The main aim of this study was to explore how pregnant women and health professionals experience the quality and provision of antenatal and obstetric care in Afghanistan. Using a qualitative approach, we explored patient perspectives regarding obstacles and challenges to safe and comprehensive care. We also assessed viewpoints and perspectives by health care providers, including physicians, midwives, and traditional birth attendants.
This study has several limitations that should be noted. A small number of individuals from only two selected geographical areas were interviewed. However, we attempted to include patients and providers from various health care settings: a big public hospital, a small village clinic, an NGO clinic, as well as a private hospital, to increase representativeness. Another potential limitation involves the translation process, as translating the interviews from Dari to Norwegian, and then publishing in English, may have led to inconsistencies. However, the first author is fluent in all three languages, the interviews were purposefully conducted using simple and unsophisticated language, and the item responses were easy to understand. Therefore, this potential limitation is considered to be of minimal importance. Additionally, the interviewer spent several days observing each health care facility, yet these observations were not systematized and incorporated into the study and this might be considered a weakness of the study. The role and position of the interviewer were made clear to all participants to avoid potential confusion.
Even if public antenatal care exists in Afghanistan and the government recommends routine check-ups, our study confirmed underuse of these resources. Our study identified numerous reasons why women may not utilize these accessible and available services. Participants reported several obstacles, including their own personal views and beliefs, family decisions, financial reasons, as well as transportation difficulties. The National Reproductive Health Strategy 2006–2009 document states that more than 70% of families in Afghanistan who did seek help encountered barriers either because of costs or poor quality offered at the only accessible health care facility : “Health care knowledge and ability to seek care decline with remoteness and low literacy rate. Decisions to seek care are also influenced by the family’s perception of accessibility. Families do not seek care because of lack of transportation, insecure travelling conditions and inability to afford either transport or care.”
Insecurity, lack of infrastructure, economic instability, poor communication and coordination, poor public health infrastructure, as well as lack of qualified health workers are the main challenges to rebuilding the Afghan health care system . Level of civil unrest was substantial when this study was carried out, especially in Ghazni. This may have also influenced the patients' perception of the accessibility of health care.
Barriers grounded in traditional belief systems that influence birthing generally or affect interpretation of complications are found to be important in several parts of the world, such as Bolivia, Jamaica, and Sub-Saharan Africa . In our study, health personnel confirmed that this still is a substantial problem in Afghanistan, for example, serious complications may be interpreted as the woman being possessed by evil spirits. Social customs within an area may also influence women’s internal barriers, such as shame . Feeling shameful or embarrassed by asking for help, from family members and health care workers, was stated by several of our participants.
In our study, patients reported being rejected at the clinic or were received in an unprofessional manner. This has also been found in other studies, mainly from countries in Latin America, Sub-Saharan Africa and South-Asia [16–20]. Maternity care can be disrespectful and inhumane, or even exploitative . Offensive and demeaning language might be used by health personnel , as well as the carrying out of procedures during labour without information or discussion . Women in a lower social position are considered particularly vulnerable to such negative experiences and this may certainly apply to women in Afghanistan. A 2008 study with focus groups of men or women in Afghanistan investigating the perception of quality in health services revealed that “poor people are treated badly in health services” . A review from Vietnam suggested this may be partly mediated by behaviors of health care personnel who are likely to come from another social class and are unable to separate their discriminatory attitudes from their work as professionals . Negative attitudes from health care staff may deter women from seeking health care, lead to treatment delay, and ultimately prevent good practice [20–23].
Socioeconomic inequalities in maternity care are huge in developing countries, and skilled birth-attendance is the least equitable intervention, due to problems with availability, accessibility, and affordability [24, 25]. Most births without professional delivery care take place among the rural poor [6, 24]. Those few women in our study who attended routine check-ups and reported no obstacles for seeking health care were educated and lived in an urban area under reasonably good socioeconomic conditions. A survey from 2006 showed that more than half of the women in Kabul had access to midwifery care, compared to less than 2% of women in remote areas. Poverty, low educational level, and more than two hours of travel were predictors for not seeing a midwife . Maternal education has long been considered an important determinant for maternal and child health. Education implies increased knowledge about the health care system, as well as about danger signs and disease patterns [26, 27].
All our participants reported the availability of at least some midwifery services, but the need for midwives in rural areas is still far from being met [1, 6]. Afghan societal norms dictate that women should provide health care for women. During the Taliban period, virtually no female doctors or nurses were trained. Today, access to female health care workers is improving, but there are still many obstacles to overcome . Studies from other countries, i.e. Vietnam, found that lack of privacy and insufficiency of female staff prevented women from seeking reproductive health care . Under such circumstances, using the service of traditional birth attendants may be a reasonable choice. In a recent meta-analysis, training and support of traditional birth attendants has been found to positively affect perinatal outcomes .
The costs of obstetrical care can also be an important barrier to the poor . Even when these services are officially free of cost, hidden costs due to corruption may add up to a substantial amount. At the level of individuals and households, there is mounting evidence of the negative effects of corruption on health in low- and middle-income countries around the world . The poor are disproportionately harmed by corruption, because they are less able to afford bribes or the use of private initiatives [31–35]. In our study, bribery was reported to be necessary in order to obtain health services which were intended to be free of charge. This mirrors the dominating position of corruption in the Afghani society. A report from 2010 reveals that one third of the population sees corruption as a necessity, and up to 20% had paid bribes to a doctor or a lawyer during the last year . A study from the Baltic States found that nearly half of those interviewed did not consider unofficial payments to health workers as corruption .
In a recent WHO and UNICEF report , Afghanistan was found to make some progress towards the Millennium Development Goal 5 - the reduction of maternal mortality - but insufficient progress towards Goal 4 – the reduction of mortality in children under five years of age, of which 40% of deaths occur during the first month of life. Our study has shed some light upon possible obstacles to achieving these improvements. Socioeconomic inequalities in the delivery of antenatal and obstetrics care are significantly greater than other forms of health care in developing countries . Reducing these inequalities is essential if improvements in perinatal outcomes shall be reached, and this requires increased coverage among the rural poor . These inequalities also mirror demand factors, and interventions aimed at overcoming barriers at the individual and community level have shown some positive effects in other developing countries [16, 38]. For example, local women’s groups have been shown to affect birth outcomes positively in rural Nepal . Improving the quality of care, including the behavior and attitudes of health personnel, and implementing effective systems for referral are important [16, 39].
Medical education in developing countries should focus more on patient-centered care, including communication skills and attitudes . Introduction of institutional and individual codes of conduct and continuous training of anti-corruption awareness and behavior are essential for health care providers [20, 40]. Higher benefits for health care workers could also be an important step.
What works to improve perinatal health care in resource-poor settings is now clearer, but implementation remains a challenge [41, 42]. It has been stated that underevaluating political issues and excessive belief in management are reasons why improvement in reproductive health has stalled . Many countries – like Afghanistan – now have the political will to improve mother and child health care . But still, “the availability of good medical care tends to vary inversely with the need for it in the population served” . “Proportionate universalism” has been launched as a solution. This means that those in greater need ought to be treated in proportion to that greater need . Reproductive health does not exist in a vacuum, it is affected by how society is organized. Gender inequality leading to early marriage and recurrent child-bearing, as well as limited education regarding sexual health are important barriers to progress . In a wider context, a profound political movement is needed to put an end to gender oppression in order to create a better and more equitable world for women .