Journal of Women's Health Care
Open Access

Contraceptive Methods, Maternal and Neonatal Mortality in Afghanistan: Based on the Interview

Marika Merits^1*, Kaire Sildver¹, Irena Bartels² and Sandra Tamme^{3 *}Correspondence: Marika Merits, Midwifery Department, Tallinn Health Care College, Estonia, Tel: +372 6711 731, Email:

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Introduction

It is estimated that globally 222 million women in developing countries would like to delay or stop childbearing but do not use any methods of contraception. The main reasons for this disparity include limited choice of methods, limited access to contraception, fear or experience of side effects, cultural or religious opposition, poor quality of available services, and gender-based barriers [1]. Over 200 million women in developing countries do not desire pregnancies and they fail to use modern contraceptive methods, which is a high risk for a woman’s health [2]. Maternal mortality in the world is unacceptably high. About 830 women die from pregnancy or childbirth related complications around the world every day. The high number of maternal deaths in some areas of the world reflects inequities in access to health services, and highlights the gap between the rich and the poor. Almost all maternal deaths (99%) occur in developing countries [3]. The neonatal period represents the most vulnerable time for a child’s survival. In 2016, 2.6 million deaths, or roughly 46% of all under-five deaths, occur during this period. This translates to 7000 newborn deaths every day [4,5]. Afghan women’s health indicators vary significantly from global standards. Afghanistan’s maternal mortality rate is one of the highest in the world. By 2015, the maternal mortality rate had reduced to 396 deaths per 100,000 live births [6]. Neonatal mortality was 46 deaths per 1,000 live births in 2016 [7]. Increasing the availability of contraceptive methods and developing high-quality maternity care would prevent one of the three mothers or newborns from dying [8]. Afghanistan still has the lowest contraceptive prevalence rate compared to other countries in the region. This low rate of contraception is also one of the leading causes of Afghanistan’s fertility rate (5.2 per women) the highest in southern Asia [5]. The decades of conflict and political instability in Afghanistan have devastated the state’s health and education system, which has left a mark on maternity care and also limits the possibilities of learning as a midwife. Healthcare services, especially midwifery service, are limited and/or difficult to access. The countdown 2015 report for Afghanistan indicates that the number of midwives is 211 to 3,333 women [9]. All factors mentioned above affect higher maternal and neonatal mortality. Nine midwives and/or teachers of midwifery from Afghanistan were in Estonia from May 2015 to June 2015 under the development cooperation project “Improving Quality of Medical and Info-technological education in North and East Afghanistan in the provinces of Herat, Balkh, Nangarhar and Faryab in Afghanistan 2014- 2016”. They took part in continuing professional training organized by the Department of Midwifery of Tallinn Health Care College to improve their professional knowledge and information technology skills. The partners of the project are NGO Mondo and Ministry of Foreign Affairs of the Republic of Estonia; the supporters of the project are Estonia’s Development Cooperation and the European Union [10,11]. Under the project mentioned above, it was necessary to research more precisely, which contraceptive methods are used in Afghanistan and which influencing factors affect the maternal and neonatal mortality rates. Accordingly, it was possible to plan and organize the content quality of the training. The Afghan midwives were educated about contemporary professional theoretical and practical skills, which covered pregnancy and delivery period and postpartum period, counseling in reproductive health, including family planning, newborn care, women’s rights and digital technology within the training. Midwifery education is a key solution in a challenge of providing universal and quality maternal and newborn care, also family planning [12].

Methods

The research method is qualitative. The study was conducted by using the semi-structured interviews. The interview was on a voluntary basis and safe for the participants. The permission for the study was applied from Council of Ethics Committee of Tallinn Health Care College. The aim of the study, the tasks, the process of the interviewing, approximate length and benefits of the study were introduced to the participants. At the same time it was explained that the process of interviewing is recorded on a tape and the results will be presented anonymously as general data. The participants confirmed their agreement with a signature. The process of interviewing was recorded on a tape, which was deleted after the analysis and the process of transcription. The answers of the participants were written as authentic as possible during the transcription without changing their statements. The transcription is universally essential step in scientific research that allows a detailed analysis and interpretation of the different nuances of video recordings and audio recordings. International Code of Ethics for Midwives is followed and respected, the current study relies upon its provision that the midwife takes care of the women and their families and respects their cultural differences and beliefs [13]. The participants were nine Afghan midwives and/or teachers of midwifery that were in Estonia under the development cooperation project “Improving Quality of Medical and Info-technological education in North and East Afghanistan in the provinces of Herat, Balkh, Nangarhar and Faryab in Afghanistan 2014-2016”. The participants took part in continuing professional training organized by the Department of Midwifery of Tallinn Health Care College from May to July 2015. The interviewing of midwives was carried out in a private and secure room in the form of consecutive focus group interviews. There were three focus groups, three midwives in each of them. The interviews were conducted within the time period May 22^nd 2015 until May 26^th 2015. The interview of each focus group lasted for 1.5 hours average. The current study uses a semi-structured interview as a method of interviewing, which general structure and questions have been compiled before the beginning of the interview, and that allowed getting both, detailed answers and specified answers from the participants. The questionnaire consisted of questions which were divided into themes: contraceptive methods, maternal mortality and neonatal mortality (Table 1). Thematic analysis is used within the study to find out the meanings, viewpoints and understandings that lie in themes, which the participants explain, describe or consider important. The credibility and stringency is ensured in a way that the transcription was processed as detailed as possible taking into account the verbal and non-verbal indications, the statements of the participants were not manipulated, and these are presented in an authentic way. Also, the participants were not guided in any other way or influenced with the purpose of any profit.

Table 1: The plan of interview.

Results

Contraceptive methods in Afghanistan

How many children are usually in the Afghan family?

While answering the questions the participants proposed that the number of children could be 4-10 or more. However, it was considered that the average number of children per family is 4-8. The participants explained the lower number of children resulting from the higher education of the parents, especially the education of the father. Two of the participants advise the women to plan fewer children due to financial matters. High number of children in a family was justified several times as resulting from long-term family or historical traditions.

Here are the examples of interview transcriptions:

X1: In case of many children, they are not able to support them. They cannot think about educating them. Some of them are poor and cannot afford buying a lot for the children, they are hungry and cannot even attend school. They simply say that 4 or 5 children are enough, because one has to think about their education, health, future and financial welfare.

X2: Life is good in case there will be no more children. If you will have more children and cannot support all of your family, then it is neither good for you nor for your children.

X3: I think there are typically 5 or 6 but some people only have 4. Some have 6, 9, 10 or more. Before there used to be more but now people are more educated and that is why they have less children.

X4: There have always been many children in families in Afghanistan, it has belonged under our traditions.

X5: Yeees (demonstrates the size expansively with a hand), it is a family tradition that is forwarded from generation to generation and changes are not easy to come. It is not a health issue at all, it is local, a local tradition. Health is not a topic here at all. Unfortunately.

To explain higher number of children, it was mentioned that a boy was expected to be born in a family that had before that had girls only, and living in the rural areas.

Here are the examples of interview transcriptions:

X1: No, the more educated ones want less … and some women- Yes, maybe 5. Then they say that this is enough 4 or 5, but after the 10th they do not want because the gender of the baby is important to themthey want a boy. That is why they wish to get pregnant, and in case they give birth to a baby girl, they want to get pregnant again, and so there will be 10. Giving birth to a baby boy is always preferred in the family, and it is a wish, even a demand of husbands.

X2: 7 or 8, because some families are living in a village and they have more than 10 children. I think that the average then is 7 or 8.

What is the children’s gender preference, is it a boy or a girl? Why is it so?

All participants answered that predominantly the birth of a boy is preferred in Afghanistan. In case a woman does not give birth to boys, the husband may leave the wife or marry up to three additional women. It was pointed out as a reason that when a boy grows up, he will stay at home and takes care of the family, whereas a girl moves to the family of her husband when getting married. Sons in Afghanistan are as if guarantee ensuring the ongoing well-being and stability of the family.

Here is the example of interview transcription:

X1: Yes, when I married my husband, I did not have a baby boy. Two baby girls were born. He left me and married another woman. It is determined that way in our culture.

It was added that before the birth of a baby it is prayed to be a boy. X1 and X7 expressed same attitude, that when a woman is expecting a boy, she can rest more during pregnancy. After giving birth, the family support and help more the woman that has given birth to a boy. The woman having a baby girl has to return to her duties earlier and cannot take care of her health, which is dangerous. Definitely, the sequential pregnancies of the woman and frequent deliveries are risk factors for her health.

Here are the examples of interview transcriptions:

X1: And also, when they know that the baby is coming, they simply pray and thank their god. These women that gave birth to a girl, have to work at home normally a week after the delivery already, they cannot rest any longer.

X2: They pray it to be a boy, yes! Of course! And some patients come and give birth to a girl and then they simply cry.

X3: Especially in the case a woman has a baby boy. All members of the family would like to take care of her. They help a woman, so that the woman could sleep, and they give her good food and other things. But it is different in case of a boy or a girl. Birth of a baby boy is celebrated in a greater way in families.

What are the methods of contraception in the family? Midwife’s recommendations or advice on family planning.

All participants mentioned different modern methods of contraception. According to them in Afghanistan there are available and possible to use hormonal oral pills (mini pills and combined pills), birth control implants, hormone injections, intra-uterine contraceptives and condoms. There are several factors having an influence on the availability and use of contraceptives. Contraceptives are openly available in pharmacies e.g., but so called “counselors” there are men that might not have necessary competence for current topic. Women go there in case the husband agrees and comes along with the woman. Men usually express their opposition because they are mostly against using contraceptives or are afraid of their side effects. There are not many gynecologists and in case the doctor is a male, the woman cannot go there without a permission of her husband. The midwife can counsel about all contraceptives but for instance intrauterine devices and hormone injections belong to the field of the doctor. Midwife’s skill to counsel is also a very important factor. There is a lack contraceptives and counseling related to that in the countryside. Cost of contraceptives if high in Afghanistan, and many families lack of financial matters for buying them, especially in rural areas. There are many different factors hindering receiving contraceptives and/or their use.

Here are the examples of interview transcription:

X1, X2, X3, X4: They use pills, also injections, implants and condoms and intra-uterine contraceptive. We have two types of pills. The mini pills and the others are combined pills.

X5, X6: All contraceptives are available in drug stores and one has to buy them. But there are male clerks that do not know how to counsel the details. And think about if they give wrong advice, how to use contraceptives. Women cannot go there without a husband and a husband must agree. Like a circle that never ends.

X7: Contraceptive is not being used in the countryside a lot, they are expensive and the family has no money. And husbands and mothers-in-law are against it.

X8: The number of people that use methods of contraception is very low. The some people use for that is very low. They do not use because of cultural and other problems. Maybe some 10-20% of the population is using.

X9: And can you imagine the situation, the gynaecologist is a man and then a woman cannot go there without permission from their husband. But intrauterine devices and hormone injections are applied by a doctor. We are not allowed to do everything here. We, midwives, can counsel more about how to use the pills.

X10: Exactly, our hands are short, although we know that using contraceptives were useful for the health of a woman. They can have a rest from sequential pregnancies and deliveries. Even just a bit.

X2, X6: And sometimes we still do not know how to counsel immediately (several talk at the same time). Women understand differently. It is very difficult to communicate with some. Counseling is yes (X2 simply gestures with hands for too bad) we do ourselves, we have to learn more ourselves.

The participants say that men (husbands) are the main obstacle when planning a family because they do not allow using contraceptives. Reluctance is justified by religious or cultural considerations. The participants highlighted that in many cases the husbands do not know the variety of contraceptives, or how to use them or side effects are being afraid of. Socio cultural and religious beliefs and/or normative are one of the main obstacles when it comes to using contraceptives.

Here are examples of interview transcription:

X1: Some of them are for contraceptive, but the ones that have many girls, they do not want. The ones that have a boy, they are for. It depends on a family. Also about awareness, which contraceptives are there, or how to use them.

X2: Yes, if we recommend family planning for some women, then she says that “My husband does not believe in that a lot and he may beat me. I cannot do that”. And the midwife that advised it to the family, may also face violence because they say that you recommended the woman to do bad things.

X3: And once more, it is not easy for the midwife to counsel the woman and her family, if there is an opposition like that.

X4: Their family did not allow giving them pills because people in Afghanistan believe that children are a gift from Allah that cannot be rejected.

According to the participants, the abortion is forbidden in the country but is still practised under the table.

Here is an example of interview transcription:

X5, X6, X7, X8: Some doctors still do them, but should the government find out about it, they can arrest the doctor.

Maternal and neonatal mortality in Afghanistan

The place of childbirth (hospital, home)? Who is present at home birth (mother, husband, midwife)?

According to the participants the women living in the rural areas give birth mostly at home and the women in urban areas at hospital. They come to give birth to the hospital from the villages in case, there is transportation and a journey is safe. Safety is still a major issue in Afghanistan, because there are still military activities in many areas, or other conflict situations. Resulting from that the health of women is endangered, and safety of the midwives is not ensured, too. There is a lack of midwives in rural areas and midwives from urban areas do not want to provide their services in rural areas, the main reason for that is the safety issue.

Here are examples of interview transcription:

X1: Now, all the midwives have told the women that giving birth at home is very dangerous, which is the reason the women come to the hospital.

X2: Yes. Nowadays, more women come to the hospital, especially in a town. But there are different situations in the village. If a woman has no problems with transportation or safety, she comes to the hospital. They give birth at home in case of bad economic situation or a dangerous journey.

X3: You know, unfortunately we have some obstacles, with safety. Most parts of Afghanistan; there they have no access to doctors, hospitals, clinics, nurses and to midwives, too. So the first obstacle is safety. Second obstacle is that most doctors, nurses- it is good for them to go to cities, they do not want to go to rural areas.

X4: Unfortunately the midwives have to think about their safety, too. You cannot go to the countryside to conduct the deliveries if the trip is dangerous. The country should ensure our safety. There are still enough midwives in towns, (pause), but in the countryside (expresses with hands a gesture of too bad)…..well that is a problem, a big problem.

At home childbirth is assisted by women close to the family and if possible, the traditional birth attendants.

Here are the examples of interview transcription:

X1: They cannot go to the hospital in villages therefore they give birth at home. Childbirth is then assisted by their relatives because some areas are not safe, therefore we cannot go, too. We usually recommend them to come to the hospital.

X2: Their members of family participate in childbirth, grandmother, mother-in-law and a traditional birth attendant. It is always related to great danger because in case something happens to the woman, there is no help available.

X3: And although some older women are experienced with conducting the delivery, it does not replace the midwife. Think yourself, bleedings, any other complications, this is so dangerous.

X4: Giving birth at home is dangerous, if something happens, there is no help available. And so these mothers and children die.

Unassisted childbirth at home is a preferred option in rural areas because there are no hospitals nor midwives nearby. The midwives, nurses and doctors work in urban areas because of their own safety, better living conditions and higher income. Unstable situation in the country causes the situation, where it is complicated for the midwives to go to attend home births, which is not safe for both parties. The women choose home as a place of giving birth for safety reasons by risking at the same time with the health of themselves and of the unborn baby. Midwives, despite of their desire to help choose better living environment for the provision of midwifery services in urban areas. Midwives emphasize that giving birth at home is one of the reasons of maternal and neonatal mortality.

What is the nature of midwifery care for a woman?

There is very often lack of space in hospitals. There are many women in labor. There are 5-10 women at the same time in delivery rooms, sometimes more. In order to offset the lack of capacity and to ease the work of the midwives only the so called classical childbirth position is allowed to use during the expulsion phase of the women. During the dilation phase the woman in labor is free to move at hospital, too. The interviewees confirm that although the only position for expelling the fetus is lying on their back on childbirth table or in bed, then in dilation phase changing positions is accepted and even recommended. At home a woman can decide herself, which childbirth position to use.

Here are the examples of interview transcription:

X1: When in delivery pains, they move, they choose different positions, where she is relaxed and at the end of the delivery they sit and are on their backs and give birth. And at the hospital they simply- If they come to the delivery room from another room... they simply have to be in one position only. They cannot change it because she only has one bed and she has to (Demonstrates using a hand lying down horizontally). And the midwife is not able to assist everyone at the same time.

X2: At home a woman always chooses.

X3: If any woman gives birth at home with her mother-in-law. She sits, she sits and in front of her... like that (Demonstrates a position as if giving birth by crouching or on a footstool). They lie on their backs at hospital.

What is the nature of maternal care after the childbirth?

According to the interviewees the working mother can be on an official leave after the childbirth for 3-4 months in Afghanistan and she can have a rest of housework for 5-40 days, depending on the gender of the baby, economic situation of the family and on their level of education. The interviewees highlighted that they invite women to the hospital for postpartum examination at midwife´s but mostly women prefer not to come, which is the reason for higher risk for the onset of postpartum complications.

Here are the examples of interview transcription:

X1, X2: It is allowed by the government for the working women to take a holiday for three months, either before or after the childbirth. In private sector it is allowed to rest for 4 months.

X3, X4: For example in the educated families the women only sleep and do not do any other chores for 42 days. In poor families they do everything already 2-3 days after the childbirth.

X5: They have to rest with the baby and some women- again it depends on the family. In some families they only rest for 5-10 days and after that they have to return to their work and duties. In some families they can rest maybe for 40 days. Also the problem is that mothers of the baby boys can have a longer rest than the mothers of the baby girls.

X6, X7: We recommend the women to come to the hospital during the postpartum period for examination to find out if there are any complications, can be helped. It happens rarely when they come, it is a pity. We actually give advice, how to recover in a better way or how to take care of the newborn in a proper way.

X8: Unfortunately yes, it is not a routine activity. We can only counsel the ones that come to us.

X9, X10: Complications may occur that women do not come. Well, there are different reasons for that.

Mostly female members of the family: a mother, a mother-in-law, a sister help the neonatal woman with household work, taking care of the new-born and with bathroom assistance.

Here is an example of interview transcription:

X1, X2: Mostly, a mother-in-law takes care of the women, and in case their relationship is bad, the mother or a sister of a woman comes and helps.

During postpartum period, if the woman gives birth in a healthcare institution, the woman is being counseled after the childbirth on various topics, such as postpartum recovery and threats during postpartum period, also on newborn care. It is not quite clear whether the counseling is a routine or random activity. In the villages traditional birth attendants and elder female relatives counsel and help new mothers. It is not resulted from the interviews what is the time period spent in hospitals during postpartum period under the observation of midwives and what is the time period the traditional birth attendants observe the woman after the childbirth.

Here are the examples of interview transcription:

X1: Yes, as you asked before. Of course, we counsel women during postpartum period and in different issues. But only a few come back. We can only counsel immediately after the delivery. Although we again advise women to visit the midwife some time later. Everything does not occur immediately. Isn’t it like that? (Looks at other interviewees doubting and they nod as a sign of agreement).

X2: After childbirth I always try to help and talk a lot. To the mother how to hold a baby, about threats after childbirth and about bleeding and infections and vaccination and breastfeeding and from the vaccination and... until sex. When she came and when she had stayed in the clinic.

X3, X4: In rural areas, in villages either the mother-in-law or a traditional birth attendant or the relatives take care of the woman. But it is always dangerous; they do not have means, skills. And a woman may die. Even from bleeding or any other dangerous problem. It is a big problem in Afghanistan all the time. The maternal mortality rate is high.

What is the nature of neonatal care of the newborn?

The interviewees highlighted that they always explain the mother, the family that it is important to start with breastfeeding as soon as possible after the childbirth. Despite of the prior, the awareness of early breastfeeding and the importance of colostrum are modest. The colostrum is considered dirty in families of Afghanistan, and not suitable for feeding the baby with it mostly because of its color. The colostrum is pumped out and thrown away. The newborn is fed with powdered milk, milk of domestic animals or with glucose for about three days. Attention was paid to the wrong nutrition of the mother, too.

Here are the examples of interview transcription:

X1: It is different. Sometimes at hospitals and health centers, because there the midwives counsel and inform them about healthcare topics, especially about breastfeeding, then they start immediately after childbirth in an hour after the childbirth. And at home they do not breastfeed for three days because they think the first milk is dirty and it is not good for the baby’s health.

X2: Sometimes they think in the village that first milk in breasts is not pure for the baby. All midwives have told the first milk is the most important milk in breasts. They put it into the glass and lift to another place (Laughter).

X3: I always tell them, do not do that, please. Because first milk, it is like a vaccine for the child. But they do not like this first milk.

X4: They give powder milk or milk from animals. Like cows or other animals, which they use. But now, since we did more and we have raised the awareness of people, that they should not give them other milk. And it is still a problem.

X5: Glucose. They give glucose.

X6: But mothers themselves eat wrong things, they eat traditional food, but it is not useful concerning health. But it is not talked a lot about. I have tried to counsel about the nutrition of the mother but it is as if a voice crying in a desert.

How long is the child breastfed?

They are breastfeeding about two years on average. Two years in case of girls and two and a half years in case of a boy. If a breastfeeding mother becomes pregnant during two years, the breastfeeding is stopped immediately. Children of working mothers get either powdered milk or milk of domestic animals when the mothers are away.

Here are the examples of interview transcription:

X1: When they go to the clinic, then the doctors or midwives always tell them that they should breastfeed the child up to two years. And mother always breastfeed their children for two years or more than a year and it is common.

X2: After childbirth? Two years. If it is a boy, then two and a half, if it is a girl, then two years or little less.

X3: If mothers do not become pregnant again, they will continue for two years. If she becomes pregnant, then they stop as soon as possible, they stop breastfeeding.

X4: If they go to work, it is a 50% job. Then they get powdered milk once or twice a day and after that breast milk. And if they work fulltime, then they have to extend this time when a child is given powdered milk.

In case of childbirth at hospital the midwife tells the woman in addition to breastfeeding about vaccination and newborn care. Knowledge about newborn care, especially after home births, is modest, related to prejudice, and carry various risks to the health of the newborn. Midwives explain the importance of different activities or threats when taking care of the newborn but in many cases it is not taken into account.

Here are examples of interview transcription:

X1: After childbirth I always try to help and tell about many things. How to hold the baby, to wash them properly, put on clothes and you know… all that.

X2, X3: And it is all discussed, but there are still many problems. For example, in case of home births they want to wash the baby immediately … well, with water. It is not good, the baby has not adapted to, yet.

X4: We teach navel care, skin care but it is not always taken into account. The worst is yes, if they want to bathe a baby immediately after being born. The baby is not yet adopted with the external environment. Many problems… (shakes her head). Just in the countryside.

X5: It is enough if to wipe the baby properly and dry and put on clothes. But they do not do that and the condition of the newborn may worsen. They think without it the baby is dirty.

X6: And when the newborn falls ill, there is no help available in the village. And they simply die.

Which other factors would you like to highlight having an influence on the health of the newborn?

X1: Well, there are many yes. Children fall ill, and then they do not know how to help them at home. It is necessary to go to the doctor’s or invite the doctor at home. But it is a problem again. Professional help is not available. Not always.

X2: Infections, different infections.

X3: Newborns weigh so little and there are many preemies, this is a separate topic. It is one of the reasons for their mortality.

X4: Fever, cold, cough, it is often the problem. And …preemies are weak and die.

X5: Diarrhea, viral infections. All these are dangerous for the infant and need either the advice of the doctor or a midwife. Mothers cure them on their own, using so called traditional methods, but there are definitely medications needed or to come to the hospital.

X6: Well, we have here many reasons for neonatal mortality, definitely infections.

The interviewees name factors, which influence the health of the newborn and/or reasons for their mortality, such factors are infections, prematurity of the newborns and low birth weight, and also lack of professional help available.

Discussion

The midwives participated in the current study consider the number of children in the Afghan families from 4 to 10 or even more. On average, the number of children is considered from 4 to 8 though. The interviewees explain the lower number of children with higher level of education of the parents. As the explanation for higher number of children, expecting a boy to the family, which had so far had girls only, and living in rural areas were mentioned. In Afghanistan a woman gives birth to 6.6 children on average [14]. Also, it is confirmed that there is a connection between the number of children and the level of education in Afghanistan, fertility rate is higher among illiterate women than among educated women [15]. All midwives that participated in the current study shared opinion that the birth of a boy is preferred in Afghanistan. It was mentioned as a reason that the son stays at parents´ home as a grown-up and takes care of the welfare of the family. Several sources also confirm that traditionally the sons stay and live in their parents’ home in Afghanistan, and the higher number of sons in the family is related to better financial future [16,17]. The midwives that participated in current study highlighted that more care and rest is allowed to the woman after giving birth to a son during postpartum period. According to the interviewees the husbands put more pressure on women to have sons. There are several modern methods of contraceptives available in Afghanistan: hormonal oral pills, birth control implants, hormone injections, intra-uterine contraceptives and male condoms [8]. There are many factors, which have an influence on the availability and the use of contraceptives. Contraceptives are available in pharmacies but mostly male pharmacists are working there, who in the opinion of the interviewees do not have enough competence in the current field. The women visit the pharmacy in case the husband gives his permission and/or comes along with the woman. Usually men do not give their permission because they find using contraceptives unnecessary, they prefer higher number of children in the family or they are afraid of harmful side effects of the contraceptives. In Afghanistan, the midwife is allowed to counsel about all different contraceptives but inserting intrauterine devices and hormone injections belong to the field of the doctor. Gynaecologists are mostly male, and in case a woman would like to visit a male doctor, she needs permission from her husband and/or the husband participates at the doctor’s appointment with the wife. Counseling skills of the midwife is also a very important factor, several midwives highlighted that their skills on counseling about contraceptives could be better. Contraceptives and related counseling is not available a lot in rural areas. The cost of contraceptives is high in Afghanistan and many families do not have enough financial matters for buying them, especially in rural areas. The maternal and neonatal mortality rate could be reduced by the informed use of contraceptives while family planning. The midwives participated in the current study confirm that various methods of contraceptives are available but men (husbands) form the main obstacle on family planning, that they do not allow to use birth control. Religious and/or cultural misconceptions are used as an explanation for the reluctance. The respondents highlighted that the abortion is forbidden in the country by law but it is practiced illegally. Therefore, there are many various factors hindering receiving contraceptives and/or using them and they have an influence on high maternal and neonatal mortality rate. National Family Planning Behavioral Study on the use and Non-use of contraceptives in Afghanistan also highlights several factors that hinder more successful use of contraceptives and are obstacles while family planning, having a direct influence on maternal and neonatal mortality: self-efficacy perception, perceived religious norms and values, perceived social and economic value attached to childbearing, life experiences and beliefs of close family members, knowledge about methods, perceived side effects, addressing difference in views between husband and wife, provider skills as a barrier to accessing specific methods, education and counseling on family planning methods etc. [18]. Several factors mentioned above were confirmed in the current research, in which the interviewees repeatedly mentioned them. Complicated conditions and lack of transportation are major obstacles for visiting healthcare institutions [19,20]. The participants of the study confirmed that the women living in rural areas in Afghanistan mostly give birth at home and the women living in urban areas at hospital. If they have means of transportation and the journey is safe, then they come to give birth from the villages. Safety is still a major problem in Afghanistan. Homebirth carries high risk for the occurrence of complicated situations both during the delivery and after the delivery. There is lack of space in hospitals; there are many women in labor at the same time. There are 5-10 women in the delivery rooms at the same time, sometimes even more. A classical position is allowed to use by midwives as a childbirth position, which is explained as most comfortable for the midwife (birth attendant). When giving birth at home, it is the woman that chooses her position; a close elder female relative is mostly at childbirth and counsels the woman given birth also during postpartum period. During postpartum period, in case the woman gives birth in a healthcare institution, the participants say that the midwives counsel the new mother on various topics, such as postpartum recovery and threats during postpartum period, also on newborn care. It is not quite clear and stays a bottleneck whether counseling is a routine or random activity. The interviewees emphasized that they have invited the women repeatedly to the midwife’s appointment to the hospital during the postpartum period but mostly the women prefer not to come, which causes the higher risk for the onset of postpartum complications. According to the participants the children are being breastfed in Afghanistan for 2 years. Several participants highlighted that the colostrum is considered dirty and harmful to the newborn, which is the reason why the newborn is given rather artificial food, cow milk or glucose during their first days of life. According to the references from various authors 53.6% of the women in Afghanistan breastfeed during the first hour of life. The reason for that is insufficient information about the importance of breastfeeding and cultural beliefs and customs [21,22]. There is a widespread misunderstanding that colostrum smells, looks repulsive and it should be thrown away. It was also mentioned that washing a newborn immediately after being born is a harmful activity. The interviewees mentioned several activities, which are important but which are often not followed, such as umbilical care, skin care, vaccination, care or treatment of a sick child. The factors that especially have an influence on the health of the newborn and/ or reasons for mortality were named by the interviewees, such as infections, prematurity of the newborns and low birth weight, also lack of availability of professional help and uneven availability, especially in rural areas. Several other sources confirm similar reasons for maternal and neonatal mortality rate [9,23].

Conclusion

There are several factors hindering the use of contraceptives and family planning in Afghanistan, such as family and societal religious norms and values; fear and ignorance of side effects, lacking counseling skills of the midwives and lack of female doctors, also high cost of contraceptives. Abortions are officially forbidden but still practiced illegally. There are many children in the families and sequential pregnancies and frequent deliveries cause high risk for maternal and neonatal mortality. There is a well-established misconception that delivery of a boy ensures the well-being and success of the family. The women living in towns and urban areas give birth at hospital, where there are many women in labor in the same hospital room at the same time. The women in the countryside give birth at home, where they are assisted by female relatives or traditional birth attendant. Giving birth at home carries high risk, because in case of complications there are no professional help available, and it is one of the reasons for maternal mortality. The women are invited to the hospital to the midwife’s appointment during postpartum period but mostly the women prefer not to come, which causes higher risk for the onset of postpartum complications. The midwives teach proper nursing and care of the newborn but several misconceptions cause a serious threat to the health of the newborn- colostrum is considered as dirty and it is thrown away, children are fed with artificial food or with glucose, also it is advised to bathe the newborn immediately after the birth, which carries high risk for the health of the newborn. As reasons for neonatal mortality, prematurity, low birth weight, problems in baby care and infections are mentioned. Midwifery care is unevenly available in Afghanistan, services of midwives are available in urban areas but midwifes refuse to go the rural areas because it is not safe due to unstable situation in the country. Women from the rural areas cannot access the towns for the same reason or the financial matters of the family are insufficient. Healthcare in Afghanistan is overall uneven and needs systematic rearrangements. The training of midwives should be supported nationally and to improve it to ensure the even availability and quality of midwifery care. The measures mentioned help to alleviate the problems related to family planning and to decrease the maternal and neonatal mortality rate. Afghan midwives require modern and evidence-based training what is based on accepted guidelines, medical and info-technological education. Tallinn Health Care College will continue to improve medical and info-technological education training of Afghan midwives, by teaching the target group contemporary professional theoretical and practical skills, which covered pregnancy and delivery period and postpartum period, counseling about reproductive health, incl. family planning, newborn care, women´s rights and digital technology.

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