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.