Case study: improving maternal health in Afghanistan August 2018 Summary Over three years, more than 2,500 women and men have taken part in village-based maternal health training. The project took place in a remote, rural part of Afghanistan where a lack of access to medical services and persistent harmful traditional practices have led to high rates of maternal and neonatal mortality. Participants have learned about how to stay safe and healthy in pregnancy and birth, and how to respond if issues arise. They received Birth Kits to assist with hygienic home births, and had access to a snowmobile ambulance in winter for expectant mothers who needed emergency transport. A key message was to access medical services for antenatal care and delivery. Beneficiaries are now practicing their new knowledge of maternal health, for instance: eating healthily, attending antenatal care, saving money for getting to health centres, and breastfeeding in the first hour of delivery. Men are important catalysts in this behaviour change process, and they have engaged well with the training, with even a few men volunteering to be local trainers in their villages. The impact of the project will be a reduction in death and complications arising from pregnancy and birth. The project was funded with UK aid from the UK government. 1
Project details Project title Location Grant holder Implementing partner Maternal health education for women and men in order to reduce the maternal mortality ratio and achieve access to reproductive health for 2,000 women in rural Afghanistan Afghanistan Cyan International International Assistance Mission (IAM) Project start date 1 September 2014 Project end date 31 August 2017 Donor UK Aid Direct UK aid grant Year 1 (Sept 2014 March 2015): 25,014.07 Year 2 (April 2015 March 2016): 40,650.18 Year 3 (April 2016 March 2017): 45,136.90 Year 4 (April 2017 August 2018): 21,418.11 TOTAL: 132,219.26 Background and context The project was located in a remote and mountainous region of Afghanistan. The project district has a population of around 150,000 people. At an altitude of 2,700-3,900m, people are isolated due to mountainous terrain, heavy snowfall in winter, poorly maintained primary roads and lack of vehicle access. This isolation cuts people off from educational, development and health opportunities. The district s remoteness also leaves many traditional beliefs and practices unchallenged, such as harmful home remedies for illnesses, or pushing on the abdomen to help a difficult delivery. It is a largely male-dominated and illiterate society. Family life is traditional and conservative, with two or three generations living together. For many years, Afghanistan was known for having had the highest maternal mortality ratio (MMR) in the world. Latest figures (2015) put Afghanistan as 28 th worst in the world (at 396 maternal deaths per 100,000 live births); this is the highest MMR outside Africa. Much of this improvement has focussed around the cities, with women there having greater access to skilled birth attendants. However, isolated, rural areas like the project location still lag behind. 2
The Afghanistan Mortality Survey (2010) estimated that 1 in 50 women in Afghanistan will die of pregnancy-related causes, and the lifetime risk of pregnancy-related death was 5 times as high in rural as in urban areas. Universally recognised good maternal health practices (such as four antenatal visits, birth assisted by skilled health personnel, breastfeeding within the first hour of birth) were severely lacking. According to baseline surveys carried out by the implementing partner, only 8% of women attended four antenatal visits and 7% had a skilled attendant at delivery. It is estimated that around half the newborn deaths in the district are due to neonatal tetanus, which is caused by poor hygiene, such as the local practice of sealing the umbilical cord with cow dung. The low level of knowledge surrounding maternal health issues, among both women and men, has led to preventable maternal and newborn deaths. There is a District Hospital the only health facility with ultrasound, x-ray, maternity ward and a doctor able to perform obstetric procedures and five Basic Health Centres which usually have a midwife present. There is no travelling midwife or ambulance service. Health services are free at the point of use. However, the mountainous terrain and harsh winter climate make accessing the health centres costly and time-consuming: travel times can be 3-4 hours in summer and up to a day, if not impossible, in winter and spring flood season. The location has been relatively untouched by conflict, insecurity or major incidents which affect much of the rest of the country. The context therefore allows for relative freedom of local travel and project implementation. Project approach and activities The project takes a preventative approach to tackling the major causes of maternal health problems through basic maternal health lessons. Local people are selected to be trained to deliver birth and life-saving skills (BLiSS) lessons in their own villages. BLiSS uses a participatory learning style. It uses picture books, demonstration dolls, storytelling and discussion to ensure it is appropriate for the local context and literacy levels. 3
The course helps to improve knowledge around maternal health by challenging harmful traditional practices; it teaches practical skills, nutrition and basic first aid; and encourages people to access existing health services. Innovations include: Local women trained as trainers. This enhances local ownership and keeps knowledge and expertise in participating villages. Local delivery of lessons is also cost-efficient. Courses run especially for men. The BLiSS for Men lessons highlight actions specifically relevant to men, such as saving money for transport to clinic, and awareness of the nutritional and practical needs of pregnant women. Participatory learning style. The lessons are designed to be appropriate and accessible for a variety of ages and literacy levels. Working within the paternalistic and hierarchical society, the BLiSS course is delivered to women of child-bearing age, men and older women, as it is often the mothers-in-law along with the husbands who are responsible for making decisions about the care and treatment of pregnant woman, particularly should any difficulties arise. Emphasis on safe birth preparation. Recognising the distance and difficulty in accessing health clinics, the project teaches the importance for high-risk pregnancies to travel ahead of time to the clinic, and saving money to pay for transport or medical bills. It also teaches what can be done in the home if they are unable to travel to the clinic, such as improving hygiene. Safer birthing practices. Due to the prevalence of unchallenged and unsafe traditional birthing practices, the BLiSS course teaches why these practices are potentially harmful to mother and baby, and replaces these with knowledge of good practices. The safer practices can be applied at home, often with the support of local women and traditional birth attendants, such as using the Birth Kit and breastfeeding within the first hour. Involvement of the shura (community development committee). Meetings are held with village leaders before any courses start to get permission to host courses locally, to identify women as local trainers, and to promote courses. Shuras also advocate to the local government for improved health services. 4
Approach to monitoring & evaluation The project used a Knowledge, Attitudes and Practices (KAP) survey. The KAP survey captures participants details, tests their maternal health knowledge (good practices according to local context) and asks about their last pregnancy (based on recommended maternal health indicators, such as births attended by skilled health personnel). The KAP surveys are carried out by trained facilitators with each course participant at three separate moments: before the course starts, immediately after completing the course, and one year later. The before and after surveys identify improvements in knowledge and understanding; the one-year post-course surveys identify actual changes in practice (where there has been a pregnancy). The M&E data is therefore collected throughout the project on a rolling basis as the BLiSS courses take place. The reported outcomes below are based on information available at the end of the project (ie it does not include the one-year post-course data from villages which took the BLiSS courses in the final year). Project achievements and outcomes We are pleased that the project has been scored an A (project met expectation at outcome level) by the Fund Manager. A summary of the key achievements and lessons learned are below. Number of beneficiaries Target Achieved Women 2,000 1,703 Men 720 889 TOTAL 2,720 2,592 Over the three years, 75 women were recruited as local BLiSS teachers and over 2,500 people were trained. The project exceeded its target for the number of men who participated, which reflects an openness to see maternal health as a family issue and not just a women s issue. Improvements in knowledge There have been significant improvements in knowledge (understanding and recollection) on safe birthing practices especially among women who attended the training. It is also encouraging that 56% of women who attended the training are sharing their new knowledge with their immediate family and beyond. 5
Maternal health knowledge indicators Baseline End of project Women s awareness of the importance of antenatal care and 50% 98% family planning Women s ability to identify emergency actions to take in case of 0% 47% maternal bleeding Women s ability to identify emergency actions to take in case of a 2% 55% new-born not breathing after birth Men s ability to identify emergency actions to take in case of 0% 5% maternal bleeding Men s ability to identify emergency actions to take in case of a new-born not breathing after birth 0% 16% Practical changes The BLiSS courses have contributed to changes in maternal health practices, as reported by women who have become pregnant after attending the lessons. Many of these behaviour-based indicators were much higher than expected. Changed practices include: Improvement in use of antenatal care. Vaccination coverage of pregnant women. Giving birth in a clean environment. Births attended by a skilled health professional. Immediate breast feeding. Men saving money for their wives to access maternal health care. Maternal health practice indicators Baseline End of project Women attending at least one antenatal visit 20% 90% Women attending at least four antenatal visits 5% 41% Women having a full-course of vaccines 27% 49% Births attended by a skilled health professional 5% 20% Breastfeeding within the first hour of delivery 50% 97% Men saving money for their wives to access maternal health care 2% 53% 6
Learning The effect of instability on core capacity. In the broader context of Afghanistan, the project location is relatively peaceful. However, the ongoing conflict, general instability and particular incidents involving aid workers elsewhere in the country affected the core operations and functions of the implementing partner during the project period. This risk was mitigated through recruitment and relocation of some personnel. The need to diversify data collection methods. The project s approach to monitoring and evaluation relied upon the Knowledge, Attitudes and Practice (KAP) survey as the only source of data. While the KAP survey was refined throughout the project, with the improved format and learning being shared with other organisations in Afghanistan using the BLiSS methodology, it became clear that additional methods would help to strengthen the data. Some of the methods used in the independent evaluation (including Focus Group Discussions and Key Informant Interviews) will be built into future work. The KAP survey will continue to inform those indicators which relate to individual behaviour changes; focus group discussions will be used for assessing how knowledge is retained by groups of women and men. Connections with the health clinics. A recommendation coming from this project is the need to improve the connections with the health clinics and District Hospital. This is because many of the key maternal health outcomes which the BLiSS lessons promote involve accessing the medical services provided by these health centres (antenatal care, trained midwives, vaccinations, etc). Improved connections could also help with tracking and verifying BLiSS participants usage of clinic services. 7
Training of trainers. A core element of the project s design involves training local women to be the local teachers of the BLiSS courses. This has been important for effectiveness, ownership and sustainability. However, the way the training of trainers occurs has been dependent on external experts, which is time limiting and costly. The implementing partner has therefore explored other ways to deliver the Training of Trainers in a more cost efficient way whilst maintaining quality. Local men as BLiSS teachers. The project did not expect to be able to train local men as BLiSS teachers in their villages, and instead provided the lessons via male staff members. However, a small number of men were trained and this was relatively successful. Going forward, the implementing partner will seek to recruit and train more local men as BLiSS teachers. Use of the snowmobile ambulance. The project had budget provision for the running costs of a snowmobile, which was used in winter months for emergency transport to hospital. The snowmobile was used by 12 women during the three years of the project. However, the use of the ambulance became a difficult indicator to assess as a core message of the BLiSS course is to improve preparedness, therefore reducing the need for emergency interventions. Next steps Building upon the successes and learning gathered from this project, Cyan International has been awarded another UK Aid grant for a second phase project working in more remote villages in the same district. The Phase II project started in April 2018 and will complete in March 2021. 8