Midwifery training in post-conflict Afghanistan: tensions between educational standards and rural community needs.

OBJECTIVE To compare the performance of students selected for midwifery education by three methods: community mobilization in rural Afghanistan, a regional examination by the Institute of Health Sciences (IHS), and the National University Entrance Examination (NUEE). METHODS A retrospective survey was conducted in January 2009 on academic records of 178 midwives trained at the IHS in Herat, including 147 graduates from 2003-08 and the cohort of 31 final-semester students graduating in March 2009. An interview survey of the 31 final semester students was also conducted. Outcome variables included knowledge, skills and employment status, stratified by method of selection. Individual attributes including completion of high school, marital status, age and urban/rural residence were also assessed. Data analysis used STATA version 2009. Significance was measured by appropriate statistical tests. Findings were verified by key informant interviews. RESULTS Ninety-six per cent of midwifery graduates selected by communities were employed, compared with 74% chosen by the IHS and 82% by the NUEE. Sixty-three per cent of community-selected graduates were working in rural locations, compared with 43% recruited by IHS and 9% by the NUEE. While fewer midwifery graduates selected by communities had completed high school and their academic performance was slightly lower during training, there was no difference in their pass rates and acquisition of practical skills. CONCLUSIONS Community mobilization for local selection of trainees achieved significantly higher employment levels of trained midwives in high-risk rural communities than usual selection methods, without compromising quality of skills.