KATHMANDU, Nepal — Over the past 15 years, Afghanistan has been among the dozens of least-developed countries to prioritize midwife training to improve maternal health. The United Nations’ Millennium Development Goals encouraged the strategy, arguing that fewer mothers and child die when each birth is attended by a skilled birth attendant, or SBA. Overall, it seemed to work: The global maternal mortality rate declined from 400 deaths per 100,000 live births in 1990 to 210 in 2010.
Yet in Afghanistan, and many countries like it, the efforts run into a fundamental challenge: Few newly-minted midwives want to work in rural and remote areas, where they are needed most. Afghanistan has faced perennial difficulty staffing local health centers. The country’s latest Demographic and Health Survey found the MMR to be at 1,291 per 100,000 live births, making it one of the world’s most dangerous places to give birth.
As the global health community now turns it focus on the Sustainable Development Goals, aid workers in Afghanistan and its least-developed peers are asking whether the best measure of progress is the number of births attended by skilled birth personnel. The SDG global target is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. However, for countries with the highest MMR, the aim is to reduce deaths to 140 per 100,000 live births.
The focus on SBAs could be distracting from even more fundamental health system reforms, analysts and aid implementers working in Afghanistan told Devex. Interventions to assist community health workers, ensure basic antenatal and postnatal care and even improve local transport infrastructure — to ferry emergency cases — could make a greater impact, they said. Others raised concerns about the very definition of SBAs, warning that if attendants lack the correct skills, the indicator could misrepresent progress.
The debate isn’t merely one of technicalities. As with the MDGs, the indicators themselves can incentivize countries to prioritize certain interventions over others. Despite midwives’ hesitation to work in rural and remote areas, their training is a key piece of Afghanistan’s strategy to reach the SDGs on reducing maternal mortality.
Target of intervention
Experts agree that a key strategy for reducing maternal deaths is ensuring every birth occurs with the assistance of a skilled birth attendant — a doctor, nurse or midwife.
A midwife with the right skills and training can provide 87 percent of the health care needed during pregnancy and following birth. Ahead of the International Confederation of Midwives' 31st triennial congress, former Tanzanian President Jakaya Kikwete and Wellbeing Foundation Africa's Founder-President Toyin Saraki explain.
The U.N.’s 2015 MDG report, however, found that the increase in the proportion of births delivered with SBAs has been modest. More than 1 in 4 babies and their mothers are still without access to medical care during childbirth. The report also revealed major discrepancies between regions and within countries themselves, particularly across sub-Saharan Africa and Asia.
Dr Stewart Britten, Afghanistan project adviser for HealthProm, a United Kingdom-based NGO working to reduce maternal and child health in Central Asia, believes aiming for all births to be attended by SBAs in a country such as Afghanistan is an unrealistic goal.
“I think it’s a mistake for a low-income country like Afghanistan to put all its hopes in midwifery,” Dr Britten added. The focus on SBAs, he said, pulls “resources away from where they could be better spent like community health workers.”
Britten argues more resources should be put into training community health workers, who are more prevalent in rural and remote areas. These local health workers are currently barred from assisting women to give birth. Britten believes CHWs’ role should extend to antenatal care — so complications can be detected earlier on — and delivery.
Expanding community-based programs and increasing antenatal care services are key to decreasing maternal mortality, particularly in rural and remote areas, said Gulam Muhammed Al Kibria, research data coordinator at the department of international health at Johns Hopkins Bloomberg School of Public Health. Such community-based programs could address issues such as getting a woman to a health facility by providing vehicles or designating skilled birth attendants to conduct home deliveries in certain regions.
Are skilled birth attendants really skilled?
Others in public health argue that SBAs should still be a priority, but their impact and skills need to be carefully measured.
“I don’t think the standard is too high,” said Professor Oona Campbell, a reproductive epidemiologist and head of the London School of Tropical Medicine and Hygiene’s maternal health program. “I think it’s a good indicator in theory.”
What’s less clear, she said, is how it can be effectively monitored.
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Most countries use household surveys to ask women: “Who attended your delivery?” At times, she said, the women aren’t sure. “We see in some settings that women assume someone is a midwife but may be the cleaner. Or in some private sector settings, unskilled providers wear white coats and are called doctors,” she said.
The definition of “skilled” can also vary to include roles from village midwives to traditional birthing attendants. A case in point unfolds in 2014 data from Sudan, in which the World Health Organization asserts that 77.5 percent of births were attended by SBAs but UNICEF reported that number as 27.7 percent. Why the discrepancy? Because, as Campbell explains, WHO includes village midwives as “skilled” personnel.
“Governments want to look good and push the WHO to label some cadres as called ‘skilled’ even though they are not trained in midwifery skills,” Campbell added.
Measuring skilled birth attendance also fails to take into account the environment in which a woman gives birth. Just because a delivery is done by an SBA, it doesn’t mean the environment was enabling to ensure a safe birth. Health can depend on having access to the right medicines and equipment, in a hygienic environment. In cases in which there are complications, maternal health can depend on access to transportation availability and a good road.
Health experts admit there is a balance to be struck between the possible and the ideal — the most accessible and the best quality.
“If you go for top quality, you will miss large numbers of women,” Britten argues. “There’s a trade-off between quality and quantity.”
He advocates a more holistic means of measuring progress on maternal health, including indicators about whether the woman had antenatal care in the four weeks before birth, if she had access to transportation to a health facilities, and whether a female CHW was available to assist.
The focus on maternal health should extend beyond just the health sector, to address issues such as education, poverty and other socio-economics, Kibria agrees. “Only improving the health sector wouldn’t be able to accelerate the rate of deliveries attended by SBAs, so if a program just focuses on improving the health sector, then it’s not suitable.”
Back in Afghanistan, inching closer to the SDGs' goal of 140 maternal deaths per 100,000 live births will be a daunting task. While training midwives is a national priority, more than improved health care will be needed, especially in the face of increasing violence.
Update, August 9, 2017: This article has been updated to clarify that the SDG global target is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030, but for countries with the highest MMR, the aim is to reduce deaths to 140 per 100,000 live births.
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