The findings are presented according to the three major themes identified from the data; (1) Decision for where to give birth, (2) Access to health facilities and (3) Receiving and valuating midwifery care.
The 14 informants were all relatively young women, aged between 17 and 30, although most did not know their exact age. Despite their young ages, most of the women had been pregnant and given birth, some several times, and some had experienced losing a child. Most of the participants told the research team that they had given birth at home (Table 2).
Decisions for where to give birth
Women in the study areas had access to midwifery care throughout pregnancy and childbirth, although most had more than one hour’s walking distance to a health facility (see Table 2). While most women were aware of the benefits of midwifery care, it turned out that not all of them used such a service. There were several reasons for this—which will be discussed further. A number of women managed to assist themselves in labour and childbirth and stated that they did not need nor did they want midwifery care.
Helping oneself: “I had 13 babies born at home”
Most of the older informants stated during the focus group discussions that it is best to give birth at home, and that giving birth in a health facility is a modern practice they did not feel confident with. Some managed labour and childbirth by themselves:
“I had 13 babies born at home. [..] In my first childbirth an old expert village woman helped me. Then I learned and in the other 12 births I was alone, I helped myself…[..] When a woman today becomes pregnant, she leaves her work and goes to the clinic… The women are so pampered… - it´s like a diversion for them, they pass the time…” (Woman, FGD 1)
A younger woman seemed to have a similar opinion:
“If the woman does not feel pain, why should she go to the clinic? Some women just pass the time… Some women just waste time…, I don´t like to idle away the hours with such un-important issues… I work in the house, with the children and the animals. Why should I go to the clinic? [..] I can help myself during childbirth. I don´t need help from others.” (Afrooz)
However, some women had, during their pregnancies and after talking with other women, changed their opinions about where to give birth, especially after having trouble. One woman explained:
“I had three children at home with a lot of problems. My neighbour advised me to go to the clinic. When I went there the midwives behaved so well and I was very happy and satisfied.” (Khandan)
Thus, some women, independently of their age, felt confident about own coping with childbirth. As has been observed elsewhere in Afghanistan, some viewed pregnancy and childbirth as natural processes that should not require external help [23]. Such cultural attitudes may, on the one hand reflect resilience, yet, on the other hand, represent barriers for safe childbirth in case of unexpected problems and emergencies.
Besides those women who claimed that they could manage to give birth on their own, some women expressed that they would have opted for the clinic, but they were not allowed to do so by their husbands or in-laws.
Choosing for the clinic: Depending on others’ approval
Pregnancy and childbirth are, in Islam, considered as a special time in life, and religious traditions and rituals become more essential to the pregnant woman. An expectant mother prays and reads the Qu´ran more often. As long as she is taken care of by female relatives, it may be seen as unnecessary to seek professional health care in labour and childbirth [24]. In addition, according to Islamic tradition, Afghan women need permission from and need to be accompanied by a close male family member—a Mahramto seek professional health care and to go to a health facility [23]. Frequently, husbands and in-laws did not give consent to women to give birth in a clinic. However, during the discussions many of the research participants agreed that it is better to give birth in a clinic. Notwithstanding, one of the older women confirmed the general state of women’s lack of freedom to choose where to give birth: “It is much better to give birth in the clinic than at home, but unfortunately most women are not allowed to go to the clinic…” (Woman, FGD 2)
Other research participants explained that women should use health facilities only in emergency situations, which sometimes ended up like in “Nadia’s” case:
“I was pregnant in the fourth month and suffered from pain for four days. My in-laws didn´t agree that I should go to the clinic; they said it was shameful. Only when I became unconscious, they took me to hospital. But I lost my child.” Nadia)
The in-law families’ opinions seemed to have a powerful influence on the women: “My in-laws opposed me about going to the health facility. They felt ashamed and said it was not good for a woman to go to the clinic” (Khandan)
One woman explained that her first pregnancy ended in a miscarriage. She was bleeding severely, but her mother-in-law still did not want her to go to a clinic. When she was in shock and unconscious, they finally carried her to the clinic, four hours away from their home. "The midwife said to us; you came very late to the clinic…” (Camila)
As illustrated above, some families considered that attending a clinic for childbirth was shameful. In fact, some women expressed personal shame about having to reveal their bodies, and these women did not want to give birth in health facilities.
The clinic as a site of shame
The privacy and intimacy of labour and childbirth apparently influence the choice of place of birth, and many of the women had decided to give birth at home because they felt it was disgraceful to expose themselves to a health professional. Some felt this so intimidating and embarrassing that they themselves refused to go to a facility when in labour:
“They [the family] wanted to help me when it was time for the baby to come. They wanted me to go to the clinic. I refused. I don´t like women to see me… there… during the birth of the baby. I am ashamed during childbirth… So, I did it alone.” (Afrooz)
Several women confirmed this with similar statements about a lack of privacy in clinics’ premises and the potential of shameful exposure to other women: "The windows in the delivery room do not have curtains. The clinic has few beds…one woman was delivering on the floor with other women present. We don´t feel relaxed there…” (Bahar)
Thus, it seems that women have many obstacles and considerations when it comes to choosing a place for birth, due to a combination of individual, cultural, religious and practical considerations. In a study where Afghan women were asked about their customs and traditions in the perinatal period, the women emphasized that being a good Muslim is particularly important in this period, where e.g. to undress in front of a stranger and expose oneself to a provider are seen as inappropriate [24]. This interpretation might be particular to local cultural contexts in Afghanistan, as according to Islam, even a male doctor is considered Mahram for women, meaning that he is allowed to see, touch and examine the women for therapeutic purposes (personal communication by KS). Moreover, many women in our study also saw the benefit of giving birth in clinics, where they could get help in case of complications. Besides socio-cultural barriers, as described above, infrastructural and environmental factors put constrains on women´s use of skilled care, as discussed below.
Access to the health facilities
The villages included in the study are situated in relatively remote areas of Kunar and Laghman provinces, and the walking distances to the nearest Basic Health Centres varied from 20 minutes to four hours. In the summer it is usually hot, and people seek shade from the sun. For instance, during fieldwork, discussions had to take place in shady areas between people’s houses. In wintertime, there is often a lot of snow in these areas, which makes transportation difficult. The only routes into most of these villages are by roads that, in most cases, only can be accessed by donkey or bicycle. When discussing transport, the women explained that very few people in their areas have access to a car. Some car-owners would be willing to lend their cars out, but suspicion and security issues affected their trust and willingness to do so. Some families had a donkey they could use for transportation.
Distance and the need for transportation
Most of the women in the study lived far away from a health facility (see Table 2). Some women did not give birth in clinics because of the distance from the women’s homes. This could have fatal consequences:
“Too often I gave birth to a dead baby…[..] When I was full term pregnant my labour pains did not start. In all my pregnancies my labour pain did not start… So, I went to the clinic… The clinic is two hours walk away, far from my home. When I came to the clinic the midwife gave me an injection to start the labour, but the baby was already dead in my womb… The midwife advised me to come [early] to the clinic the next time. If not, my baby might die, again.” (Bahar)
Families and communities would often help the women to reach a facility, when judged necessary. One woman who lived one hour´s walk from the clinic explained that it was hard to get there, but each time, she was brought to the facility by her spouse. "My first five children were born in the clinic. My husband carried me to the clinic.” (Delara)
Parents or other villagers would help as well: “My father’s family and the village people prepared transportation for me.”, Afrooz said.
Thus, in spite of the problems with distance and poor means of transportation, it seems like a number of families and women tried to find solutions to the transport issue, as well as its costs.
Coping with financial constrains
The people in the villages represented in the research were generally very poor and during the FGDs, poverty was often mentioned as a general problem which prevented them from having access to transport. Nevertheless, it seemed that many women and their families were trying to plan transport when their labour started. Many women explained about various efforts done by relatives to facilitate transport in case of need.
“The clinic is one hour by foot from my house. I had planned to give birth at home, because we did not have money for transport. But my husband took the decision and borrowed money so I could go to the clinic [..] If you have money it is good to give birth in the clinic. But you need money for transportation and medicine.” (Delara)
Some women explicitly planned to give birth in the clinic and prepared themselves as best they could: "I got advice from the midwife to give birth in the clinic. We are poor… So, when I was pregnant, I sold a sheep and saved money for the birth of my baby.” (Afrooz)
In spite of being prepared for the economic costs of safe birth care, it is difficult for most women and their communities to prepare for the lack of security during travel to clinics.
Going for safe births on unsecure roads
The insecurity situation in the study area, particularly at night, posed a risk to women who wanted and needed to go to the clinic, as explained by a community midwife: "Every mother should have antenatal care. However, many women don´t come because of the poor security situation” (Paksima, midwife)
Another midwife specified what people were afraid of:
“The most challenging thing is safety. This problem with lack of security is very, very difficult and challenging for us, both for me as a midwife to go to work, and also for the women in labour. When going to the clinic we use the same road as the bombers… we are on the roads where something happens every day… Something… an explosion, a suicide… or something else… It makes moving from one place to another very dangerous and difficult”. (Ramineh, midwife)
The ongoing conflict and insecurity situation in Afghanistan are well known, currently worsening and are an international concern. This pervasive situation reduces the availability of healthcare and limits access to essential health care services in the long-run [23, 25]. This has a secondary impact on health care workers and health care services, as they have become integrated in the conflict. Nevertheless, health care providers continue to provide services and expose themselves to this insecurity [23, 25].
Receiving and valuating midwifery care
The women had different views and experiences of the midwives and midwifery services. Some women had given birth both at home and in a clinic and they could compare the experiences. Some had experienced complicated deliveries at home as well as in the clinic, and this resulted in both positive and negative valuations of expected and received care.
The good experiences with midwives: “… they are like members of the family”
Most women expressed that the midwives in the clinics were knowledgeable, skilled and confident and that they cared for the women patients. "When we come to the clinic the midwives treat us well during labour and childbirth. We feel that they are not like other health professionals…- they are like members of our family!” (Woman, FGD 4)
Although some initially were unsure and sceptical about midwifery services, most women claimed to be satisfied after delivering in the clinics, and after experiencing the midwives’ vital professional competency: "After the delivery I had very serious bleeding. I was very afraid and worried. However, the midwife helped me and gave me medicine. Otherwise I could have died.” (Khandan)
Women expressed genuine gratitude:
“I am really thankful to the midwives, they are really nice and patient, may Allah keep them happy [..]. It is very important and good to give birth in the clinic rather than at home. If a problem happens such as bleeding or the woman collapses, it is treated well in the clinic. At home nothing will be done.” (Maheen)
The fact that the midwives explained about what was happening and why, created trust among the women:
“My last baby was born in the clinic. The midwife assisted me, she was kind and friendly. I had severe bleeding. The midwife said that a few pieces of placenta were left in the womb. She helped me, took the pieces out and stopped the bleeding.” (Bahar)
Moreover, the mothers seemed to appreciate the way their newborns were put in close bodily contact with them after delivery, as well as the prompt initiation of breastfeeding. "The midwife was so kind. She put my baby on my chest after he came out.” (Afrooz)
Another woman explained: “The midwife put my baby on my belly. After two hours I started breastfeeding.” (Bahar)
The midwives in the village clinics were taught and pursued “Baby-friendly environment” guidelines; a program launched by the WHO in 1991 with the aim of improving maternal health care. This includes, for example, immediate skin-to-skin contact and initiation of breastfeeding immediately after birth. These practices seemed to be particularly appreciated by the women, even though there is no tradition for immediate skin-to skin-contact and early breastfeeding in Afghanistan [26, 35]
Midwifery care for the worse: “… she called me a donkey”
In spite of many good experiences in the various communities, a few women shared negative experiences with the midwives and the care received.
“My last childbirth was in the clinic… The midwife assisted me, but she was not a kind woman. I did not feel comfortable. I had bleeding, and she had to send me to the hospital. Giving birth at home is risky… The clinic is better…. However, the midwife was not kind. I did not feel good.” (Farzana)
Some women even felt harassed and intimidated:
"I had severe pain, I was crying, I was moving around, I couldn´t be calm. The midwife became angry and said; “You behave like a donkey, you are not a human being!” [..] Sometimes midwives become so angry with mothers, I don´t know why? [..] I am happy that she helped me, but I feel so sad because she called me a donkey.” (Camila)
Other women explained that the physical environment and conditions in the clinic were additional reasons for not giving birth there. They complained about the poor equipment and about staff’s behaviour.
“I went to the clinic to give birth. In our clinic there are midwives, but no female doctor […] There was no light or fan… They did not turn on the generator…- it was so hot! […] The midwife examined me, and afterwards she went to sleep. When I called for her, she became angry and did not behave well […] They don´t pay attention to the patients.” (Woman, FGD 2)
To understand such poor caring behaviours by midwives, the professionals’ working load, with a poor shift system for the midwives, may be important to mention. Sometimes, they had to work for 24 or 32 hours consecutively. Moreover, it is suggested that some midwives suffer domestic violence in their family because of their work, which also may result in disrespectful care of their patients (personal communication by KS).
In spite of these negative experiences, women expressed that midwifery services were appreciated by many, and that midwifery seemed to be an increasingly valued career path for women in the communities.
Becoming a midwife: a valued professional career
The discussion during the FGDs and during the interviews usually began with talking about the trained midwives operating in the localities. In some of the villages, the midwife was the only educated health care provider in the community, and the profession, as such, represented a rare opportunity for the education and increased status for women. This was discussed during some of the conversations.
“I am really enthusiastic about this education and I wish I could be a midwife in order to help my family and the villagers. But unfortunately, I got engaged during my school period and after marriage my husband didn´t want me to continue my schooling, he didn´t understand the value of education” (Woman, FGD 3)
Some older women expressed how the worth of education had changed over time, as had their own ideas about it.
“Before, we did not allow our children to learn and to get an education, I wanted my children to work in the field instead. Now I know and understand and meet educated people, I see their attitude and value in society. I want my granddaughters to learn and get an education”(Woman, FGD 2)
Another woman said something similar, and intended to involve her husband in promoting their daughter’s education:
“Some people agree about women getting an education. I want my daughter to learn and get an education. I want to ask my husband to allow her to start [in the midwifery program], if not I will make him allow her.” (Woman, FGD 3)
Some even stated the importance of the profession at the national level: “I want my granddaughter to learn and to get [midwifery] education to serve the people of Afghanistan.” (Woman, FGD 3)
Thus, training in midwifery seemed to give some status and recognition and was apparently considered as an important pathway to increasing education for women in the country.