Afghan women and the culture of care in a Kabul maternity hospital.

Abstract

Female Afghan healthcare providers are vital to reduce the number of women dying in labour. Since 2001 the numbers of female providers have been substantially increased. Ensuring quality care for women in childbirth, however, remains a more elusive goal. The aim of this qualitative ethnographic study was to analyse the culture of care of a Kabul maternity hospital and explore the barriers and facilitators to quality care. My particular focus was the experiences, thoughts, feelings, and values of the doctors, midwives and care assistants. Six weeks of participant observation, 23 semi-structured interviews with hospital staff, 41 background interviews and 2 focus group discussions with women in the community, between 2010 and 2012, were used to gather diverse perspectives on childbirth and care in Kabul maternity hospitals. A thematic approach was used to analyse the data. Five themes were identified: the culture of care; motivation; fear, power and vulnerability; challenges of care; family and social influences. Three themes are explored in depth in this thesis. They are discussed in the following order: the culture of care, challenges of care, and fear, power and vulnerability. The influence of family and social norms on healthcare providers was integral to understanding hospital life; it therefore contributes to each chapter. Women in childbirth laboured alone with minimal monitoring, kindness or support. For staff, the high workload was physically and emotionally demanding, resident doctors struggled to acquire clinical skills, midwives were discouraged from using their skills. Family expectations and social pressures influenced staff priorities. A climate of fear, vulnerability and horizontal violence fractured staff relationships. ‘Powerful’ hospital staff determined the behavioural agenda. This study offers multiple insights into healthcare provider behaviour. It reveals complex interrelated issues that affect care in this Afghan setting but its relevance is far broader. It is one of few international studies that explore care from the perspective of healthcare providers in their cultural and social environment. It reveals that understanding the context of healthcare is pivotal to understanding behaviour and the underlying obstacles to quality care. Furthermore, it challenges conventional assumptions about individual staff agency, motivation, and common strategies to improve the quality of care.