Ensuring high-quality respectful care in a climate of fear & intimidation.

Authors: Arnold, R., van Teijlingen, E., Ryan, K. and Holloway, I.

Start date: 19 June 2017

Background/purpose: To increase skilled attendance and reduce maternal mortality in Afghanistan, more than 4,600 midwives were trained between 2003 and 2014 . Ensuring quality care for women in childbirth, however, remains a more elusive goal. Newly qualified midwives quickly discover that they are unable to care as they have been taught.

Methods: This qualitative ethnographic research explored the culture of care in a Kabul maternity hospital to determine the barriers and facilitators to quality care. The main focus was the experiences, values and perspectives of the midwives, doctors and care assistants. Six weeks of participant observation, 23 interviews with hospital staff, 41 background interviews and 2 focus groups with women in the community were used to gather diverse perspectives on childbirth and care in Kabul maternity hospitals. A thematic analysis was applied and ethical approval was granted in Afghanistan.

Findings: One key finding was that care of women in childbirth was profoundly affected by poor relationships between the healthcare providers. Powerful staff controlled the working environment through fear and intimidation. Horizontal violence and a culture of blame created a toxic working environment. Drawing on observations and quotations from healthcare providers this presentation will explore how hidden interpersonal dynamics undermined the care of perinatal women. The lack of partnership discouraged even highly motivated midwives from using their skills and treating women with kindness and respect.

Application to midwifery practice/education/regulation/policy: High-quality respectful care in facility-based childbirth requires effective teamwork. This study/presentation demonstrates the vital importance of exploring the underlying interpersonal relationships. It suggests that creating trust and partnerships between healthcare providers is vital to enable midwives to make a difference.

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