Providing OB-GYN Care to Afghans in the U.S.
OB-GYN Care for Afghans: A Toolkit for Clinicians

On this page:
Strengths-based approaches
Cultural considerations
Health care navigation
Medical history
Family planning
Prenatal care
Labor and delivery
Postpartum and infant care
References
 

• All-female healthcare teams are typically preferred for female patients. Ask patients what their gender preferences are, including in the event of an emergency if female providers are not available.
• Provide general information about the U.S. healthcare system, if possible. Consider discussing what to do in emergencies, consent, and confidentiality. 
• It is essential to ensure the presence of a medical interpreter, preferably certified, during clinic visits. Pashto and Dari are the most commonly spoken languages among Afghans.¹
• Muslim patients may dress modestly, avoid alcohol, pork and its byproducts (including pork-derived gelatin), and fast (abstain from food and water) from sunrise to sunset during the month of Ramadan. People who are chronically ill, pregnant, breastfeeding, or menstruating may be exempt from fasting practices.²
• Patients may already be familiar with IUDs, pills, injections, implants, and condoms as they are available in urban areas of Afghanistan. Women who are married, educated, affluent, and/or reside in urban areas may be more likely to have utilized such contraceptives.³
• Consider educating patients about the value of regular prenatal and postpartum care, including when visits occur and what happens during appointments.
• Birth plans may be helpful to ensure patients’ and families’ preferences are honored during the birthing process. Addressing potential barriers they might encounter such as communication, technology, transportation, and childcare is also important.

Strengths-based approaches

The Afghan community, like all newcomer communities, enriches our society and culture. Afghan new arrivals are resilient and have strong values of community and family.⁴ Multi-generational homes are common and can create a strong foundation of support during times of stress and joy. Familial support can positively impact physical and emotional wellbeing, including through sharing household tasks and helping take care of children, and can potentially enable family members to pursue education and/or work. Recognizing and drawing on these strengths when collaborating in care can build trust, enhance quality of care, and improve patient outcomes.⁵

Cultural considerations

Gender preferences

When interacting with Afghan patients, respect for provider gender preferences is vital. All-female healthcare teams are typically preferred for female patients.⁶ Providers should discuss healthcare team gender preferences with patients, including in the event of an emergency if female providers are not available.⁷ Male interpreters may be accepted if they are virtual and cannot see the patient. While it is preferable to see the patient alone, she may request to be accompanied by a family member. If it is not possible to see the patient alone or it is not the patient’s preference, it may be helpful to ask to do a portion of the exam alone and use that time to ask sensitive questions (such as about contraception or personal safety at home).

Communication preferences 

It is common in Afghan culture to consult with family members regarding medical decisions, so some patients may desire time to discuss with family prior to making decisions.⁸ Some Afghan women may avoid eye contact as a form of modesty, especially if their husband is present during appointments, and may defer to their husband when asked questions. However, Afghan women are often curious and eager to learn.⁶ It is important for providers to build trust with and create space for patients, especially for those not empowered to advocate for themselves, to ask questions and express their preferences and needs.

Religious considerations

Muslim patients may dress modestly and may also fast (abstain from food and water) from sunrise to sunset during the month of Ramadan. People who are chronically ill, pregnant, breastfeeding, or menstruating may be exempt from fasting practices. However, some people may still opt to fast. The dates of Ramadan shift every year according to the lunar calendar. Discuss a plan for Ramadan with patients prior to the start date, including if they plan to fast, medication adjustments, nutrition advice for the pre-dawn and evening meals, and increased rest during daytime hours.² Muslim patients may require alternative meals during hospital stays, as they may avoid alcohol, pork and its byproducts (including gelatin), and any animal that wasn’t slaughtered according to Islamic guidelines (halal is permissible and haram is forbidden).⁹ Consider discussing dietary preferences while completing the birth plan and ensure there are appropriate options for the patient and/or discuss a plan to bring in outside food. Further, certain medications may contain gelatin derived from pork products. Islamic scholars have endorsed the use of such medical products, but alternatives may be preferred by some patients.¹⁰ No exhaustive list exists of pork-containing medications, so it may be necessary to review active or inactive ingredients from the manufacturer and/or discuss with a pharmacist.

Health care navigation

Review the various members of their healthcare team, consent, confidentiality, and limits to confidentiality with all patients at the beginning of the first visit. It is essential to ensure the presence of a certified medical interpreter during clinic visits.

Medical history

Sensitive questions, including those regarding personal safety or menstruation, are best to ask without the presence of other family members or male staff. Use clinical judgment to determine the most appropriate way to privately discuss topics with patients; strategies may include noting that it is clinic protocol to discuss certain topics with patients one-on-one, asking sensitive questions when visitors leave the room during physical exams, or walking with the patient to the restroom during urine sample collection. It may be challenging to determine an expected date of delivery in the early days of a pregnancy, as some Afghan women, especially those who have had limited access to education, may not track their menstrual period or may not use the Gregorian calendar. Patients’ responses will be influenced by the systems of care they previously experienced. Therefore, certain routine questions or concepts in the U.S. healthcare system (e.g., developing a birth plan) may not be familiar. Additionally, be aware that indications for C-sections in Afghanistan may be different and that access may have been limited.¹¹

Family planning

It is important for providers to initiate conversations about family planning and contraception early on and provide opportunities to ask questions, as not all patients feel comfortable or know how to introduce the topic. Patients may already be familiar with IUDs, pills, injections, and implants as they may be available in Afghanistan, especially in urban areas.³ However, their feelings or thoughts towards contraception may be influenced by their home health system and culture, as well as family members’ or friends’ prior experiences with contraception. Preferences for family planning methods may also change upon arrival to the U.S. ¹²

To dispel any misconceptions and assist the patient in choosing a family planning method that fits her needs, consider reviewing the following information:

• Available options and resources
• Efficacy and reversibility of methods
• Duration of long-acting contraceptives
• Common side effects and how they may or may not align with the patient's goals
• Appropriate methods for using contraceptives to maximize efficacy

Prenatal care

Patients may not be aware of the importance of preventive care. As such, consider educating patients about the value of regular prenatal care, and encourage them to attend all appointments. During initial visits, it may also be beneficial to review expectations for the prenatal care schedule, as well as medication safety, vaccines, labs, home safety, and dietary recommendations. Use the initial visit as an opportunity to screen for elevated blood lead levels and need for mental health services. More information on lead toxicity screening and mental health is available on General Health Care Recommendations. Considering consanguineous marriage, such as that between first or second cousins, is not uncommon in Afghanistan, arrange private consultations to address potential genetic implications, as appropriate.⁸

Labor and delivery

Discussing the birth plan with patients in advance will allow them to consult with their families, as desired. As part of the birth plan conversation, consider discussing and documenting in the medical record: 

• Plan for emergencies and the onset of labor. Many newly-arrived Afghans have barriers to communication, technology, transportation, and/or childcare. It is important to review the signs and symptoms of labor and emergencies like preeclampsia, how to contact the care team, and when and how to present to the hospital. Also consider discussing a plan in case an all-female care team is not possible. If the patient has limited English proficiency, it may be helpful to provide a written document containing the patient’s name, date of birth, language, anticipated delivery hospital, and provider that she may provide to emergency medical services in case of emergency transport.
• Traditional or cultural practices that the patient would like to incorporate. 
• Father’s presence in the delivery room. Consider sharing that it is common and appropriate in the U.S. for fathers to be present in the delivery room, though not required. If possible, offer the option of a privacy screen to separate the father from the patient in the labor room, as this may be more comfortable.
• Labor and delivery practices in the U.S. Experiences in the U.S. will be different from prior experiences in Afghanistan. Consider reviewing members of the care team, delivery methods, induction, pain management options, C-section indications, episiotomy risks and aftercare, what is offered while the patient is admitted (e.g., food, formula, gowns, toiletries, etc.), common lengths of stay, and visitor protocols. 
• Newborn care, including newborn screening, bathing, rooming in or newborn nursery care, and if the family would prefer to bathe the baby themselves. 
• Male circumcision, which is a common practice among Afghans. When discussing the option for male circumcision prior to delivery, include that it is an elective procedure, the average cost and potential insurance coverage, and when and how it will occur. 
• Naming the baby. Consider asking if the family would like to bring a note to the hospital with the baby’s name written in English to provide for the birth certificate. Some new Afghan arrivals struggle to spell their child’s name in English and may ask a friend, family member, or community volunteer to assist them in advance.

Postpartum and infant care

Encourage patients to present for postpartum visits, and consider scheduling these visits prior to hospital discharge. During these visits, discuss pain management, physical activity, breastfeeding support, and resources such as those described in the connecting to other resources section on General Health Care Recommendations. 

Create space and initiate conversations about family dynamics at home and goals for family planning. As with all postpartum visits, complete a mental health screening exam. More information can be found in the mental health section on General Health Care Recommendations.

In addition to discussing the mother’s health, address the need for pediatric or family medicine follow-up visits for the baby after birth. Advise patients about the importance of well-child visits and childhood vaccinations. If possible, provide families with educational materials regarding best practices for caring for the newborn over the first few weeks. These topics could include:

• Use of a thermometer
• Sleep safety, including avoidance of co-sleeping to reduce the risk of sudden infant death syndrome (SIDS), and use of a bassinet or cradle
• Hygiene
• Feeding, including information about lactation and latching. Consider making a referral to a lactation consultant to assist with any common difficulties in breastfeeding, including how to hold or angle the baby while feeding, knowing when to switch breasts, and what to do about breast or nipple pain
• Baby-proofing the living environment
• Car safety, including having an appropriately sized car seat

References