Patterns in training, knowledge, and performance of skilled birth attendants providing emergency obstetric and newborn care in Afghanistan.

OBJECTIVE: To assess current skilled birth attendants (SBAs) in Afghanistan, looking for opportunities to improve quality and expand emergency obstetric and newborn care (EmONC) services.
METHODS: The EmONC training, knowledge, and skills of 82 doctors and 142 midwives in 78 facilities were assessed using interviews, knowledge tests, observation of performance on anatomic models, and decision-making scenarios.
RESULTS: Three-quarters had training in at least half of the 24 possible skills. Doctors' and midwives' levels of training in specific skills were generally similar. Doctors were more likely to be very confident of their skills. Midwives and doctors scored similarly in assessments of decision making and performance of technical skills. SBAs showed weaknesses in specific steps to manage common high-risk emergencies. Decision-making skills were good in a maternal care scenario but weak on managing a newborn not breathing. Doctors' and midwives' scores were similar.
CONCLUSION: Midwives and doctors in Afghanistan are similarly competent. Focusing on training and deploying midwives may be cost effective without diminishing quality. In-service training and job rotation could help SBAs retain their EmONC skills. Training and practice to manage common high-risk emergencies deserve priority.