Villains or victims? The role of maternity staff in decreasing or enhancing respectful care

Afghanistan has one of the highest rates in the world of maternal mortality despite nearly two decades of effort to train more skilled providers and make maternity care more accessible. One contributing factor to this may be the quality and respectfulness of care provided. In this blog post, the authors of a newly published qualitative study in BMC Pregnancy and Childbirth discuss the contributions of healthcare providers to respectful maternity care and positive outcomes in light of narratives that depict them as either the ‘villains’ or the ‘victims’ of the system.

The challenge of high-quality respectful care

Worldwide, many childbearing women have little opportunity to make autonomous childbirth decisions themselves and experience poor care. This relates to the general status of women in society, and more specifically to the failure of maternity services to produce optimal and dignified care for all. The latter is an issue reported in high-income countries as well as low- and middle-income countries, including Afghanistan.

Healthcare providers are the vital link between evidence-based policies and women receiving high-quality respectful maternity care. Explanations in the literature for suboptimal care often include poor working conditions for staff and a lack of essential supplies. Other explanations suggest that doctors, midwives and care assistants might lack vital skills or be unaware of the rights of the women for whom they care.

What we did

Our study examined the everyday lives of maternal healthcare providers working in a tertiary maternity hospital in Kabul, Afghanistan, between 2010 and 2012. The aim was to understand the staff’s notions of care, their varying levels of commitment to providing care for women in childbirth, and the obstacles and dilemmas that affected standards, and thereby gain insight into their contributions to respectful maternity care, whether as ‘villains’ or as ‘victims.’

credit: author

We employed an ethnographic approach to qualitatively explore the culture of care. Dr. Arnold spent six weeks observing care and interacting with staff. She then conducted 23 semi-structured interviews with doctors, midwives and care assistants, as well as 41 background interviews. In addition, focus groups were held with two diverse groups of women in community settings to understand their experiences and how they wished to be cared for.

What we found

The key findings of this paper are that women related many instances of neglect, verbal abuse and demands for bribes from staff. Doctors and midwives concurred that they did not provide care as they had been taught and blamed the workload, lack of a shift system, insufficient supplies, and inadequate support from management. Closer inspection revealed a complex reality where care was impeded by low levels of supplies and medicines, caused by supply shortages and further reduced by theft; where some staff were unfairly blamed by management but others flouted rules with impunity; and where motivated staff tried hard to work well but, when overwhelmed with the workload, admitted that they lost patience and shouted at women in childbirth. In addition, there were extreme examples of both abusive and vulnerable staff.


We conclude that providing respectful, quality maternity care for women in Afghanistan requires multifaceted initiatives because the factors leading to suboptimal care or mistreatment are complex and interrelated. Standards need to be enforced and abusive practices need to be confronted in order to provide a supportive, facilitating environment for both staff and birthing women. Polarized perspectives such as ‘villain’ or ‘victim’ are unhelpful as they exclude the complex realities of human behavior and consequently limit the scope of problem solving.

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