Influence of cultural beliefs and practices on unassisted homebirths in Afghanistan: A qualitative exploration

Unassisted homebirths persist in Afghanistan, accounting for approximately one-third of all births. Despite efforts to increase skilled birth attendance, unassisted homebirths remain high, especially in rural and conservative areas. This study explores the cultural beliefs and practices that influence unassisted homebirths, aiming to inform culturally sensitive skilled birth care. A qualitative case study approach was employed, focusing on Afghan refugees resettled in Canada. Data were collected between September 20 and October 3, 2022, through in-depth interviews with women who had experienced at least one unassisted homebirth in Afghanistan, as well as focus group discussions with separate groups of men and women. In these discussions, participants shared their experiences and observations of unassisted homebirths and skilled birth care facilities in their communities. The data were transcribed and then thematically analyzed using Atlas.ti. Findings revealed three main themes: positive, existential, and negative cultural influences. Positive influences, such as husbands' education and women's concerns about complications associated with unassisted homebirths, motivated some women to seek skilled care. Existential factors, including preparations for childbirth, seeking divine protection, the practices of Dayas (traditional birth attendants), and traditional diets and remedies, represented neutral cultural practices shaping homebirth experiences. Negative influences, such as perceptions of facility births as disgraceful, reliance on family elders' decisions, and traditional norms favoring homebirths, significantly hindered access to skilled care. Unique cases, including secretive homebirths driven by traditions like women's veiling and seclusion within families, as well as delays in dowries, underscore the sociocultural complexities surrounding unassisted homebirths. The findings underscore the need for culturally sensitive health interventions that respect traditional practices while promoting skilled birth attendance. Engaging elder family members in health initiatives, integrating dayas into the healthcare system, and incentivizing community midwives to provide home-based skilled care could help shift perceptions and improve maternal health outcomes in Afghanistan.