Villains or victims? An ethnography of Afghan maternity staff and the challenge of high quality respectful care

Abstract

Background Healthcare providers are the vital link between evidence-based policies and women receiving high quality maternity care. Explanations for suboptimal care often include poor working conditions for staff and a lack of essential supplies. Other explanations suggest that doctors, midwives and care assistants might lack essential skills or be unaware of the rights of the women for whom they care. This ethnography examined the everyday lives of maternal healthcare providers working in a tertiary maternity hospital in Kabul, Afghanistan between 2010 and 2012. The aim was to understand their notions of care, varying levels of commitment, and the obstacles and dilemmas that affected standards. Methods The culture of care was explored through six weeks of observation, 41 background interviews, 23 semi-structured interviews with doctors, midwives and care assistants. Focus groups were held with two diverse groups of women in community settings to understand their experiences and desires regarding care in maternity hospitals. Data were analysed thematically. Results Women related many instances of neglect, verbal abuse and demands for bribes from staff. Doctors and midwives concurred that they did not provide care as they had been taught and blamed the workload, lack of a shift system, insufficient supplies and inadequate support from management. Closer inspection revealed a complex reality where care was impeded by low levels of supplies and medicines but theft reduced them further; where staff were unfairly blamed by management but others flouted rules with impunity; and where motivated staff tried hard to work well but, when overwhelmed with the workload, admitted that they lost patience and shouted at women in childbirth. In addition there were extreme examples of both abusive and vulnerable staff. Conclusions Providing respectful quality maternity care for women in Afghanistan requires multifaceted initiatives because the factors leading to suboptimal care or mistreatment are complex and interrelated. Standards need enforcing and abusive practices confronting to provide a supportive, facilitating environment for both staff and childbearing women. Polarized perspectives such as ‘villain’ or ‘victim’ are unhelpful as they exclude the complex realities of human behaviour and consequently limit the scope of problem solving.

Assessing respectful maternity care in a fragile, conflict-affected context: Observations from a 2016 national assessment in Afghanistan

“…we have so many problems, so what does respectful maternity mean for us?" (a31_B3) mistreatment including weak working environments, poor human resource management (maldistribution of staff is a persistent bottleneck), lack of accountability across all levels and a dysfunctional institutional culture (Arnold et al, 2019).…”

Facility-Level Determinants of Quality Routine Intrapartum Care in Afghanistan

“…Studies have noted that women of younger age and lower education experience higher levels of disrespect and abuse during labor and delivery [30]. In Afghanistan, qualitative research has demonstrated that respectful maternity care is a gap that must be addressed [17,19]. If providers are better able to recognize their unconscious bias and actively attempt to engage in more equitable care, clients will bene t from improved clinical care.…”

“…Ethnographic studies in a tertiary hospital providing women's health services in Kabul capture myriad challenges facing maternity care providers, including complex power dynamics [17,18], and a recent qualitative study examining women's experiences during childbirth at primary health care facilities in eastern Afghanistan suggests quality of care is highly variable [19]. We are not aware of any studies to date reporting on the quality of clinical care practices during routine labor and delivery in Afghanistan.…”

Facility-level determinants of quality routine intrapartum care in Afghanistan

“…Given socio-cultural norms, all maternity providers in Afghanistan are female, however, they remain a minority amongst the broader health workforce dominated by men [ 11 ]. Ethnographic studies in a tertiary hospital providing women’s health services in Kabul capture myriad challenges facing maternity care providers, including complex multi-faceted power dynamics [ 13 , 14 ]. Conservative gender norms and discrimination are pervasive such that female health workers may face stigma, violence, and security risks both inside and outside of the workplace [ 11 ].…”