Healthcare providers and the challenge of evidence-based decision-making.

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

Start date: 23 May 2017

Background: The Afghan Ministry of Public Health (MoPH) and international partners have employed various successful strategies to reduce Afghan maternal mortality and morbidity (Akseer et al.). Multiple skill-based training programmes in particular have addressed the lack of female healthcare providers and increased the proportion of skilled birth attendance. Ensuring that training translates into high quality respectful care and kindness towards women in facility-based childbirth is, however, a more complex issue.

Objectives: To analyse the culture of care and identify the barriers and facilitators to quality care in a Kabul maternity hospital and explore the experiences and perspectives of healthcare providers on their role and care in the hospital.

Methods: This qualitative ethnographic study consisted of six weeks of participant observation, 23 semi-structured interviews with hospital doctors, midwives and kholas, 41 background interviews, 4 informal group discussions with staff and 2 focus group discussions with women in the community. Thematic analysis was used to analyse data. Ethical approval was granted by the Afghan MoPH Institutional Review Board and Bournemouth University, UK.

Results: Despite knowing how to provide quality care, many staff said that it was not possible to care like they were taught in their current working environment. Fear of colleagues, pressures from senior managers or family and exhaustion from the workload all influenced their decisions and behaviours towards women in childbirth. Motivated doctors and midwives shared interesting ideas for improving care but acknowledged their lack of power and authority to make changes.

Conclusion & Recommendations: The MoPH has a crucial role in facilitating and supporting positive change in Kabul hospitals. ‘Evidence-based policies’ can only become ‘evidence-based decision-making’ through their leadership and support. Doctors and midwives depend on hospital managers and the MoPH to facilitate their work, to monitor, listen, encourage, act with force where needed, and demonstrate fairness, impartiality and integrity in decision-making.

Akseer, N., Salehi, A. S., Hossain, S. M., et al. 2016. Achieving maternal and child health gains in Afghanistan: a Countdown to 2015 country case study. The Lancet Global Health, 4 (6), e395-e413.

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