“It’s Different Here” Afghan Refugee Maternal Health Experiences in the United States

“It’s Different Here” Afghan Refugee Maternal Health Experiences in the United States | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “It’s Different Here” Afghan Refugee Maternal Health Experiences in the United States Heidi Worabo, Fatima Safi, Sara Gill, Moshtagh Farokhi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4193621/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Jul, 2024 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 12 You are reading this latest preprint version Abstract Background: The number of Afghan families in the U.S. has grown over the past two decades, yet there is a paucity of research focused on their healthcare experiences. Afghan families have one of the highest fertility rates in the world and typically have large families. As the U.S. faces rising maternal mortality rates, it is crucial to understand factors that affect health outcomes for culturally distinct groups. We aimed to better understand Afghan women’s experiences of giving birth in the U.S. and to identify protective and risk factors that affect Afghan women’s reproductive health. Methods: Twenty Afghan women who had given birth in the U.S. within the past two years participated in audio-recorded interviews. The first and second authors conducted each interview using a semi-structured interview guide. The authors used a deductive, in vivo coding method to analyze the transcribed narrative data. Results: We identified three over-arching categories with corresponding sub-categories: 1) Healthcare: pregnancy, birthing, and postpartum, 2) Culture: communication, husband, and family, 3) Access to Care: transportation, financial, and insurance. The participants expressed perspectives of gratefulness and positive experiences, yet some described stories of poor birth outcomes that led to attitudes of mistrust and disappointment. Distinct cultural preferences were shared, providing invaluable insights for healthcare providers. Conclusions: The fact that the Afghan culture is strikingly different than the U.S. mainstream culture can lead to stereotypical assumptions, poor communication, and poor health outcomes. The voices of Afghan women should guide healthcare providers in delivering patient-centered, culturally sensitive maternity care that promotes healthy families and communities. The women’s stories highlight risk factors, including communication barriers, discordant cultural values, lack of social/community networks, and lack of transportation/healthcare navigation. The protective factors to nurture are attitudes of gratefulness and resilience, strong husband support, commitment to breastfeeding, openness to child spacing, and desire to learn more. Maternal Health Refugees Reproductive Healthcare Afghan Women Cultural Qualitative Birthing Experience Background The people of Afghanistan have seen one violent conflict after another for more than five decades. From the Soviet Union invasion in 1979, to the Afghan Civil War, and the United States’ (U.S.) military involvement in 2001, there has been constant insecurity and economic hardship [ 1 , 2 ]. During the 20 years of U.S. involvement, the country’s health system made strides toward improved health outcomes, including lowering the infant mortality rate from 66 to 45 deaths per 1000 live births and from 87 to 55 deaths per 1000 children under 5 years old [ 3 ]. The U.S. withdrawal from Afghanistan in August of 2021 resulted in an immediate takeover by the Taliban. One-hundred, twenty-two thousand people were airlifted out of Afghanistan, [ 4 ] of which 55,000 Afghans were placed on U.S. military bases before resettling in cities across the country. Military medical personnel who were tasked with assessing and treating Afghans on military bases concluded that reproductive health must be prioritized [ 5 ]. Afghanistan families have one of the highest fertility rates (4.53 children per woman) in the world [ 6 ] but also have one of the highest maternal mortality rates at 621 deaths per 100,000 [ 7 ]. In addition to war, poverty, and minimal health infrastructure, Afghans traditionally get married early and have low contraception utilization rates [ 3 ]. Refugee women are particularly vulnerable to poor health outcomes due to the extreme circumstances they endured as they fled their homeland and settled in a new country [ 8 , 9 ]. Resettled refugees in the U.S. face challenges with healthcare navigation, language barriers, and complicated, fragmented funding sources for healthcare [ 10 ]. For women of reproductive age, pregnancy poses certain risks to their health that can be exacerbated through the migration process [ 11 ]. Despite the rising number of Afghan immigrants in the U.S. [ 12 ], there is a lack of research to guide healthcare providers with practical, culturally sensitive reproductive health care delivery. Research in Australia with Afghan refugees found that health information and community engagement during and after pregnancy were important and that health literacy and language barriers affected the quality of care [ 13 , 14 ]. Studies based in Iran revealed that Afghan refugee women had worse maternal health outcomes compared to the general population [ 15 ]. Interviews with Afghan women who had almost died from a maternal health complication in Iran cited health professionals’ discriminatory lack of attention and delays in diagnosing complications as causes of poor health outcomes [ 16 ]. Through qualitative interviews with Afghans in Iran, Dadras et al. (2020) found that lack of health insurance reduced access to prenatal care, and the high costs of hospital care burdened Afghan families [ 17 ]. To provide high-quality, culturally sensitive care for Afghan women in the U.S., we embarked on this study to understand Afghan women’s experiences of giving birth in the U.S. and to identify protective and risk factors that affect Afghan women’s reproductive health. Methods Because of the lack of literature on Afghan maternal health, and their unique cultural, linguistic, and literacy levels, we approached the research methodology with an open strategy that would capture their experiences and perspectives. Therefore, we utilized descriptive qualitative methods to gather and analyze the data [ 18 ]. A local refugee social service agency has a program for postpartum women, which provides free diapers and related supplies. The agency staff provided the first and second authors with a list of Afghan women who had given birth within the past two years. The second author, who speaks Pashto, Dari, and English, used a script to call and request interviews. A convenience sample included 52 women contacted from the list; 17 could not be reached through the telephone number on file; 15 declined to participate, and 20 agreed. To decrease barriers to attending the interview (childcare responsibilities, lack of transportation, etc.), we offered the participant options for conducting the interview—in-person at their home or the social service agency, over Zoom, or by telephone. A $ 30 gift card was given to each participant after the interview. The university’s institutional review board determined the study was non-regulated research (Protocol #20210606NRR). The first and second authors conducted 20 interviews using a semi-structured interview guide (Appendix A). The first author led the interviews, and the second author interpreted between English and Pashto or Dari languages, depending on the participant’s preference. The interviews were audio-recorded, and a professional transcription company transcribed the English on the recordings verbatim. After the first eight interviews, the authors analyzed the transcripts and modified the interview guide to add ten follow-up questions (Appendix B). The second author, also fluent in Pashto and Dari, validated the English transcripts’ consistency with the audio recordings' non-English content. The authors carefully read the transcripts multiple times. The first and second authors reflected on each interview by comparing the notes they had made during the live interviews. The authors used a deductive, in vivo coding method. The iterative process of line-by-line coding was manually completed by two of the authors. Then, they came together to discuss intercoder agreements between their list of codes. The four authors reviewed the list of codes and began to cluster the codes according to similarity. Through in-depth analysis and debriefing of the meaning of the data, the authors grouped the codes into broader categories with three sub-categories under each broad category. Illustrative quotes were highlighted and listed under each of the sub-categories. The authors discussed reflexivity by acknowledging how author biases and experiences could shape the interpretation of the data [ 19 , 20 ]. Results The interviews lasted between 23 and 71 minutes, with an average time of 48 minutes. Six interviews were conducted in person, and 14 were over the phone with a 3-way conversation between the first author, the second author, and the participant. All 20 (100%) participants were originally from Afghanistan, identified as Muslim, were married, and had an average of 4.1 children. The details of their demographic data are displayed in Table 1 . Table 1 Demographics of the Participants (n = 20). n % Country of origin: Afghanistan 20 100 Religion: Islam 20 100 Married 20 100 Primary language Pashto Dari 15 5 75 25 Education level None Elementary Secondary Can read or write: Pashto Dari English English spoken proficiency None Conversational Fluent 13 3 4 3 2 3 11 9 0 65 15 20 15 10 15 55 45 0 Unemployed 19 95 Has health insurance 17 85 Mean Range Age Number of pregnancies 38 years 5 23–40 2–10 Number of children 4.1 2–7 Time in the U.S. 5.1 years 1.5–11 The participants’ words painted common perspectives of gratefulness and positive experiences, yet some described stories of poor birth outcomes that led to attitudes of mistrust and disappointment. Distinct cultural preferences were shared, providing invaluable insights for healthcare providers. The overarching theme of the participants’ accounts was “it’s different here.” The three broad categories were 1) Healthcare, 2) Culture, and 3) Access to Care (Table 2 ). Table 2 Categories Category Sub-Category Codes Healthcare Pregnancy Helpful Close monitoring Self-pregnancy Economic situation Nutrition Birthing Doctors and nurses check on me Epidural made it easy Not comfortable with males in the room Want natural births Postpartum Breastfeeding is smooth Space between children Didn’t get information Culture Communication We don’t know the language Prefer my husband to interpret Keep it to ourselves Husband I share with my husband first Husband was the biggest support Respect their husbands Family Learn from female family members Shameful topic Busy with kids Responsibilities Access to Care Transportation I can’t drive Husband has to drive me Cancel appointments Finances Need financial support Economic problems Can’t help bring income Insurance If I have insurance, I’ll go to the doctor Need Medicaid Home remedies Confusing Healthcare This category encompasses the women’s experiences with maternity care in the U.S. versus what they experienced in Afghanistan. It includes prenatal care and how they took care of themselves during pregnancy, their labor and delivery experiences in the hospital setting, and their postpartum practices, preferences, and engagement with healthcare services. Pregnancy : The women were pleased with the prenatal care they received in the U.S. They felt the providers were caring, helpful, and closely monitored them during pregnancy. They contrasted this with their experience of being pregnant in Afghanistan, where only two of the women had prenatal care. The women indicated not receiving special care and only sought healthcare if they had bleeding or pain. As one participant noted, “ It was really self-pregnancy back home” (Participant 12). They identified the poor economic situation that made the difference. “In Afghanistan, since the economic situation is so bad, people cannot afford to make an appointment with doctors more frequently the way they can here. Usually, you only go to the doctor when you are in severe trouble, or there is something urgent” (Participant 3). The participants described a lack of attention to personal health and heavy physical work in Afghanistan. “In Afghanistan it was hard to think about my own health; it was not a thing. I was like, ‘Okay, I’m pregnant.’ I didn’t even realize my blood sugar was elevated until I came here” (Participant 1). “We lived in a joint family, so there was more workload on me. Now, I only need to take care of my kids, and that's really easy for me while pregnant” (Participant 8). Another woman described her life in Afghanistan when pregnant: “We didn’t have water at home, so we would have to bring water from the river so that was physically hard. I had a lot of fieldwork, animals, and a farm. Here in the U.S., everything is provided, so it’s really good” (Participant 20). Most of the women described a “healthy pregnancy” as one that was void of pain or abnormal bleeding. They self-relied on eating healthy and avoiding lifting heavy things to have a healthy pregnancy, which they found easier to do in the U.S. “Back in Afghanistan, the fact that there’s a lot of poverty, so nutrition was a big difficulty during the pregnancy due to our poor economic status. Here, the nutrition is not a problem, so I could eat well” (Participant 8). Birthing : Most participants spoke positively about giving birth in the U.S. They felt that the nurses and physicians were kind and attentive. As most had previously given birth in Afghanistan, they explained that there were not enough physicians or nurses in Afghanistan to care for women in labor. As a result, they gave birth at home or in a hospital room with several other women. They were not allowed to have family members with them, and there were not enough nurses to give them attention, so they were on their own. “[Giving birth in Afghanistan] was bad in a sense because in one room there are 20 to 30 women giving birth at the same time” (Participant 9). Overall, the women were grateful for their birthing experiences; however, a few women had negative experiences. One participant described her experience of having an episiotomy during birth without any medications in Afghanistan. When she went home, her pain worsened. She was told it would heal in a week, but it did not. It became infected. “I was in pain and suffering for a month and a half because the surgical site was badly infected; I couldn’t take care of the baby. It was an extremely painful and miserable experience. It was like giving birth not only once but 3 or 4 times. It was a disaster” (Participant 12). The women appreciated the professional care they received from doctors and nurses in the U.S. “Then the nurses and doctors, when they found out that my husband was not there, they were trying to comfort me. It was a really good experience. I didn't even realize my husband was not there. I was really happy that they were so mindful and were there for me. They would make sure that I understand and explain the steps to me, like, ‘If things go wrong, then we will probably do a C-section.’ They would tell me ahead of the time and make sure that I understand, and then explain the steps” (Participant 3). In contrast, “Back in Afghanistan, the doctors were aggressive sometimes. They didn't have respect. They would cuss around me while I was giving birth which was really disrespectful” (Participant 2). In addition to appreciating the care and attention they received in the U.S.; most women were grateful for the epidural. “During my prenatal visits, the doctor explained that the epidural is an option. The experience was pleasant because I didn’t have to feel any pain” (Participant 13). Some of the women had negative experiences giving birth in the U.S. and expressed reluctance for medical interventions. Common perceptions among Afghan women regarding epidurals were that the procedure caused chronic headaches, led to Cesarean deliveries, and caused paralysis. “The majority of Afghan ladies want to go through the birthing process naturally. They don’t want to be induced. I got induced both times I gave birth in the U.S. versus back home; it was all-natural, and it went smoothly compared with the U.S. The [U.S.] experience was not pleasant for me, and I didn’t even know why I was being induced. Maybe it was because I was not exercising well?” (Participant 10). Another participant was frustrated that she had to have a Cesarean birth. She preferred natural births. The doctor was concerned that there was too little amniotic fluid, so they told her she needed a Cesarean delivery. Afterward, the doctor admitted that it was not necessary. “That made me really frustrated. After that procedure, I am not back to normal; I still have aches and pains. It’s really devastating for me to not be able to take care of my kids” (Participant 17). The other issue brought up by multiple participants was how uncomfortable they felt when there were males in the birthing room. Some women did not even want their husbands in the delivery room. “I did not prefer to have my husband in the delivery room because I felt uncomfortable. My husband was not comfortable either, but felt it was expected” (Participant 19). Participant 11 told a story about a friend who went to the hospital in labor, and there was a male doctor. “When they saw there was only a male doctor, they packed up and went home to give birth. The poor lady gave birth, and then it got complicated by a severe hemorrhage, so they got nervous and called the ambulance” (Participant 11). Another participant went through birth without an interpreter because a male was the only interpreter available at the hospital. “I just told them I don’t want the interpreter because he is a man, and I cannot have him there while I’m having the baby” (Participant 4). Postpartum : The postpartum experiences regarding breastfeeding were overwhelmingly positive. All the women explained that breastfeeding was a usual and customary practice and that they breastfed their children for about two years. “I don’t have any problem with breastfeeding my children; it’s a really smooth process.” (Participant 12). Regarding child spacing, the women favored space between their children; their preferences ranged from two to five years between each child. The contraceptive methods they preferred varied. One mentioned she had a tubal ligation after her seventh child. A few of the women used the copper IUD, and others used condoms and oral contraceptives. Those who used the injection (Depo Provera) didn’t like the weight gain. Those with the implant perceived it to cause depression, headaches, and nausea. A few of the women who tried oral contraceptives stopped due to their side effects and resorted to the natural method. “I do not prefer medication. I just like the natural way to not have kids” (Participant 15). Some women discussed the lack of information provided by healthcare providers about contraceptive options. “ a lot of these Afghan ladies want to have some contraceptive after birth. But the fact that they don’t get a follow-up with their obstetrician, and they’re not educated enough that they can get pregnant right after giving birth, so before they even go to the OB, they’re already pregnant again” (Participant 5). Another participant shared that they need additional contraceptive education. “It’s hard to take care of ourselves with these back-to-back children. We don’t know about the birth control options; we tend to stop them if we have any adverse effects” (Participant 12). Culture The women highlighted the cultural contrasts between Afghanistan and the U.S. They noted that the most difficult issue in the U.S. was the communication barrier, but also the discordant cultural values related to their role as a woman and the sensitivity of reproductive health topics. Communication : As the women reflected on their maternal health experiences, they identified the most challenging concern to be the language barrier, which they did not face in Afghanistan. “The biggest problem among Afghan women here is the fact that they don't know the language, so it just makes it really difficult for them to do anything for themself” (Participant 11). Most of the women stated that their husbands or professional interpreters helped them understand the childbirth protocol in the U.S. Some women preferred their husbands to interpret rather than the professional interpreter. “We were given the option of an interpreter, but I preferred my husband to do the interpretation for me because that way, I understand it better” (Participant 7). Women described instances when only a male interpreter was available, so they opted to be quiet or have a family member interpret instead. “Then it gets difficult if the interpreter is a male. That’s when we are not comfortable sharing concerns, and we usually don’t talk about it. We keep it to ourselves ’cause we are not comfortable talking about any reproductive concerns” (Participant 9). One participant was frustrated with the interpreter. “I took my son with me to the appointment, and I was having some trouble. When I was there, the interpreter translated my message completely differently to the doctor, and my son noticed and told him, 'Hey, that's wrong. That's not what my mom is saying.' Then the interpreter got mad at the little kid, ‘How dare you tell me I'm wrong? I'm the interpreter. I know what I'm saying.’ Yeah, we had a big problem, not with the doctor or the staff, but the interpreter was not communicating the message right” (Participant 2). Most women acknowledged having access to interpretation services at the facility where they were treated, but at times, misunderstandings occurred. “When I went to give birth they asked me, ‘Are you having a boy or a girl?’ I didn't understand what boy or girl meant, so I told them, ‘I'm having a boy.’ They arranged paperwork for circumcision and all that, and then I couldn't understand so I signed on everything. And then a nurse who spoke Farsi came and explained what boy and girl meant. And then I told them, ‘No. I'm having a girl,’ so they had to cancel the whole paperwork and all that” (Participant 5). In addition to the language component of communication, the participants also described their appreciation of anticipatory guidance and explanations of the process. Three women felt the doctor did not explain medical interventions (Participants 5, 10, 17). Several women expressed interest in learning more about reproductive health and child spacing options. They felt that Afghan women needed educational sessions and language classes. “Yeah, so after my second daughter, when I went for the postpartum visit they said, ‘Oh, you're not having bleeding and everything. You're done with us and we're not going to be seeing you anymore because you gave birth, and everything looks okay.’ I was not even given any information; I didn't understand anything because I couldn't speak English. I was not given any information about contraceptives. I asked people from Afghanistan to send me birth control medication so I could use that as a contraceptive” (Participant 5). When probed further about preferences for health education sessions, Participant 8 commented, A lot of Afghan ladies, they have kids up to seven and eight. Usually, they are not able to go anywhere—just because they have a lot of kids. I think if there is—if somebody came into our house and gave us information; that would be so helpful. Husband : Given that all the participants were married, their relationship with their husbands was a common topic that revealed aspects of their culture. The women's narratives were intertwined with a strong sense of respect, reliance, and appreciation for their husbands, yet at the same time, a shared understanding of traditional Afghan culture of women submitting to men as the decision-makers. The participants described both satisfaction with more freedom for women in the U.S. and fear and challenges with the discordant cultures. When asked what actions women took concerning a health problem, most said they would share the problem with their husbands first. He would decide what to do next, such as making an appointment with the doctor. “If I’m not comfortable sharing my health concern with the doctor, then I share it with my husband, then he will talk to the doctor” (Participant 14). Other women shared how grateful they were for their husbands. Participant 7 described complicated pregnancies that included hyperemesis and diabetes. When asked how she managed, she responded, My husband was the biggest support for me. He would try to look after our little girl and tried to help with the house chores; he helped me record the blood sugar levels and taught me how to operate the machine. My husband is supportive so that helped me through that pregnancy. Some of the participants felt it would be helpful for healthcare providers to understand traditional marital dynamics for Afghan families. Since the husband makes the decisions for the wife, healthcare providers should provide health recommendations to the husband. “Ladies really respect their husbands. If the husband wants to have more kids, they don’t tell their husbands, ‘Hey, I cannot do it. My body is not able to get another pregnancy to term.’ Husbands don’t usually listen to their wives, but they do listen to the doctor if the doctor tells them, ‘Your wife needs some time before she gets pregnant again.’ They will most likely take that into consideration instead of their wives telling them” (Participant 3). Despite a few of the participants sharing stories about other women dealing with a controlling husband, most of the women felt that their husbands were supportive and addressed their needs. Family : As the women reflected on their maternal health experiences, they shared that they usually only discuss reproductive issues with their close female family members. Many of them did not even learn about childbearing issues until they were pregnant themselves. None received health education in a formal setting, such as school. “I learned about pregnancy and childbirth by seeing other family members going through the process and talking to females in the family” (Participant 10). Participant 14 commented, No one ever really talked about it–like how pregnancy happened or what the 9 months of pregnancy is like and then the delivery. A couple of the women stated that by living in the U.S., they had learned to search the internet to educate themselves on their concerns or questions. For example, Participant 10 wondered about having sex during pregnancy and was too shy to ask the doctor. She also wondered which sleeping position was best during pregnancy. I researched Google and found that sleeping on the left side and using a pregnancy pillow is a good option. The participants were in favor of educational sessions on reproductive health and contraceptive options, as they described the cultural taboo surrounding discussing reproductive health topics. “It’s considered a shameful topic or taboo; it’s not a topic that women will share with each other or talk about it in a gathering, so usually they keep it to themselves” (Participant 10). Several of the participants explained that Afghan women are “shy.” They are afraid to talk about their health problems. A few participants painted the difference between women who came from more conservative rural areas and women who lived in the city. “When it comes to ladies from villages, they don’t know how to get help for themselves. Sometimes they miss out, like miss their appointments, and they’re shy. They are afraid to tell the doctor about it, such as problems with their period” (Participant 3). The other common concern was that the women were busy with childcare responsibilities that left no time for socializing with other women. “I stay very busy with my kids and don’t get together with other Afghans. I never have conversations to see what some of the problems are that they are facing or how I could help those problems” (Participant 6). Another participant wished women could get together but concurred, “The fact that most of these women have a lot of kids to take care of. They don’t drive—they are just homebound” (Participant 9). Access to Care The women acknowledged the limited access to healthcare in Afghanistan due to extreme resource limits; but also identified structural barriers they encountered in the U.S. as they sought health care services. Transportation : One of the primary barriers to women attending prenatal care appointments was the lack of transportation. Only one out of the twenty women mentioned that she could drive herself and had a car. The others relied on their husbands to drive them. “On the days my husband went to work, I would just cancel the appointment because I couldn’t drive” (Participant 5). Several women noted that this was a problem common to Afghan women. “The biggest challenge for women in the Afghan community is transportation. Most of us do not drive, so we cannot make the doctor’s appointments. We must wait for our husbands ” (Participant 17). Finances : Most women noted that their financial situations had improved in the U.S. However, some mentioned the financial strain on their husbands about making ends meet and their desire to assist with income generation. “The husband is the only one that brings income to the house. That’s used up monthly. Women are trying, but they’re unable to help their husbands with the income” (Participant 8). Insurance coverage : Most women reported having Medicaid or some form of insurance coverage. However, some mentioned that when their pregnancy coverage ran out, they did not know how to navigate follow-up care. “If you have insurance, then you can go to the doctor; if not, then you are just on your own. One of the new Afghan refugees is nine months pregnant and doesn’t have insurance or any paperwork. She is frail. I tried to help, but she doesn’t have health insurance. I don’t know what to do” (Participant 2). The participants stated that the primary healthcare resource women need is Medicaid coverage. “ Some of these Afghan ladies have been sick for a long time. If the government can help, it would be helpful because most Afghan ladies stay home sick. They fear they will go to a doctor and be sent a high bill, which they cannot pay. It’s just so hard when you are sick and have many kids to look after” (Participant 8). Some women described their inability to understand and navigate the U.S. healthcare system. “When I got pregnant here the first time, it was so confusing; I didn’t know where to go, so I went to the emergency room. I told them, ‘I’m pregnant; what do I do?’ Then, they guided me, ‘You need to make an appointment, and once they find out you’re pregnant, you can apply for insurance.’ That’s how I figured it out” (Participant 3). Discussion The findings from this study contribute critical insights into Afghan women's perceptions, preferences, and maternal health experiences in the U.S. We found that Afghan women appreciated the kind, mindful, and attentive care of the nurses and physicians providing their reproductive healthcare. They contrasted their U.S. experiences with what they were used to in Afghanistan, describing extremely resource-poor conditions. Similarly, Shafiei et al. [ 21 ] found that Afghan women in Australia felt the kind, caring attitude of the healthcare provider was the most important factor in their perception of maternity care. In contrast, Afghan refugee women in Iran attributed their poor maternal health experience to discrimination and a lack of attention. They felt that their concerns were ignored and that they were given incompetent midwives and doctors. These experiences caused mistrust and reluctance to utilize health services [ 16 ]. A comparative review of studies in five countries revealed that immigrant and non-immigrant women had a similar desire for safe and attentive care. However, immigrant women faced communication problems and perceived a need for more kindness and respect [ 22 ]. The women in our study faced communication barriers and desired precise information; however, most did not perceive discrimination and felt the providers were kind and attentive. We found that women were opposed to excessive medical interventions, including inductions and Cesarean deliveries. However, most were in favor of having an epidural during labor, especially if the procedure was explained ahead of time. Providing anticipatory guidance with health literacy levels in mind is essential for Afghan women in Australia [ 13 ]. The U.S. has one of the highest Cesarean delivery rates in the world (32.1%) [ 23 ]. In contrast, the World Health Organization reported a Cesarean delivery rate of 2.7% in Afghanistan [ 24 ]. The difference in maternity care practices can contribute to discordant expectations and disappointment, as was evident with a few of the participants in our study who were attributing their chronic pain to an unnecessary Cesarean delivery. Healthcare providers should consider providing extensive explanations of medical procedures ahead of treatment. The fact that 65% of our participants had no formal education and only 25% could read and write in their primary language speaks to the gap in health literacy and the potential for misunderstanding health providers’ instructions. Communication was a crucial factor in their maternal health experiences, including the critical role of the interpreter or a family member, most commonly, their husband, who spoke English. A study in Afghanistan found a correlation between low maternal health literacy and poor pregnancy outcomes [ 25 ]. Even more reason to ensure clear communication that includes confirmation of understanding. A study in California with older Afghan refugee women found that miscommunication led to mistrust of healthcare providers [ 26 ]. Mistrust of healthcare providers is more common among immigrant patients [ 22 ]. Health providers should consider using visual or audio rather than written material to improve communication and health literacy. A study in Afghanistan found a high satisfaction rate with community health workers who used a computer tablet-based health video library to enhance health counseling sessions [ 27 ]. Another clear cultural preference was for only female healthcare providers and interpreters. The women are culturally “shy” and do not feel comfortable explaining their feelings or symptoms—especially when it has to do with their reproductive health. Having a male in the room made it even more challenging to express their concerns. Some studies found that Afghan women are embarrassed to ask questions because of their illiteracy [ 13 , 21 ]. The participants in our study acknowledged the topic of reproductive health as taboo, where the only male involved should be the woman’s husband. Healthcare providers in the U.S. should understand this cultural value that may get overlooked and result in ineffective patient-provider interactions, leading to poor health outcomes. Cultural insights revealed a complex interplay in the husband-wife relationship that was marked by a common understanding that the husband is the decision-maker, and the women primarily relied on their husbands for interpretation, transportation, and communicating symptoms with healthcare providers. They expressed gratefulness when their husband assisted and supported them through the process of pregnancy and birthing. They reflected, that in Afghanistan, female family members provided support during pregnancy and childbirth; so, in the U.S. where they lacked extended family, they relied more on their husbands. This group of 20 women had been in the U.S. for an average of five years; therefore, their views and preferences had likely evolved as they assimilated in the U.S. None of the women mentioned experiencing violence from their husbands. Yet, surveys within Afghanistan from 2015 revealed that 46.1% of women experienced sexual or physical violence from their husbands [ 28 ]. Our study and other studies of Afghan refugee women revealed complementary husband-wife bonds through childbearing [ 29 ]. Afghan women in Iran talked about how their husbands gave them sacrificial support—even begging for money in the streets to pay hospital bills [ 16 ]. Given our findings, U.S. healthcare providers must avoid making assumptions about the husband-wife relationship; instead, they should respect and nurture for the strengths it brings. Most of our participants were successful in breastfeeding their children for two years. As 100% of the women identified as Muslim, it is worth noting that the Quran states that a child has a right to receive breastmilk until the age of two years [ 30 ]. This successful breastfeeding practice in the community should be highlighted and examined further to encourage sustainment throughout the assimilation process and subsequent generations. This protective factor can serve as an example for U.S. women and families of other cultures. Participants were open to using child spacing methods. They reported using a variety of contraception types. None of the women mentioned religious opposition to contraception but mentioned adverse effects that drove them to natural methods. The findings from studies in Australia also cited that both men and women were open to contraception, but the preferences varied due to side effects [ 31 ]. Even studies in refugee camps in Asia found a rate of 54% contraception utilization among Afghan women [ 32 ]. Aside from the challenges with contraceptive side effects, our findings revealed a lack of communication between the provider and the woman about child spacing options. The women outlined several barriers to accessing healthcare, including the tendency to treat with natural remedies and to “grin and bear it” until it was causing significant problems. They needed confirmation from their husbands first, then transportation and language interpretation assistance. If they did not have Medicaid coverage, they were unlikely to seek care unless it was a life-or-death situation. Again, the women had to rely on their husbands to navigate health services. Studies in Australia found similar dynamics, with Afghan men playing significant roles in supporting their wives throughout the pregnancy and birth process. Health professionals rarely engaged with the husbands regarding their concerns or perspectives on the pregnancy [ 29 ]. Within the U.S. culture of emphasizing patient autonomy, health professionals need to reinvigorate their approach to Afghan families, consider engaging the husband to accentuate the strengths of their support and consider the social and economic burdens faced by Afghan men as husbands. Conclusions The fact that the Afghan culture is strikingly different than the U.S. mainstream culture can lead to stereotypical assumptions, poor communication, and poor health outcomes. The voices of Afghan women should guide healthcare providers in delivering patient-centered, culturally sensitive maternity care that promotes healthy families and communities. The women’s stories move us to address the risk factors they face, which include communication barriers, discordant cultural values, lack of social/community networks, and the lack of transportation and healthcare navigation. The protective factors to nurture are attitudes of gratefulness and resilience, strong husband support, commitment to breastfeeding, openness to child spacing and desire to learn more. Abbreviations U.S United States Declarations Ethics approval and consent to participate: Ethical approval was obtained from the University of Texas Health Science Center San Antonio Institutional Review Board. They determined the study was non-regulated research (Protocol #20210606NRR). Informed consent was obtained from all the participants. Consent for publication: Not applicable. Availability of data and materials: The fully anonymized datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request from authenticated researchers. Competing interests : The authors declare that they have no competing interests. Funding: This study received funding from the Nursing Advisory Council at the University of Texas Health Science Center San Antonio. Authors’ contributions: HW and SG designed the study. HW was the principal investigator. FS assisted with participant recruitment. HW and FS conducted the interviews, with qualitative research guidance from SG. MF and HW carried out the data analysis with assistance from SG and FS. HW wrote the manuscript, with all authors drafting, reviewing, and approving the final version. Acknowledgements: The authors would like to thank the women who gave their time to participate in this study and the staff at the Center for Refugee Services for their collaboration and support of health research efforts to improve the lives of refugees in the community. References Shahrani, M. Resisting the Taliban and Talibanism in Afghanistan: Legacies of a century of internal colonialism and cold war politics in a buffer state. J Int Aff. 2000;5:4. Ramos AA. Considerations in designing trauma-focused interventions for displaced Afghan women. Front Glob Womens Health. 2023; doi:10.3389/fgwh.2022.893957. USAID. Demographic health surveys program: Afghanistan, 2016. https://dhsprogram.com/Countries/Country-Main.cfm?ctry_id=71&c=Afghanistan&r=4 Accessed 25 January 2024. Gaouette N, Hansler, J, Starr B, Liebermann O. The last US military planes have left Afghanistan, marking the end of the United States’ longest war. CNN Politics. 2021. https://www.cnn.com/2021/08/30/politics/us-military-withdraws-afghanistan/index.html Accessed 30 Jan 2024. Lieberman Lawry L. Review of humanitarian guidelines to ensure the health and well-being of Afghan refugees on U.S. military bases. Mil Med. 2022; doi:10.1093/milmed/usac086. CIA. The World Factbook. Country comparisons: Total fertility rate, 2023. https://www.cia.gov/the-world-factbook/field/total-fertility-rate/country-comparison/. Accessed 30 Jan 2024. CIA. The World Factbook. Country comparisons: Maternal mortality ratio, 2020. https://www.cia.gov/the-world-factbook/field/maternal-mortality-ratio/country-comparison/. Accessed 12 Mar 2024. Sudhinaraset M, Cabanting N, Ramos M. The health profile of newly-arrived refugee women and girls and the role of region of origin: using a population-based dataset in California between 2013 and 2017. Int J of Equity Health. 2019; doi:10.1186/s12939-019-1066-3 Wanigaratne S, Cole DC, Bassil K, Hyman I, Moineddin R, Urquia ML. The influence of refugee status and secondary migration on preterm birth. J Epidemiol Community Health. 2016; doi:10.1136/jech-2015-206529. Ho, CH, Denton, AH, Blackstone, SR, Saif N, MacIntyre K, Ozkaynak M, Valdez RS, Hauck FR. Access to healthcare among US adult refugees: A systematic qualitative review. J Immigr Minor Health. 2023; doi:10.1007/s10903-023-01477-2 Gagnon AJ, Redden KL. Reproductive health research of women migrants to Western countries: a systematic review for refining the clinical lens. Best Pract Res Clin Obstet Gynaecol. 2016; 32:3-14. American Community Survey 1-Year Estimates: Afghan. United States Census Bureau. 2022. https://data.census.gov/table/ACSDT1Y2022.B04006?q=Ancestry&t=Ancestry&tid=ACSDT1Y2019.B04006. Accessed 1 Feb 2024. Riggs E, Yelland J, Szwarc J, Duell-Piening P, Wahidi S, Fouladi F, Casey S, Chesters D, Brown S. Afghan families and health professionals' access to health information during and after pregnancy. Women Birth. 2020; doi: 10.1016/j.wombi.2019.04.008. Cheng IH, Wahidi S, Vasi S, Samuel S. Importance of community engagement in primary health care: the case of Afghan refugees. Aust J Prim Health. 2015; doi: 10.1071/PY13137. PMID: 25102862. Mohammadi S, Saleh Gargari S, Fallahian M, Källestål C, Ziaei S, Essén B. Afghan migrants face more suboptimal care than natives: a maternal near-miss audit study at university hospitals in Tehran, Iran. BMC Pregnancy Childbirth. 2017; doi:10.1186/s12884-017-1239-2. Mohammadi S, Carlbom A, Taheripanah R, Essén B. Experiences of inequitable care among Afghan mothers surviving near-miss morbidity in Tehran, Iran: A qualitative interview study. Int J Equity Health. 2017; doi:10.1186/s12939-017-0617-8. Dadras O, Taghizade Z, Dadras F, Alizade L, Seyedalinaghi S, Ono-Kihara M, Kihara M, Nakayama T. "It is good, but I can't afford it …" potential barriers to adequate prenatal care among Afghan women in Iran: a qualitative study in South Tehran. BMC Pregnancy Childbirth. 2020; doi:10.1186/s12884-020-02969-x. Sandelowski M. Qualitative analysis: What it is and how to begin. Res Nurs Health. 1995;18: 371-355. Schreier M. Qualitative content analysis in practice. Sage Publishing. 2012; ISBN 978144628992. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Quality Health Care. 2007;19 (6): 349–357. https://doi.org/10.1093/intqhc/mzm042. Shafiei T, Small R, McLachlan H. Women’s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia. Midwifery. 2012; 28:198-203. Small R, Roth C, Raval M, Shafiei T, Korfker D, Heaman M, McCourt C, Gagnon A. Immigrant and non-immigrant women's experiences of maternity care: a systematic and comparative review of studies in five countries. BMC Pregnancy Childbirth. 2014. doi:10.1186/1471-2393-14-152. Center for Disease Control and Prevention: Cesarean delivery rate by state. 2021. https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm. Accessed 30 Jan 2024. World Health Organization. Eastern Mediterranean Region. Afghanistan Department of Health Services. 2015. https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm. Accessed 30 Jan 2024. Rostamzadeh M, Ezadi Z, Hosseini M, Husseini AA. Maternal health literacy and pregnancy outcomes in Afghanistan. J Educ Health Promot. 2022 Dec 28;11:421. doi:10.4103/jehp.jehp_746_22. Siddiq H, Alemi Q, Lee E. A qualitative inquiry of older Afghan refugee women’s individual and sociocultural factors of health and health care experiences in the United States. J Transcult Nurs. 2023; 34(2):143-150. doi:10.1177/10436596221149692. Dal Santo LC, Rastagar SH, Hemat S, Alami SO, Pradhan S, Tharaldson J, Dulli LS, Todd CS. Feasibility and acceptability of a video library tool to support community health worker counseling in rural Afghan districts: a cross-sectional assessment. Confl Health. 2020 Aug 5;14:56. doi:10.1186/s13031-020-00302-z. USAID Demographic Health Survey Program: Afghanistan demographic health survey 2015. https://dhsprogram.com/topics/gender/index.cfm. Accessed 1 Feb 2024. Riggs E, Yelland J, Szwarc J, Wahidi S, Casey S, Chesters D, Fouladi F, Duell-Piening P, Giallo R, Brown S. Fatherhood in a new country: A qualitative study exploring the experiences of Afghan men and implications for health services. Birth. 2016;43(1):86-92. doi:10.1111/birt.12208. Hefnawi FI. Lactation in Islam. Popul Sci. 1982;(3):7-9. Russo A, Lewis B, Ali R, Abed A, Russell G, Luchters S. Family planning and Afghan refugee women and men living in Melbourne, Australia: new opportunities and transcultural tensions. Cult Health Sex. 2020;22(8):937-953. doi:10.1080/13691058.2019.1643498. Hossain MA, Dawson A. A systematic review of sexual and reproductive health needs, experiences, access to services, and interventions among the Rohingya and the Afghan refugee women of reproductive age in Asia. WHO South East Asia J Public Health. 2022;11(1):42-53. doi:10.4103/WHO-SEAJPH.WHO-SEAJPH_144_21. Additional Declarations No competing interests reported. Supplementary Files AppendicesInterviewGuide.docx Cite Share Download PDF Status: Published Journal Publication published 16 Jul, 2024 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 10 Jun, 2024 Reviews received at journal 10 Jun, 2024 Reviewers agreed at journal 10 Jun, 2024 Reviews received at journal 30 May, 2024 Reviewers agreed at journal 29 May, 2024 Reviewers agreed at journal 29 May, 2024 Reviewers agreed at journal 25 May, 2024 Reviewers invited by journal 24 May, 2024 Editor invited by journal 03 Apr, 2024 Submission checks completed at journal 02 Apr, 2024 Editor assigned by journal 02 Apr, 2024 First submitted to journal 30 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4193621","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":288299134,"identity":"8432e93e-6235-4276-a60f-c9d416b1a759","order_by":0,"name":"Heidi Worabo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxUlEQVRIiWNgGAWjYJACZgYGGwYGCRj3AHFa0hh4SNVymAQtBsd7H34uqDifuF+6/eHHHzUMcnw3EghoOXPcWHrGmduJPTJnjKV5jjEYSxLSYnYjjUGatw2oRSKHjZmBjSFxAxFamH/ztp0Dakl/xvjjH0M9MVrYgLYcAGpJMGPgbWNIMCCkxf7MMTbrGWeSjXtu5BhL8/ZJGM488wC/Fsn2NubbBRV2su0z0oEh9s1Gnu84AVvQgQRhJaNgFIyCUTAKCAMATuREAkQvN1EAAAAASUVORK5CYII=","orcid":"","institution":"The University of Texas Health Science Center at San Antonio","correspondingAuthor":true,"prefix":"","firstName":"Heidi","middleName":"","lastName":"Worabo","suffix":""},{"id":288299135,"identity":"a769f778-bb80-4875-b1c1-97e4b6b0dd42","order_by":1,"name":"Fatima Safi","email":"","orcid":"","institution":"HCA Healthcare Medical City Arlington","correspondingAuthor":false,"prefix":"","firstName":"Fatima","middleName":"","lastName":"Safi","suffix":""},{"id":288299136,"identity":"022dcd6f-cd7b-4221-8daf-c041588ae4c8","order_by":2,"name":"Sara Gill","email":"","orcid":"","institution":"The University of Texas Health Science Center at San Antonio","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Gill","suffix":""},{"id":288299137,"identity":"f792e79d-a346-454d-955a-4dea144e3fd4","order_by":3,"name":"Moshtagh Farokhi","email":"","orcid":"","institution":"The University of Texas Health Science Center at San Antonio","correspondingAuthor":false,"prefix":"","firstName":"Moshtagh","middleName":"","lastName":"Farokhi","suffix":""}],"badges":[],"createdAt":"2024-03-30 21:59:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4193621/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4193621/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-024-06678-7","type":"published","date":"2024-07-16T15:57:01+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61594809,"identity":"91d7e01e-64c0-43c8-ab2a-a82d8a9509e4","added_by":"auto","created_at":"2024-08-01 17:16:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":430268,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4193621/v1/9e9fd96d-9f84-4e62-a81c-122df76a065a.pdf"},{"id":54321585,"identity":"d10159f3-e87e-436d-baf7-6831226ac201","added_by":"auto","created_at":"2024-04-08 19:31:44","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":17034,"visible":true,"origin":"","legend":"","description":"","filename":"AppendicesInterviewGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-4193621/v1/7dfad7eca70559a70a53ea03.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"“It’s Different Here” Afghan Refugee Maternal Health Experiences in the United States","fulltext":[{"header":"Background","content":"\u003cp\u003eThe people of Afghanistan have seen one violent conflict after another for more than five decades. From the Soviet Union invasion in 1979, to the Afghan Civil War, and the United States\u0026rsquo; (U.S.) military involvement in 2001, there has been constant insecurity and economic hardship [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. During the 20 years of U.S. involvement, the country\u0026rsquo;s health system made strides toward improved health outcomes, including lowering the infant mortality rate from 66 to 45 deaths per 1000 live births and from 87 to 55 deaths per 1000 children under 5 years old [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe U.S. withdrawal from Afghanistan in August of 2021 resulted in an immediate takeover by the Taliban. One-hundred, twenty-two thousand people were airlifted out of Afghanistan, [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] of which 55,000 Afghans were placed on U.S. military bases before resettling in cities across the country. Military medical personnel who were tasked with assessing and treating Afghans on military bases concluded that reproductive health must be prioritized [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Afghanistan families have one of the highest fertility rates (4.53 children per woman) in the world [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] but also have one of the highest maternal mortality rates at 621 deaths per 100,000 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In addition to war, poverty, and minimal health infrastructure, Afghans traditionally get married early and have low contraception utilization rates [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRefugee women are particularly vulnerable to poor health outcomes due to the extreme circumstances they endured as they fled their homeland and settled in a new country [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Resettled refugees in the U.S. face challenges with healthcare navigation, language barriers, and complicated, fragmented funding sources for healthcare [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. For women of reproductive age, pregnancy poses certain risks to their health that can be exacerbated through the migration process [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Despite the rising number of Afghan immigrants in the U.S. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], there is a lack of research to guide healthcare providers with practical, culturally sensitive reproductive health care delivery.\u003c/p\u003e \u003cp\u003eResearch in Australia with Afghan refugees found that health information and community engagement during and after pregnancy were important and that health literacy and language barriers affected the quality of care [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Studies based in Iran revealed that Afghan refugee women had worse maternal health outcomes compared to the general population [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Interviews with Afghan women who had almost died from a maternal health complication in Iran cited health professionals\u0026rsquo; discriminatory lack of attention and delays in diagnosing complications as causes of poor health outcomes [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Through qualitative interviews with Afghans in Iran, Dadras et al. (2020) found that lack of health insurance reduced access to prenatal care, and the high costs of hospital care burdened Afghan families [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo provide high-quality, culturally sensitive care for Afghan women in the U.S., we embarked on this study to understand Afghan women\u0026rsquo;s experiences of giving birth in the U.S. and to identify protective and risk factors that affect Afghan women\u0026rsquo;s reproductive health.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eBecause of the lack of literature on Afghan maternal health, and their unique cultural, linguistic, and literacy levels, we approached the research methodology with an open strategy that would capture their experiences and perspectives. Therefore, we utilized descriptive qualitative methods to gather and analyze the data [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e A local refugee social service agency has a program for postpartum women, which provides free diapers and related supplies. The agency staff provided the first and second authors with a list of Afghan women who had given birth within the past two years. The second author, who speaks Pashto, Dari, and English, used a script to call and request interviews. A convenience sample included 52 women contacted from the list; 17 could not be reached through the telephone number on file; 15 declined to participate, and 20 agreed. To decrease barriers to attending the interview (childcare responsibilities, lack of transportation, etc.), we offered the participant options for conducting the interview\u0026mdash;in-person at their home or the social service agency, over Zoom, or by telephone. A \u003cspan\u003e$\u003c/span\u003e30 gift card was given to each participant after the interview. The university\u0026rsquo;s institutional review board determined the study was non-regulated research (Protocol #20210606NRR).\u003c/p\u003e \u003cp\u003eThe first and second authors conducted 20 interviews using a semi-structured interview guide (Appendix A). The first author led the interviews, and the second author interpreted between English and Pashto or Dari languages, depending on the participant\u0026rsquo;s preference. The interviews were audio-recorded, and a professional transcription company transcribed the English on the recordings verbatim. After the first eight interviews, the authors analyzed the transcripts and modified the interview guide to add ten follow-up questions (Appendix B).\u003c/p\u003e \u003cp\u003eThe second author, also fluent in Pashto and Dari, validated the English transcripts\u0026rsquo; consistency with the audio recordings' non-English content. The authors carefully read the transcripts multiple times. The first and second authors reflected on each interview by comparing the notes they had made during the live interviews. The authors used a deductive, in vivo coding method. The iterative process of line-by-line coding was manually completed by two of the authors. Then, they came together to discuss intercoder agreements between their list of codes. The four authors reviewed the list of codes and began to cluster the codes according to similarity. Through in-depth analysis and debriefing of the meaning of the data, the authors grouped the codes into broader categories with three sub-categories under each broad category. Illustrative quotes were highlighted and listed under each of the sub-categories. The authors discussed reflexivity by acknowledging how author biases and experiences could shape the interpretation of the data [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe interviews lasted between 23 and 71 minutes, with an average time of 48 minutes. Six interviews were conducted in person, and 14 were over the phone with a 3-way conversation between the first author, the second author, and the participant. All 20 (100%) participants were originally from Afghanistan, identified as Muslim, were married, and had an average of 4.1 children. The details of their demographic data are displayed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of the Participants (n\u0026thinsp;=\u0026thinsp;20).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry of origin: Afghanistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligion: Islam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary language\u003c/p\u003e \u003cp\u003ePashto\u003c/p\u003e \u003cp\u003eDari\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003cp\u003eElementary\u003c/p\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003cp\u003eCan read or write:\u003c/p\u003e \u003cp\u003ePashto\u003c/p\u003e \u003cp\u003eDari\u003c/p\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003cp\u003eEnglish spoken proficiency\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003cp\u003eConversational\u003c/p\u003e \u003cp\u003eFluent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e11\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65\u003c/p\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e55\u003c/p\u003e \u003cp\u003e45\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas health insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eRange\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003eNumber of pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 years\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u0026ndash;40\u003c/p\u003e \u003cp\u003e2\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime in the U.S.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.1 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u0026ndash;11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe participants\u0026rsquo; words painted common perspectives of gratefulness and positive experiences, yet some described stories of poor birth outcomes that led to attitudes of mistrust and disappointment. Distinct cultural preferences were shared, providing invaluable insights for healthcare providers. The overarching theme of the participants\u0026rsquo; accounts was \u003cem\u003e\u0026ldquo;it\u0026rsquo;s different here.\u0026rdquo;\u003c/em\u003e The three broad categories were 1) Healthcare, 2) Culture, and 3) Access to Care (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-Category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCodes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealthcare\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHelpful\u003c/p\u003e \u003cp\u003eClose monitoring\u003c/p\u003e \u003cp\u003eSelf-pregnancy\u003c/p\u003e \u003cp\u003eEconomic situation\u003c/p\u003e \u003cp\u003eNutrition\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBirthing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDoctors and nurses check on me\u003c/p\u003e \u003cp\u003eEpidural made it easy\u003c/p\u003e \u003cp\u003eNot comfortable with males in the room\u003c/p\u003e \u003cp\u003eWant natural births\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostpartum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBreastfeeding is smooth\u003c/p\u003e \u003cp\u003eSpace between children\u003c/p\u003e \u003cp\u003eDidn\u0026rsquo;t get information\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCulture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWe don\u0026rsquo;t know the language\u003c/p\u003e \u003cp\u003ePrefer my husband to interpret\u003c/p\u003e \u003cp\u003eKeep it to ourselves\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHusband\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI share with my husband first\u003c/p\u003e \u003cp\u003eHusband was the biggest support\u003c/p\u003e \u003cp\u003eRespect their husbands\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFamily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLearn from female family members\u003c/p\u003e \u003cp\u003eShameful topic\u003c/p\u003e \u003cp\u003eBusy with kids\u003c/p\u003e \u003cp\u003eResponsibilities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAccess to Care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransportation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI can\u0026rsquo;t drive\u003c/p\u003e \u003cp\u003eHusband has to drive me\u003c/p\u003e \u003cp\u003eCancel appointments\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeed financial support\u003c/p\u003e \u003cp\u003eEconomic problems\u003c/p\u003e \u003cp\u003eCan\u0026rsquo;t help bring income\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIf I have insurance, I\u0026rsquo;ll go to the doctor\u003c/p\u003e \u003cp\u003eNeed Medicaid\u003c/p\u003e \u003cp\u003eHome remedies\u003c/p\u003e \u003cp\u003eConfusing\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHealthcare\u003c/strong\u003e \u003cp\u003eThis category encompasses the women\u0026rsquo;s experiences with maternity care in the U.S. versus what they experienced in Afghanistan. It includes prenatal care and how they took care of themselves during pregnancy, their labor and delivery experiences in the hospital setting, and their postpartum practices, preferences, and engagement with healthcare services.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePregnancy\u003c/span\u003e: The women were pleased with the prenatal care they received in the U.S. They felt the providers were caring, helpful, and closely monitored them during pregnancy. They contrasted this with their experience of being pregnant in Afghanistan, where only two of the women had prenatal care. The women indicated not receiving special care and only sought healthcare if they had bleeding or pain. As one participant noted,\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eIt was really self-pregnancy back home\u0026rdquo;\u003c/em\u003e (Participant 12).\u003c/p\u003e \u003cp\u003eThey identified the poor economic situation that made the difference.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;In Afghanistan, since the economic situation is so bad, people cannot afford to make an appointment with doctors more frequently the way they can here. Usually, you only go to the doctor when you are in severe trouble, or there is something urgent\u0026rdquo;\u003c/em\u003e (Participant 3).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe participants described a lack of attention to personal health and heavy physical work in Afghanistan.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;In Afghanistan it was hard to think about my own health; it was not a thing. I was like, \u0026lsquo;Okay, I\u0026rsquo;m pregnant.\u0026rsquo; I didn\u0026rsquo;t even realize my blood sugar was elevated until I came here\u0026rdquo;\u003c/em\u003e (Participant 1).\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We lived in a joint family, so there was more workload on me. Now, I only need to take care of my kids, and that's really easy for me while pregnant\u0026rdquo;\u003c/em\u003e (Participant 8).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother woman described her life in Afghanistan when pregnant:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We didn\u0026rsquo;t have water at home, so we would have to bring water from the river so that was physically hard. I had a lot of fieldwork, animals, and a farm. Here in the U.S., everything is provided, so it\u0026rsquo;s really good\u0026rdquo;\u003c/em\u003e (Participant 20).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost of the women described a \u0026ldquo;healthy pregnancy\u0026rdquo; as one that was void of pain or abnormal bleeding. They self-relied on eating healthy and avoiding lifting heavy things to have a healthy pregnancy, which they found easier to do in the U.S.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Back in Afghanistan, the fact that there\u0026rsquo;s a lot of poverty, so nutrition was a big difficulty during the pregnancy due to our poor economic status. Here, the nutrition is not a problem, so I could eat well\u0026rdquo;\u003c/em\u003e (Participant 8).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBirthing\u003c/span\u003e: Most participants spoke positively about giving birth in the U.S. They felt that the nurses and physicians were kind and attentive. As most had previously given birth in Afghanistan, they explained that there were not enough physicians or nurses in Afghanistan to care for women in labor. As a result, they gave birth at home or in a hospital room with several other women. They were not allowed to have family members with them, and there were not enough nurses to give them attention, so they were on their own.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[Giving birth in Afghanistan] was bad in a sense because in one room there are 20 to 30 women giving birth at the same time\u0026rdquo;\u003c/em\u003e (Participant 9).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOverall, the women were grateful for their birthing experiences; however, a few women had negative experiences. One participant described her experience of having an episiotomy during birth without any medications in Afghanistan. When she went home, her pain worsened. She was told it would heal in a week, but it did not. It became infected.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I was in pain and suffering for a month and a half because the surgical site was badly infected; I couldn\u0026rsquo;t take care of the baby. It was an extremely painful and miserable experience. It was like giving birth not only once but 3 or 4 times. It was a disaster\u0026rdquo;\u003c/em\u003e (Participant 12).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe women appreciated the professional care they received from doctors and nurses in the U.S.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Then the nurses and doctors, when they found out that my husband was not there, they were trying to comfort me. It was a really good experience. I didn't even realize my husband was not there. I was really happy that they were so mindful and were there for me. They would make sure that I understand and explain the steps to me, like, \u0026lsquo;If things go wrong, then we will probably do a C-section.\u0026rsquo; They would tell me ahead of the time and make sure that I understand, and then explain the steps\u0026rdquo;\u003c/em\u003e (Participant 3).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn contrast,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Back in Afghanistan, the doctors were aggressive sometimes. They didn't have respect. They would cuss around me while I was giving birth which was really disrespectful\u0026rdquo;\u003c/em\u003e (Participant 2).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn addition to appreciating the care and attention they received in the U.S.; most women were grateful for the epidural.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;During my prenatal visits, the doctor explained that the epidural is an option. The experience was pleasant because I didn\u0026rsquo;t have to feel any pain\u0026rdquo;\u003c/em\u003e (Participant 13).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome of the women had negative experiences giving birth in the U.S. and expressed reluctance for medical interventions. Common perceptions among Afghan women regarding epidurals were that the procedure caused chronic headaches, led to Cesarean deliveries, and caused paralysis.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The majority of Afghan ladies want to go through the birthing process naturally. They don\u0026rsquo;t want to be induced. I got induced both times I gave birth in the U.S. versus back home; it was all-natural, and it went smoothly compared with the U.S. The [U.S.] experience was not pleasant for me, and I didn\u0026rsquo;t even know why I was being induced. Maybe it was because I was not exercising well?\u0026rdquo;\u003c/em\u003e (Participant 10).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant was frustrated that she had to have a Cesarean birth. She preferred natural births. The doctor was concerned that there was too little amniotic fluid, so they told her she needed a Cesarean delivery. Afterward, the doctor admitted that it was not necessary.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;That made me really frustrated. After that procedure, I am not back to normal; I still have aches and pains. It\u0026rsquo;s really devastating for me to not be able to take care of my kids\u0026rdquo;\u003c/em\u003e (Participant 17).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe other issue brought up by multiple participants was how uncomfortable they felt when there were males in the birthing room. Some women did not even want their husbands in the delivery room.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I did not prefer to have my husband in the delivery room because I felt uncomfortable. My husband was not comfortable either, but felt it was expected\u0026rdquo;\u003c/em\u003e (Participant 19).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 11 told a story about a friend who went to the hospital in labor, and there was a male doctor.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When they saw there was only a male doctor, they packed up and went home to give birth. The poor lady gave birth, and then it got complicated by a severe hemorrhage, so they got nervous and called the ambulance\u0026rdquo;\u003c/em\u003e (Participant 11).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant went through birth without an interpreter because a male was the only interpreter available at the hospital.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I just told them I don\u0026rsquo;t want the interpreter because he is a man, and I cannot have him there while I\u0026rsquo;m having the baby\u0026rdquo;\u003c/em\u003e (Participant 4).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePostpartum\u003c/span\u003e: The postpartum experiences regarding breastfeeding were overwhelmingly positive. All the women explained that breastfeeding was a usual and customary practice and that they breastfed their children for about two years.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t have any problem with breastfeeding my children; it\u0026rsquo;s a really smooth process.\u0026rdquo;\u003c/em\u003e (Participant 12).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRegarding child spacing, the women favored space between their children; their preferences ranged from two to five years between each child. The contraceptive methods they preferred varied. One mentioned she had a tubal ligation after her seventh child. A few of the women used the copper IUD, and others used condoms and oral contraceptives. Those who used the injection (Depo Provera) didn\u0026rsquo;t like the weight gain. Those with the implant perceived it to cause depression, headaches, and nausea. A few of the women who tried oral contraceptives stopped due to their side effects and resorted to the natural method.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I do not prefer medication. I just like the natural way to not have kids\u0026rdquo;\u003c/em\u003e (Participant 15).\u003c/p\u003e \u003cp\u003eSome women discussed the lack of information provided by healthcare providers about contraceptive options.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003ea lot of these Afghan ladies want to have some contraceptive after birth. But the fact that they don\u0026rsquo;t get a follow-up with their obstetrician, and they\u0026rsquo;re not educated enough that they can get pregnant right after giving birth, so before they even go to the OB, they\u0026rsquo;re already pregnant again\u0026rdquo;\u003c/em\u003e (Participant 5).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant shared that they need additional contraceptive education.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It\u0026rsquo;s hard to take care of ourselves with these back-to-back children. We don\u0026rsquo;t know about the birth control options; we tend to stop them if we have any adverse effects\u0026rdquo;\u003c/em\u003e (Participant 12).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCulture\u003c/strong\u003e \u003cp\u003eThe women highlighted the cultural contrasts between Afghanistan and the U.S. They noted that the most difficult issue in the U.S. was the communication barrier, but also the discordant cultural values related to their role as a woman and the sensitivity of reproductive health topics.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCommunication\u003c/span\u003e: As the women reflected on their maternal health experiences, they identified the most challenging concern to be the language barrier, which they did not face in Afghanistan.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The biggest problem among Afghan women here is the fact that they don't know the language, so it just makes it really difficult for them to do anything for themself\u0026rdquo;\u003c/em\u003e (Participant 11).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost of the women stated that their husbands or professional interpreters helped them understand the childbirth protocol in the U.S. Some women preferred their husbands to interpret rather than the professional interpreter.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We were given the option of an interpreter, but I preferred my husband to do the interpretation for me because that way, I understand it better\u0026rdquo;\u003c/em\u003e (Participant 7).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen described instances when only a male interpreter was available, so they opted to be quiet or have a family member interpret instead.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Then it gets difficult if the interpreter is a male. That\u0026rsquo;s when we are not comfortable sharing concerns, and we usually don\u0026rsquo;t talk about it. We keep it to ourselves \u0026rsquo;cause we are not comfortable talking about any reproductive concerns\u0026rdquo;\u003c/em\u003e (Participant 9).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e One participant was frustrated with the interpreter.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I took my son with me to the appointment, and I was having some trouble. When I was there, the interpreter translated my message completely differently to the doctor, and my son noticed and told him, 'Hey, that's wrong. That's not what my mom is saying.' Then the interpreter got mad at the little kid, \u0026lsquo;How dare you tell me I'm wrong? I'm the interpreter. I know what I'm saying.\u0026rsquo; Yeah, we had a big problem, not with the doctor or the staff, but the interpreter was not communicating the message right\u0026rdquo;\u003c/em\u003e (Participant 2).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost women acknowledged having access to interpretation services at the facility where they were treated, but at times, misunderstandings occurred.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When I went to give birth they asked me, \u0026lsquo;Are you having a boy or a girl?\u0026rsquo; I didn't understand what boy or girl meant, so I told them, \u0026lsquo;I'm having a boy.\u0026rsquo; They arranged paperwork for circumcision and all that, and then I couldn't understand so I signed on everything. And then a nurse who spoke Farsi came and explained what boy and girl meant. And then I told them, \u0026lsquo;No. I'm having a girl,\u0026rsquo; so they had to cancel the whole paperwork and all that\u0026rdquo;\u003c/em\u003e (Participant 5).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e In addition to the language component of communication, the participants also described their appreciation of anticipatory guidance and explanations of the process. Three women felt the doctor did not explain medical interventions (Participants 5, 10, 17). Several women expressed interest in learning more about reproductive health and child spacing options. They felt that Afghan women needed educational sessions and language classes.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah, so after my second daughter, when I went for the postpartum visit they said, \u0026lsquo;Oh, you're not having bleeding and everything. You're done with us and we're not going to be seeing you anymore because you gave birth, and everything looks okay.\u0026rsquo; I was not even given any information; I didn't understand anything because I couldn't speak English. I was not given any information about contraceptives. I asked people from Afghanistan to send me birth control medication so I could use that as a contraceptive\u0026rdquo;\u003c/em\u003e (Participant 5).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen probed further about preferences for health education sessions, Participant 8 commented,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eA lot of Afghan ladies, they have kids up to seven and eight. Usually, they are not able to go anywhere\u0026mdash;just because they have a lot of kids. I think if there is\u0026mdash;if somebody came into our house and gave us information; that would be so helpful.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHusband\u003c/span\u003e: Given that all the participants were married, their relationship with their husbands was a common topic that revealed aspects of their culture. The women's narratives were intertwined with a strong sense of respect, reliance, and appreciation for their husbands, yet at the same time, a shared understanding of traditional Afghan culture of women submitting to men as the decision-makers. The participants described both satisfaction with more freedom for women in the U.S. and fear and challenges with the discordant cultures.\u003c/p\u003e \u003cp\u003eWhen asked what actions women took concerning a health problem, most said they would share the problem with their husbands first. He would decide what to do next, such as making an appointment with the doctor.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If I\u0026rsquo;m not comfortable sharing my health concern with the doctor, then I share it with my husband, then he will talk to the doctor\u0026rdquo;\u003c/em\u003e (Participant 14).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOther women shared how grateful they were for their husbands. Participant 7 described complicated pregnancies that included hyperemesis and diabetes. When asked how she managed, she responded,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMy husband was the biggest support for me. He would try to look after our little girl and tried to help with the house chores; he helped me record the blood sugar levels and taught me how to operate the machine. My husband is supportive so that helped me through that pregnancy.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome of the participants felt it would be helpful for healthcare providers to understand traditional marital dynamics for Afghan families. Since the husband makes the decisions for the wife, healthcare providers should provide health recommendations to the husband.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Ladies really respect their husbands. If the husband wants to have more kids, they don\u0026rsquo;t tell their husbands, \u0026lsquo;Hey, I cannot do it. My body is not able to get another pregnancy to term.\u0026rsquo; Husbands don\u0026rsquo;t usually listen to their wives, but they do listen to the doctor if the doctor tells them, \u0026lsquo;Your wife needs some time before she gets pregnant again.\u0026rsquo; They will most likely take that into consideration instead of their wives telling them\u0026rdquo;\u003c/em\u003e (Participant 3).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDespite a few of the participants sharing stories about other women dealing with a controlling husband, most of the women felt that their husbands were supportive and addressed their needs.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFamily\u003c/span\u003e: As the women reflected on their maternal health experiences, they shared that they usually only discuss reproductive issues with their close female family members. Many of them did not even learn about childbearing issues until they were pregnant themselves. None received health education in a formal setting, such as school.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I learned about pregnancy and childbirth by seeing other family members going through the process and talking to females in the family\u0026rdquo;\u003c/em\u003e (Participant 10).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant 14 commented,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eNo one ever really talked about it\u0026ndash;like how pregnancy happened or what the 9 months of pregnancy is like and then the delivery.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA couple of the women stated that by living in the U.S., they had learned to search the internet to educate themselves on their concerns or questions. For example, Participant 10 wondered about having sex during pregnancy and was too shy to ask the doctor. She also wondered which sleeping position was best during pregnancy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI researched Google and found that sleeping on the left side and using a pregnancy pillow is a good option.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe participants were in favor of educational sessions on reproductive health and contraceptive options, as they described the cultural taboo surrounding discussing reproductive health topics.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s considered a shameful topic or taboo; it\u0026rsquo;s not a topic that women will share with each other or talk about it in a gathering, so usually they keep it to themselves\u0026rdquo;\u003c/em\u003e (Participant 10).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSeveral of the participants explained that Afghan women are \u0026ldquo;shy.\u0026rdquo; They are afraid to talk about their health problems. A few participants painted the difference between women who came from more conservative rural areas and women who lived in the city.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When it comes to ladies from villages, they don\u0026rsquo;t know how to get help for themselves. Sometimes they miss out, like miss their appointments, and they\u0026rsquo;re shy. They are afraid to tell the doctor about it, such as problems with their period\u0026rdquo;\u003c/em\u003e (Participant 3).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe other common concern was that the women were busy with childcare responsibilities that left no time for socializing with other women.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I stay very busy with my kids and don\u0026rsquo;t get together with other Afghans. I never have conversations to see what some of the problems are that they are facing or how I could help those problems\u0026rdquo;\u003c/em\u003e (Participant 6).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant wished women could get together but concurred,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The fact that most of these women have a lot of kids to take care of. They don\u0026rsquo;t drive\u0026mdash;they are just homebound\u0026rdquo;\u003c/em\u003e (Participant 9).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAccess to Care\u003c/strong\u003e \u003cp\u003eThe women acknowledged the limited access to healthcare in Afghanistan due to extreme resource limits; but also identified structural barriers they encountered in the U.S. as they sought health care services.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTransportation\u003c/span\u003e: One of the primary barriers to women attending prenatal care appointments was the lack of transportation. Only one out of the twenty women mentioned that she could drive herself and had a car. The others relied on their husbands to drive them.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;On the days my husband went to work, I would just cancel the appointment because I couldn\u0026rsquo;t drive\u0026rdquo;\u003c/em\u003e (Participant 5).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSeveral women noted that this was a problem common to Afghan women.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The biggest challenge for women in the Afghan community is transportation. Most of us do not drive, so we cannot make the doctor\u0026rsquo;s appointments. We must wait for our husbands\u003c/em\u003e\u0026rdquo; (Participant 17).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFinances\u003c/span\u003e: Most women noted that their financial situations had improved in the U.S. However, some mentioned the financial strain on their husbands about making ends meet and their desire to assist with income generation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The husband is the only one that brings income to the house. That\u0026rsquo;s used up monthly. Women are trying, but they\u0026rsquo;re unable to help their husbands with the income\u0026rdquo;\u003c/em\u003e (Participant 8).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eInsurance coverage\u003c/span\u003e: Most women reported having Medicaid or some form of insurance coverage. However, some mentioned that when their pregnancy coverage ran out, they did not know how to navigate follow-up care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If you have insurance, then you can go to the doctor; if not, then you are just on your own. One of the new Afghan refugees is nine months pregnant and doesn\u0026rsquo;t have insurance or any paperwork. She is frail. I tried to help, but she doesn\u0026rsquo;t have health insurance. I don\u0026rsquo;t know what to do\u0026rdquo;\u003c/em\u003e (Participant 2).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe participants stated that the primary healthcare resource women need is Medicaid coverage.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eSome of these Afghan ladies have been sick for a long time. If the government can help, it would be helpful because most Afghan ladies stay home sick. They fear they will go to a doctor and be sent a high bill, which they cannot pay. It\u0026rsquo;s just so hard when you are sick and have many kids to look after\u0026rdquo;\u003c/em\u003e (Participant 8).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome women described their inability to understand and navigate the U.S. healthcare system.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When I got pregnant here the first time, it was so confusing; I didn\u0026rsquo;t know where to go, so I went to the emergency room. I told them, \u0026lsquo;I\u0026rsquo;m pregnant; what do I do?\u0026rsquo; Then, they guided me, \u0026lsquo;You need to make an appointment, and once they find out you\u0026rsquo;re pregnant, you can apply for insurance.\u0026rsquo; That\u0026rsquo;s how I figured it out\u0026rdquo;\u003c/em\u003e (Participant 3).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings from this study contribute critical insights into Afghan women's perceptions, preferences, and maternal health experiences in the U.S. We found that Afghan women appreciated the kind, mindful, and attentive care of the nurses and physicians providing their reproductive healthcare. They contrasted their U.S. experiences with what they were used to in Afghanistan, describing extremely resource-poor conditions. Similarly, Shafiei et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] found that Afghan women in Australia felt the kind, caring attitude of the healthcare provider was the most important factor in their perception of maternity care. In contrast, Afghan refugee women in Iran attributed their poor maternal health experience to discrimination and a lack of attention. They felt that their concerns were ignored and that they were given incompetent midwives and doctors. These experiences caused mistrust and reluctance to utilize health services [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A comparative review of studies in five countries revealed that immigrant and non-immigrant women had a similar desire for safe and attentive care. However, immigrant women faced communication problems and perceived a need for more kindness and respect [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The women in our study faced communication barriers and desired precise information; however, most did not perceive discrimination and felt the providers were kind and attentive.\u003c/p\u003e \u003cp\u003eWe found that women were opposed to excessive medical interventions, including inductions and Cesarean deliveries. However, most were in favor of having an epidural during labor, especially if the procedure was explained ahead of time. Providing anticipatory guidance with health literacy levels in mind is essential for Afghan women in Australia [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The U.S. has one of the highest Cesarean delivery rates in the world (32.1%) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In contrast, the World Health Organization reported a Cesarean delivery rate of 2.7% in Afghanistan [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The difference in maternity care practices can contribute to discordant expectations and disappointment, as was evident with a few of the participants in our study who were attributing their chronic pain to an unnecessary Cesarean delivery. Healthcare providers should consider providing extensive explanations of medical procedures ahead of treatment.\u003c/p\u003e \u003cp\u003eThe fact that 65% of our participants had no formal education and only 25% could read and write in their primary language speaks to the gap in health literacy and the potential for misunderstanding health providers\u0026rsquo; instructions. Communication was a crucial factor in their maternal health experiences, including the critical role of the interpreter or a family member, most commonly, their husband, who spoke English. A study in Afghanistan found a correlation between low maternal health literacy and poor pregnancy outcomes [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Even more reason to ensure clear communication that includes confirmation of understanding. A study in California with older Afghan refugee women found that miscommunication led to mistrust of healthcare providers [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Mistrust of healthcare providers is more common among immigrant patients [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Health providers should consider using visual or audio rather than written material to improve communication and health literacy. A study in Afghanistan found a high satisfaction rate with community health workers who used a computer tablet-based health video library to enhance health counseling sessions [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother clear cultural preference was for only female healthcare providers and interpreters. The women are culturally \u0026ldquo;shy\u0026rdquo; and do not feel comfortable explaining their feelings or symptoms\u0026mdash;especially when it has to do with their reproductive health. Having a male in the room made it even more challenging to express their concerns. Some studies found that Afghan women are embarrassed to ask questions because of their illiteracy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The participants in our study acknowledged the topic of reproductive health as taboo, where the only male involved should be the woman\u0026rsquo;s husband. Healthcare providers in the U.S. should understand this cultural value that may get overlooked and result in ineffective patient-provider interactions, leading to poor health outcomes.\u003c/p\u003e \u003cp\u003eCultural insights revealed a complex interplay in the husband-wife relationship that was marked by a common understanding that the husband is the decision-maker, and the women primarily relied on their husbands for interpretation, transportation, and communicating symptoms with healthcare providers. They expressed gratefulness when their husband assisted and supported them through the process of pregnancy and birthing. They reflected, that in Afghanistan, female family members provided support during pregnancy and childbirth; so, in the U.S. where they lacked extended family, they relied more on their husbands.\u003c/p\u003e \u003cp\u003eThis group of 20 women had been in the U.S. for an average of five years; therefore, their views and preferences had likely evolved as they assimilated in the U.S. None of the women mentioned experiencing violence from their husbands. Yet, surveys within Afghanistan from 2015 revealed that 46.1% of women experienced sexual or physical violence from their husbands [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Our study and other studies of Afghan refugee women revealed complementary husband-wife bonds through childbearing [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Afghan women in Iran talked about how their husbands gave them sacrificial support\u0026mdash;even begging for money in the streets to pay hospital bills [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Given our findings, U.S. healthcare providers must avoid making assumptions about the husband-wife relationship; instead, they should respect and nurture for the strengths it brings.\u003c/p\u003e \u003cp\u003e Most of our participants were successful in breastfeeding their children for two years. As 100% of the women identified as Muslim, it is worth noting that the Quran states that a child has a right to receive breastmilk until the age of two years [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This successful breastfeeding practice in the community should be highlighted and examined further to encourage sustainment throughout the assimilation process and subsequent generations. This protective factor can serve as an example for U.S. women and families of other cultures.\u003c/p\u003e \u003cp\u003eParticipants were open to using child spacing methods. They reported using a variety of contraception types. None of the women mentioned religious opposition to contraception but mentioned adverse effects that drove them to natural methods. The findings from studies in Australia also cited that both men and women were open to contraception, but the preferences varied due to side effects [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Even studies in refugee camps in Asia found a rate of 54% contraception utilization among Afghan women [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Aside from the challenges with contraceptive side effects, our findings revealed a lack of communication between the provider and the woman about child spacing options.\u003c/p\u003e \u003cp\u003eThe women outlined several barriers to accessing healthcare, including the tendency to treat with natural remedies and to \u0026ldquo;grin and bear it\u0026rdquo; until it was causing significant problems. They needed confirmation from their husbands first, then transportation and language interpretation assistance. If they did not have Medicaid coverage, they were unlikely to seek care unless it was a life-or-death situation. Again, the women had to rely on their husbands to navigate health services. Studies in Australia found similar dynamics, with Afghan men playing significant roles in supporting their wives throughout the pregnancy and birth process. Health professionals rarely engaged with the husbands regarding their concerns or perspectives on the pregnancy [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Within the U.S. culture of emphasizing patient autonomy, health professionals need to reinvigorate their approach to Afghan families, consider engaging the husband to accentuate the strengths of their support and consider the social and economic burdens faced by Afghan men as husbands.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe fact that the Afghan culture is strikingly different than the U.S. mainstream culture can lead to stereotypical assumptions, poor communication, and poor health outcomes.\u003c/p\u003e \u003cp\u003eThe voices of Afghan women should guide healthcare providers in delivering patient-centered, culturally sensitive maternity care that promotes healthy families and communities. The women\u0026rsquo;s stories move us to address the risk factors they face, which include communication barriers, discordant cultural values, lack of social/community networks, and the lack of transportation and healthcare navigation. The protective factors to nurture are attitudes of gratefulness and resilience, strong husband support, commitment to breastfeeding, openness to child spacing and desire to learn more.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cp\u003eU.S United States\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval and consent to participate:\u003c/u\u003e Ethical approval was obtained from the University of Texas Health Science Center San Antonio Institutional Review Board. They determined the study was non-regulated research (Protocol #20210606NRR). Informed consent was obtained from all the participants.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication:\u003c/u\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials:\u003c/u\u003e The fully anonymized datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request from authenticated researchers.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u003c/u\u003e: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding:\u003c/u\u003e This study received funding from the Nursing Advisory Council at the University of Texas Health Science Center San Antonio.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors\u0026rsquo; contributions:\u003c/u\u003e HW and SG designed the study. HW was the principal investigator. FS assisted with participant recruitment. HW and FS conducted the interviews, with qualitative research guidance from SG. MF and HW carried out the data analysis with assistance from SG and FS. HW wrote the manuscript, with all authors drafting, reviewing, and approving the final version.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAcknowledgements:\u003c/u\u003e The authors would like to thank the women who gave their time to participate in this study and the staff at the Center for Refugee Services for their collaboration and support of health research efforts to improve the lives of refugees in the community.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eShahrani, M. Resisting the Taliban and Talibanism in Afghanistan: Legacies of a century of internal colonialism and cold war politics in a buffer state. J Int Aff. 2000;5:4.\u003c/li\u003e\n\u003cli\u003eRamos AA. Considerations in designing trauma-focused interventions for displaced Afghan women. 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Int J Equity Health. 2017; doi:10.1186/s12939-017-0617-8.\u003c/li\u003e\n\u003cli\u003eDadras O, Taghizade Z, Dadras F, Alizade L, Seyedalinaghi S, Ono-Kihara M, Kihara M, Nakayama T. \"It is good, but I can't afford it \u0026hellip;\" potential barriers to adequate prenatal care among Afghan women in Iran: a qualitative study in South Tehran. BMC Pregnancy Childbirth. 2020; doi:10.1186/s12884-020-02969-x.\u003c/li\u003e\n\u003cli\u003eSandelowski M. Qualitative analysis: What it is and how to begin. Res Nurs Health. 1995;18: 371-355.\u003c/li\u003e\n\u003cli\u003eSchreier M. Qualitative content analysis in practice. Sage Publishing. 2012; ISBN 978144628992.\u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Quality Health Care. 2007;19 (6): 349\u0026ndash;357. https://doi.org/10.1093/intqhc/mzm042.\u003c/li\u003e\n\u003cli\u003eShafiei T, Small R, McLachlan H. Women\u0026rsquo;s views and experiences of maternity care: A study of immigrant Afghan women in Melbourne, Australia. Midwifery. 2012; 28:198-203.\u003c/li\u003e\n\u003cli\u003eSmall R, Roth C, Raval M, Shafiei T, Korfker D, Heaman M, McCourt C, Gagnon A. Immigrant and non-immigrant women's experiences of maternity care: a systematic and comparative review of studies in five countries. BMC Pregnancy Childbirth. 2014. doi:10.1186/1471-2393-14-152.\u003c/li\u003e\n\u003cli\u003eCenter for Disease Control and Prevention: Cesarean delivery rate by state. 2021. https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm. Accessed 30 Jan 2024.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Eastern Mediterranean Region. Afghanistan Department of Health Services. 2015. https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/cesareans.htm. Accessed 30 Jan 2024.\u003c/li\u003e\n\u003cli\u003eRostamzadeh M, Ezadi Z, Hosseini M, Husseini AA. Maternal health literacy and pregnancy outcomes in Afghanistan. J Educ Health Promot. 2022 Dec 28;11:421. doi:10.4103/jehp.jehp_746_22.\u003c/li\u003e\n\u003cli\u003eSiddiq H, Alemi Q, Lee E. A qualitative inquiry of older Afghan refugee women\u0026rsquo;s individual and sociocultural factors of health and health care experiences in the United States. J Transcult Nurs. 2023; 34(2):143-150. doi:10.1177/10436596221149692.\u003c/li\u003e\n\u003cli\u003eDal Santo LC, Rastagar SH, Hemat S, Alami SO, Pradhan S, Tharaldson J, Dulli LS, Todd CS. Feasibility and acceptability of a video library tool to support community health worker counseling in rural Afghan districts: a cross-sectional assessment. Confl Health. 2020 Aug 5;14:56. doi:10.1186/s13031-020-00302-z.\u003c/li\u003e\n\u003cli\u003eUSAID Demographic Health Survey Program: Afghanistan demographic health survey 2015. https://dhsprogram.com/topics/gender/index.cfm. Accessed 1 Feb 2024.\u003c/li\u003e\n\u003cli\u003eRiggs E, Yelland J, Szwarc J, Wahidi S, Casey S, Chesters D, Fouladi F, Duell-Piening P, Giallo R, Brown S. Fatherhood in a new country: A qualitative study exploring the experiences of Afghan men and implications for health services. Birth. 2016;43(1):86-92. doi:10.1111/birt.12208.\u003c/li\u003e\n\u003cli\u003eHefnawi FI. Lactation in Islam. Popul Sci. 1982;(3):7-9.\u003c/li\u003e\n\u003cli\u003eRusso A, Lewis B, Ali R, Abed A, Russell G, Luchters S. Family planning and Afghan refugee women and men living in Melbourne, Australia: new opportunities and transcultural tensions. Cult Health Sex. 2020;22(8):937-953. doi:10.1080/13691058.2019.1643498.\u003c/li\u003e\n\u003cli\u003eHossain MA, Dawson A. A systematic review of sexual and reproductive health needs, experiences, access to services, and interventions among the Rohingya and the Afghan refugee women of reproductive age in Asia. WHO South East Asia J Public Health. 2022;11(1):42-53. doi:10.4103/WHO-SEAJPH.WHO-SEAJPH_144_21.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Maternal Health, Refugees, Reproductive Healthcare, Afghan Women, Cultural, Qualitative, Birthing Experience","lastPublishedDoi":"10.21203/rs.3.rs-4193621/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4193621/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The number of Afghan families in the U.S. has grown over the past two decades, yet there is a paucity of research focused on their healthcare experiences. Afghan families have one of the highest fertility rates in the world and typically have large families. As the U.S. faces rising maternal mortality rates, it is crucial to understand factors that affect health outcomes for culturally distinct groups. We aimed to better understand Afghan women’s experiences of giving birth in the U.S. and to identify protective and risk factors that affect Afghan women’s reproductive health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Twenty Afghan women who had given birth in the U.S. within the past two years participated in audio-recorded interviews. The first and second authors conducted each interview using a semi-structured interview guide. The authors used a deductive, in vivo coding method to analyze the transcribed narrative data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e We identified three over-arching categories with corresponding sub-categories: 1) Healthcare: pregnancy, birthing, and postpartum, 2) Culture: communication, husband, and family, 3) Access to Care: transportation, financial, and insurance. The participants expressed perspectives of gratefulness and positive experiences, yet some described stories of poor birth outcomes that led to attitudes of mistrust and disappointment. Distinct cultural preferences were shared, providing invaluable insights for healthcare providers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003cem\u003e \u003c/em\u003eThe fact that the Afghan culture is strikingly different than the U.S. mainstream culture can lead to stereotypical assumptions, poor communication, and poor health outcomes.\u003c/p\u003e\n\u003cp\u003eThe voices of Afghan women should guide healthcare providers in delivering patient-centered, culturally sensitive maternity care that promotes healthy families and communities. The women’s stories highlight risk factors, including communication barriers, discordant cultural values, lack of social/community networks, and lack of transportation/healthcare navigation. The protective factors to nurture are attitudes of gratefulness and resilience, strong husband support, commitment to breastfeeding, openness to child spacing, and desire to learn more.\u003c/p\u003e","manuscriptTitle":"“It’s Different Here” Afghan Refugee Maternal Health Experiences in the United States","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-08 19:31:40","doi":"10.21203/rs.3.rs-4193621/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-10T13:35:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-10T10:01:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200389513136019693505169260813023782100","date":"2024-06-10T08:05:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-30T21:53:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319554431230939281758817174395177070946","date":"2024-05-29T21:23:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78850480726879340366329792055363165827","date":"2024-05-29T17:49:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274543491435952767421945270040960318146","date":"2024-05-25T19:24:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-24T17:05:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-04-03T20:15:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-02T05:41:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-02T05:41:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-03-30T21:51:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d5f1fe56-0cdd-472d-ba99-2338db228bd0","owner":[],"postedDate":"April 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-01T16:16:10+00:00","versionOfRecord":{"articleIdentity":"rs-4193621","link":"https://doi.org/10.1186/s12884-024-06678-7","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2024-07-16 15:57:01","publishedOnDateReadable":"July 16th, 2024"},"versionCreatedAt":"2024-04-08 19:31:40","video":"","vorDoi":"10.1186/s12884-024-06678-7","vorDoiUrl":"https://doi.org/10.1186/s12884-024-06678-7","workflowStages":[]},"version":"v1","identity":"rs-4193621","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4193621","identity":"rs-4193621","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}