is now a number of midwifery education programs, including in Afghanistan, where they have women who are selected by communities. And so they then have a requirement to, but also a desire to return to that community. So rather than graduating and all of them are staying in Kabul, where they can make a lot of money, they're spreading out across the country. And that's a model that's occurring in a number of different countries now.

COLEMAN: And are these midwives -- are they role models in their community?

BARTLETT: In the study that we did in Afghanistan, we did a program evaluation of the midwifery education program over 2009 and (20)10. And from the first phase of this study, where we did the qualitative component, we interviewed midwives about the education program, and what they thought were the strengths and weaknesses -- also, key stakeholders like Ministry of Health people and donors and NGOs, but then also women in communities.

And the feedback, in particular from the women in communities, who were served by a midwife, was just uniformly extremely positive. They love to have a skilled woman who can come and take care of them in their most vulnerable times.

And they also spoke to us about -- having a female, an educated female being a role model in the village or community improved the stature of educated females to them. And we've also heard that more girl children go to school in communities served by midwives than not. Now, that's not been documented in numbers, but that's what the people that we interviewed in communities told us.

COLEMAN: And how do the men view the midwives?

BARTLETT: Really, very positively. I mean, Afghan men, despite being a traditional culture, want their wives and their daughters to survive, just like anybody in any culture. And --

COLEMAN: And they recognize that the midwives help that?

BARTLETT: Yes. Yeah. So very positive overall.

COLEMAN: Are there some of the -- from this midwife evaluation that you've done of -- are there been some health impacts that you've seen already?

BARTLETT: Well, currently it's just anecdotal that people have told us there's much fewer deaths. I was in a village in Badakhshan a couple of years ago and talking to the male and female community health workers who happen to be brother and sister -- sometimes they're husband and wife, in this case it was brother and sister. And we asked them, you know, are you seeing children's deaths, and then compared to previously. And they're seeing far fewer children's deaths. Are you seeing any mothers' deaths, and compared to previously. And the CHW held up his cell phone and said, we haven't seen a mother's death in three years, because if something happens, there's a clinic down the road with midwives. They have an ambulance and we can call for help. I mean, that's an enormous difference in a country that had that maybe in Kabul if they were lucky in 2002 and before.

COLEMAN: But presumably -- I mean, the midwives can help, but when it's a real emergency, they're stuck. They can't perform a C-section, they can't --

BARTLETT: So they have to be -- midwives, for the most part, operate or work -- not operate -- work in facilities. They do some community outreach and a few community births. But women are encouraged to come into these basic or comprehensive health facilities or lower-level hospitals. They can manage normal labor and delivery and the newborn right after delivery as well, and manage complications, but then their role is to refer when care is needed that is beyond their competency level.

COLEMAN: And in most cases, is there a place where they can now refer them to?

BARTLETT: For the most part, yes.

COLEMAN: OK.

BARTLETT: And then, just going back to, has there been evidence of impact, the RAMOS that we're doing now, that's the purpose of it, is to provide what we hope will be evidence of impact. And -- but there has been evidence documented of reduction in infant and child mortality, which, as you can imagine, if infant and child mortality is reducing, maternal is probably reducing as well. And I talked to you about already, the increase in skilled birth attendants and antenatal care, which have an impact.

And we also did, in this study, the evaluation -- we compared provinces that had midwifery schools to provinces that didn't have midwifery schools, and in the provinces with schools, women were significantly more likely to access ANC and skilled birth attendants as opposed to provinces without schools, which is an indication of the impact of midwifery as well.

COLEMAN: And more broadly, on a sort of community health, I mean, how about -- are you -- are you going to collect data, you know, on immunization and broad sort of health indicators?

BARTLETT: Not in this study, no. There's other surveys that are done in the country that do that.

COLEMAN: Yeah, that have done -- yeah. But the midwives are also a channel for some of those other interventions.

BARTLETT: Well, they are because women will access them for general health care and their immunization, and then women are known as the gatekeeper to health care for the family. So it's the woman, the mother who takes her child to get immunized; it's generally not the father. And so, you know, that probably hasn't been documented quantitatively, but my assumption is that that would be -- need to facilitate it, yeah.

COLEMAN: Correlated. What are -- what are some of the things that you see today that need to be done to improve midwifery in Afghanistan?

BARTLETT: Well, actually, midwifery's very strong in Afghanistan, and the evaluation that we've done, and we're just waiting for the final report to be approved, and then we plan to publish because we want to get this out as a case study on midwifery.

There's a school in 32 of the 34 provinces, and two of those schools serve two other provinces. So in other words, women in all 34 provinces have access to a school that's either in their own province or in one very close by. So some of the smaller provinces will have one school between them because some of them are tiny.

And the cities do not have residential programs, and there's five urban schools. So the other schools, the other 27, are all community-based; so they're residential programs. Women are elected by their communities to come; they have to have -- you know, certain requirements of high school education and that type of thing -- and then they come to the school, and they live there. One of the midwives that we interviewed in the evaluation spoke about that very positively that, you know, the school, the residential schools were designed by Afghans and Afghan women for the most part. So they're very culturally appropriate, they're safe, they're comfortable, and private and all the appropriate things that they need to be. There's a creche, a day care in every school for -- because a lot of the women who come are married and have children, and security is also very good.

COLEMAN: Do you know -- do you know what percent are married?

BARTLETT: No, I don't actually.

COLEMAN: And these 32 -- I mean, the different schools in the 32 different provinces -- they are managed by different donor groups, right?

BARTLETT: Yeah, there's three main donors in Afghanistan: USAID; EC, European Commission; and World Bank. So they -- the donors pay NGOs for the most part to run the schools, but there's a number of provinces in Afghanistan which is growing -- I don't know the exact number right now -- where the Ministry of Health has taken over service implementation.

So initially, in 2002, it was contracted out to NGOs because there wasn't enough capacity to implement in the country, and the Ministry of Health had, I think, two or three small provinces that were -- like strengthening -- capacity building, they were called essentially -- provinces, and then as they learned, you know, finance and contracting and regulation and things like that, both at the central ministry level and provincial level, now more responsibility is being given to the MOPH.

COLEMAN: And is there any qualitative difference that has been discerned between these different schools? In terms of either the NGOs that are running them or the Ministry of Health --

BARTLETT: Not that I'm aware of.

COLEMAN: Not that you're aware of. OK.

Well, I'd love to open it up to your questions, if you -- you know, just raise your name card like this, and we'll take them in the order, and please all do jump in. Since we have a small group here, we can do that.

We'll start with Elizabeth.

QUESTIONER: Hi, I'm Elizabeth Prescott, and I'm serving as a science and technology adviser for the Bureau on East Asian and Pacific Affairs at the State Department.

And as you know, there's a lot of interest in using science more effectively in our diplomacy, and equally there's a lot of effort to do more health diplomacy. And I'd be interested in your views on one, if you've seen any changes in the field on that, and whether -- I mean, from what you do, which is gather up data, quite frankly, do you find that a good or a bad thing? I mean, do you think it's good for the U.S. to be touting what we're doing? Or does that undermine your ability to do what you feel you want to -- or you need to do in your research?

BARTLETT: I'm not sure I got the last part fully. But you're talking about -- you said, health diplomacy, so health as a conduit for security?

QUESTIONER: It's a concept where we recognize that the United States has -- is already doing quite a bit on health, but we're not talking about it very much. And so we're starting to engage more at levels that are beyond diplomat-to-diplomat, but getting our health practitioners or getting our scientists to engage in recognizing either the people-to-people aspects of that or that it also recognizes some of the investments that the U.S. or USAID is making in these communities. However, especially in places like Afghanistan, it can also potentially make you more vulnerable.

BARTLETT: I don't really have -- I don't think I have direct experience in what you're talking about. But certainly people do talk about having the military involved in development efforts or health development efforts. There's a lot of mixed feelings about that. What you're speaking about of people involved in health or researchers talking directly to others in country, I would see that as positive.

QUESTIONER: Having the U.S. government imprimatur on it doesn't have a negative impact? I mean, other than the military? It sounds like you're using a lot of the local hired staff, which to me indicates that, you know, that -- that's kind of a needed mechanism to not be the U.S. doing it necessarily.

BARTLETT: Yeah, there's an element of that depending on where you are and how sensitive the situation is. Yeah. So we always partner with the Ministry of Health and, as an example, in Laghman, the local people told us that we can't talk about Johns Hopkins University. It sounds too American. We got permission from the Ministry of Health and from the Hopkins Ethical Review Board to just -- so the locals can say, we're from the Ministry of Health.

QUESTIONER: Interesting.

BARTLETT: Yeah. But it did have to go through ethical review, and it did, and it was passed in both places.

COLEMAN: But that is actually working exactly at cross-purposes to what you're trying to do.

QUESTIONER: And that -- and it's often a challenge between the diplomatic and the development side because the development side of State doesn't care. They just want to do it, and the diplomatic side kind of wants to get a little credit for it. (Chuckles.)

So it's -- but it's interesting, and I just -- I don't know if you have experience in other countries that could contrast with it, because I suspect in different countries there'd be a different appetite for having the U.S. name on that.

BARTLETT: I think the U.S. name can go on most things in most places and most countries that I've been in, including in Afghanistan, but just -- you know, there would have to be a sensitivity that there's certain areas where it would endanger people. And you know, that's a no-go. So -- but certainly, the Ministry of Health and the provincial directors and the interviewers all know that this is a U.S.-funded study through a U.S. university, and there's no issue with that whatsoever.

QUESTIONER: But -- can I just also add to that? I think it's interesting because the whole development policy is being driven through the country ownership lands. So when you brand, you know, development in country with donor logos and donor -- sort of -- people representatives, it becomes hard to actually also achieve that goal of country ownership. So I see where you're struggling with -- right. Yeah.

BARTLETT: It's definitely a (tension ?). (Laughs.)

QUESTIONER: Right -- yeah.

BARTLETT: Good question.

COLEMAN: Steve (sp)?

QUESTIONER: Yes. Do you know roughly how many women have been trained now across the whole country in midwife skills? And when you have them there in the training, do you give any other kind of training besides specific midwifery skills, such as training on their rights as women under the Afghan constitution, rights as citizens, international human rights standards, their rights to engage in the political and economic life of their country, or business skills, or any -- you know, taking advantage of having that good group together, which, I think, would also help them to network with each other and to stay in touch.

BARTLETT: That's also a very good question.

So there's about -- I think it's about 2,800 now midwives across the country, starting from about 400 in 2002. And the national need is about 7,800, so close to 8,000 midwives, to cover the population required. And so we're -- well, maybe over a third there. And that's in a pretty short time period. And then that's also building all the infrastructure that's needed for that.

You know, I've looked at the curriculum recently, and I don't recall there being anything specific to what you said about teaching about their rights in Afghanistan. I know because I've witnessed women talking among themselves about that as a concept. And not that it's, you know, not taught on purpose, but I don't think it's officially in the curriculum.

The midwifery professional association, the Afghan Midwives Association, is very successful, very influential. And they do talk about that type of thing. And all the midwives in the country are members of the Afghan Midwives Association.

QUESTIONER: How long will it take to meet the need, which is 7,800, you said?

BARTLETT: We actually -- we calculated that. And it was -- what was it now -- it was about 2018. Something like that.

QUESTIONER: 2018?

BARTLETT: Around there, yeah, we would get to -- if they continued at the same pace of graduates.

QUESTIONER: At the same pace --

BARTLETT: Yeah. It might have been 2017.

QUESTIONER: OK.

BARTLETT: And so actually, when I was at USAID recently and we were talking about that, one of the things that we talked about was, it's not that often that you are funding or running a program, that you actually know that you're going to hit your target at some point, as opposed to sort of this just infinite time period of implementation. People talk about transition and scale-up and sustainability. And those are really difficult concepts when you're in the field. And so certainly sustainability is still going to be something they'll have to manage for the midwife program.

But USAID program started -- the midwifery -- USAID support started the midwifery program in Afghanistan. And by about 2018 -- not to take focus off of it completely because it'll still need support and some maturation, time, sustainability -- but they're going to be able to take off the intense resource focus that has been on it. To me, that's a big success story.

QUESTIONER: And so how much money is it from now to then?

BARTLETT: Oh, I don't know that. (Chuckles.)

QUESTIONER: You don't know that. Do you know, Mary?

MS. : No.

QUESTIONER: No?

Do you know what the annual midwifery budget is in Afghanistan today?

MS. : No, I don't know that either. It's a good question, though.

QUESTIONER: I was just wondering the -- how you are sort of realizing the success of the midwifery training program relative to other components that help to bring maternal mortality down. So you know, when I worked in India, in rural India, if a midwife was good and skilled at recognizing an emergency, part of the obstacle was getting, then, the woman to a center. So I know you said that they are delivering at these centers. But clearly those are not for emergency obstetric care.

So you know, how do you realize the success and the limitations of a midwife in a situation like Afghanistan? So it's a difficult question, but how much can you attribute to the midwifery program, as opposed to some of these other components? And especially if those are not covered, really, how much of a difference is the midwifery program alone making?

BARTLETT: OK. Well, midwives basically can be equated with basic emergency obstetric care because the competencies that they should have, and must have as directed by the International Confederation of Midwives, are the competencies to provide basic emergency obstetric care. So that includes, you know, preconceptual care, antenatal care, normal labor and delivery care, and management of complications. So if a woman has preeclampsia, she can be given magnesium sulfate and then referred if necessary -- obstructed labor recognized early, stabilize and referred if necessary.

We actually have just done an analysis that's separate from this work that I've been talking about here for an upcoming State of the World's Midwifery report. It's going to be released in June. And since I did the analysis, I can tell you what we found, although the entire report is embargoed until June.

But we -- using the LIST tool, which is a lives saved tool -- a model -- statistical model type of program that's used to calculate deaths averted through certain health and clinical interventions -- we calculated how many deaths could be averted by scaling up midwifery. In one -- we're saying is a pragmatic level, and that's roughly doubling over the next five-year period or something like that. So that might not be actually pragmatic for some countries, but for other countries, it would be -- and then a scale-up to universal.

And we found that when we scale up to universal coverage, over half of maternal fetal and newborn deaths would be averted by BEmOC, which is a proxy for midwifery. And so that's without -- that's without any comprehensive emergency obstetric care. But it does include ability to refer to comprehensive.

QUESTIONER: But in Afghanistan, I was just curious to know, when you have difficulty in the referral cases -- you know, are you losing a lot of women at that stage?

BARTLETT: Well, no. I would say no.

QUESTIONER: Yeah?

MS. BARTLETT: I would say no, we're not losing a lot. And lower-level health facilities are built such that they can access higher-level health facilities, for the most part. There's some really rural areas where there's a lower-level facility that's, you know, hours away from the higher-level one. And so that's not probably that helpful in a life-threatening situation. But are we seeing a lot of mortality at the basic centers because women aren't getting referred? I would say no.

QUESTIONER: So just to step back, I guess, to the money questions, so right now, everything we've talked about, it's funded by outside donors. And there's obviously all these other things going on in the country right now. Are there any plans in place, like -- so to say that the money from outside starts decreasing -- you have to get to that number by 2018? Are there certain plans such as maybe taking -- getting money to fund it from the government of Afghanistan, or having some nominal fee that they charge, or some other way to make it so that they're self-sustainable, we don't -- that they don't have to be dependent on anything outside?

BARTLETT: There are plans for sustainability, and I have to say, I'm not very familiar with them. I don't know if -- Mary Ellen (sp), if you can talk about that at all.

MARY ELLEN : I've -- just to the point that it's a really good question. We've been looking for -- seeing a line item in the budget grow and grow and grow. And I haven't seen this recently, and we're going to have this publication of national health accounts, which may be illuminating.

But the government commitment and contribution is going to be crucial. And I would just say, to reach a goal by 2018 may be very possible. But we know, in every place in the world, schools need to be maintained because there's attrition, and people retire out, and it doesn't just get done. And I think there's some level of lack of reality on some parts to think that you can declare success, and it will continue in perpetuity. And it wouldn't.

COLEMAN: But just to be clear, to hit that 7,800 midwife number by 2018, you don't need to build more schools. Is that right?

BARTLETT: That's correct.

COLEMAN: So the school -- the infrastructure's built. So now it's just a question of continuing and improving the training and, you know, teachers and maintenance and all of these types of things.

BARTLETT: And deployment and employment.

COLEMAN: Yeah.

BARTLETT: Yeah. Continuing employment.

COLEMAN: And do communities -- don't some communities in Afghanistan contribute? Isn't there a community contribution to the midwifery salary in some cases?

BARTLETT: Yeah. There is, actually.

COLEMAN: There is.

BARTLETT: Yeah.

COLEMAN: So some communities are finding the resources to pay the midwives, or at least a portion of their salary?

BARTLETT: Yeah and actually, probably that varies between monetary and --

COLEMAN: In-kind?

BARTLETT: -- and in-kind.

COLEMAN: Yeah.

BARTLETT: Probably maybe on the more -- more part -- more so in-kind.

COLEMAN: Uh-huh.

Eva (sp).

QUESTIONER: Sort of related to that point, is there any kind of a train-the-trainer component? I mean, I would imagine on the one hand you want to keep the accreditation -- you know, you want women going to the schools if they aren't trained properly. But is there -- you know, are the women who are trained then encouraged to share at least some basic information?

And through the cellphone technology that exists, is there any opportunity to do even basic health information messaging?

BARTLETT: Yes to both. The -- I mean, the women who are teaching the midwives are midwives themselves that have been trained to have appropriate competencies and even teaching skills. So they're taught how to teach.

And in the qualitative work that we did for the evaluation, the midwives told us about nurses and even doctors coming to them and asking how do you do a procedure, because they know they've been trained more recently and with modern standards of care. And it was one of the greater points of pride of the midwives, of teaching medical students, occasionally teaching, you know, a younger physician who still isn't too proud to ask, you know, a new midwife grad on how to do something.

And what was the third part of your question?

QUESTIONER: It was cellphone technology.

BARTLETT: Right. So there is some programs in Afghanistan -- I think it's still sort of on a pilot or testing stage -- of utilizing cellphone technology, sending text messages to midwives and health care providers with updates or reminders. I've heard about reminders of wash your hands before you see the patient, just simple things like that.

And I'm not sure, but they were talking a couple of years ago about piloting a cellphone program where just people in the community were sent health messages -- again, probably things like wash your hands; you know, make sure your baby's immunized and have a proper latrine in your community and these kinds of things.

COLEMAN: Yeah, I think in our last session we did here, Denise Byrd of Jhpiego was talking about some of the cellphone -- you know, mHealth, those types of things. But I think -- I think it was exactly what you were saying. It was reminders. And they did some studies showing that those reminders were valued by the health care professionals and forwarded on to others, which is a sign that they appreciated them. So --

QUESTIONER: Because I'm also thinking -- I mean, this all is predicated on the assumption that you're going to have women continuing to go to school and get a high school education as we go down the road, wherever we're going to end up, in a peace and reconciliation process. If that is not going to be the case, I mean, are there alternative strategies which could at least get out some basic care information, which assumes also the person holding the phone on the other end can read the text or that there's, you know, some communication flow? That's obviously a question for the future.

BARTLETT: Right. Yeah.

COLEMAN: Elizabeth (sp).

QUESTIONER: I know -- I'm sure everyone here is aware that our aid is looking more at trying to put metrics around a lot of what we're doing. And you referenced earlier how this is somewhat unique and that, you know, you can actually see the end and calculate how to get there. And I -- it made me wonder, as far as doing the second study, was that something that you'd looked at doing from an academic perspective, or did AID reach out to you and say, we'd really like to evaluate this and see how it's going? And anything -- you know, any kind of information or your perspective on standardizing and metrics for development work?

BARTLETT: We had recommended from the beginning and -- that the RAMOS be repeated after a certain time period. And then when I was with UNICEF in the country full time for two years, was also a recommendation that came from the U.N., because people were very interested in knowing whether there's been a change made. We were approached initially by the ministry of health. And then I think the ministry of health asked for USAID to support it, and USAID contacted us. But it was always --

MS. : (Inaudible.)

BARTLETT: It was always a personal and institutional interest to repeat that.

QUESTIONER: So I know that the study is not complete, that you're just starting the second go-round on this, but anecdotally, are you aware of significant declines in maternal death in Afghanistan?

BARTLETT: Yeah.

QUESTIONER: And what have been the major contributors to that? I mean, the midwifery program of course is part of it. But is it just -- I mean, can you sort of maybe divide it into levels, like there's a base level just of basic information, people are washing their hands and their -- I don't know, you know? But then there -- you know, you've seen some improvements from that. You've seen the elimination of some bad, harmful traditional practices. I've read a fair amount about that. And then it's, you know, a question of being able to access more, you know, skilled birth attendants and emergency care.

I mean -- and anecdotally, what do you think -- I mean, are we going to see some significant declines or --

BARTLETT: That's a good question. Can't really comment on whether we'll see significant declines yet. It's too early for that. But anecdotally, I would say pretty much universally across the country, both in urban and rural settings, people report far less maternal and child deaths. And so we've talked a lot about midwifery, and women do have to have access to an appropriate female health care provider or appropriate health care provider -- and in this case, in Afghanistan, it should be a female. And -- but there's many other things that are involved in reducing maternal mortality. There has to be the backup system that we talked about for referral. There has to be transport and there has to be roads. There has to be communication.

The increase in education of girls in the country I'm sure is some contribution, maybe indirect as of yet. But for the most part, most of the country values now educating girls. So there's an increasing value on girls. Some of those girls, say they were in high school in 2003, '04, well, they're now graduated young women. They're either in the -- employed, so they have the resources to access care. (Clears throat.) Excuse me. Or if they're not employed, it's well-known that educated women will access care and have better health outcomes than uneducated women.

And then all the other health programs as well.

QUESTIONER: Yeah.

BARTLETT: They would have some influence, too. So now women are being immunized against tetanus and -- whereas almost nonexistent before.

QUESTIONER: When are they being immunized?

BARTLETT: In pregnancy.

QUESTIONER: OK.

BARTLETT: During ANC or before, in a campaign and -- a vaccine campaign. And I'm sure that there's a reduction in general mortality, which is mortality from all causes --

QUESTIONER: Yeah.

BARTLETT: -- because of the water sanitation improvements, nutrition improvements, things like that.

QUESTIONER: But there's been no attempt to sort of tease out what contributes how much to?

BARTLETT: Not yet.

QUESTIONER: Not yet.

BARTLETT: No.

QUESTIONER: Will you be able to do that?

BARTLETT: Well, yes, we will actually, to some degree.

QUESTIONER: OK. Interesting.

BARTLETT: To some degree, yeah.

COLEMAN: (Inaudible.)

QUESTIONER: I had a question. Like, so, this is assuming that these goals are starting to be met, and we're seeing that this 50 percent reduction we talked about earlier starts happening. Just looking at how here in the United States, over time, as those same things started getting eliminated and the access to care got better for mothers, you could see more and more premature births and children who wouldn't have survived otherwise. Once that starts happening, are there -- are there other things that are being planned over these next couple years in which as there's more premature births, as there's more of these complicated pregnancies that start, you start being able to see better just because at first there was a lot of other easier-to-deal-with problems. Once those harder-to-deal-with problems start showing up, are there other avenues that are being explored and -- so, like, in terms of some kind of neonatal intensive care units, other things like that?

BARTLETT: Yeah, there are. There are. I would say every hospital that I've been to -- so higher-level facility -- has a neonatal ICU. And even lower-level facilities may not have an actual ICU, but they'll have a neonatal ward with a couple of functioning incubators so -- to provide special care to neonates who need it. Yeah.

I don't know about social services for, say, children who survive who otherwise wouldn't. I think there's probably some, but that -- I think there's actually probably quite a bit of growth needed in that area.

COLEMAN: Linda, as someone who has worked in, traveled through, been engaged with Afghanistan over much of the past decade, are you optimistic? Pessimistic? What's your sort of general view on the country but specifically on the -- you know, on the progress that it's made and its ability to sustain that?

BARTLETT: I think -- I think it's -- we're at a difficult time right now. It's a bit of a -- feels like a bit of a potential crossroad to me. There's been so much progress made, so many more people educated. We -- one thing we didn't talk about was the number of professionals who've gone outside the country for postgrad education and then gone back to the country. And the capacity that they bring back has really had a big influence --

COLEMAN: You've seen that in the health space?

BARTLETT: Yeah, very much, very much.

COLEMAN: Where are you seeing those people? In Kabul, for the most part?

BARTLETT: Yeah, I would -- it's in Kabul, for the most part, but other urban areas, not in rural areas. But the ministry is now run by people -- and the majority of them have a graduate degree now, and from outside, which gives them then the benefit of just sort of a bigger-picture type of thinking.

And so there's been -- there's been so many positive changes that it's -- I think it's really unlikely that it would stop completely or it would fall apart completely. There's been too much change, there's been too much momentum. But the security situation has slowed things down. And so there's less implementation. People are staying closer to home. And achieving success in that arena is important in helping -- continuing to help the development of Afghanistan.

But I think, overall, while it is -- it's -- frankly, it's less of an optimistic place than it was a few years ago, where it had this incredible positive energy, and people were just so joyful with the freedom that they were given. It's -- it is less of that. But there's maybe more of a mature attitude now that it's -- you know, they know it's not going to be easy, but there's a lot of commitment to keep it moving forward, and coming from the Afghans more, as opposed to externally brought in.

COLEMAN: Some people have made the case that, you know, maternal health is a marker for the broader health system, health care of a country. And do you think that within the Ministry of Health, within the Afghan government itself, as it does sort of stand more on its own going forward, that they would view maternal health as a marker and allocate resources -- you know, make it a priority -- continue to make it a priority?

BARTLETT: I think that the vast majority of people do very much value maternal health, and it is the number one public health priority in the country and has been for the last 10 years. So yes, I think that'll continue to have the attention that it has had.

And I hope that it does, because the ability to manage a maternal complication takes a functional health system. And so if you can -- if you can manage a maternal complication -- somebody who acutely needs blood -- then you can handle somebody who, you know, has an accident and acutely needs blood and all those similar types of things.

COLEMAN: And you mention that there are a lot of Afghans who've gone overseas, gotten graduate degrees and are coming back. I mean, do you sense that they are committed to the country? They're really there to make it work and --

BARTLETT: Definitely, yeah. There's a few, like anywhere, who --

COLEMAN: Yeah, of course.

BARTLETT: -- choose to have an easier life elsewhere.

COLEMAN: Yeah.

BARTLETT: But the majority of them come back and stay, and are very committed.

COLEMAN: Any other questions? (Pause.)

Well, this has been fascinating. Linda, I've read about your work over the years, dreamed about being on horseback in Badakhshan with you -- it must have been fascinating -- and really look forward to seeing the results of your new study.

BARTLETT: Thank you.

COLEMAN: So thank you for coming and sharing your insights with us today. Thank you.

BARTLETT: You're welcome. Thank you for having me. (Applause.)

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