Progress and inequities in maternal mortality in Afghanistan (RAMOS-II): a retrospective observational study

Background The risk of maternal death in Afghanistan is among the highest in the world; however, the risks within the country are poorly understood. Subnational maternal mortality estimates are needed along with a broader understanding of determinants to guide future maternal health programmes. Here we aimed to study maternal mortality risk and causes, care-seeking patterns, and costs within the country. Methods We did a household survey (RAMOS-II) in the urban area of Kabul city and the rural area of Ragh, Badakshan. Questionnaires were administered to senior female household members and data were collected by a team of female interviewers with secondary school education. Information was collected about all deaths, livebirths, stillbirths, health-care access and costs, household income, and assets. Births were documented using a pregnancy history. We investigated all deaths in women of reproductive age (12–49 years) since January, 2008, using verbal autopsy. Community members; service providers; and district, provincial, and national officials in each district were interviewed to elicit perceptions of changes in maternal mortality risk and health service provision, along with programme and policy documentation of maternal care coverage. Findings Data were collected between March 2, 2011, and Oct 16, 2011, from 130 688 participants: 63 329 in Kabul and 67 359 in Ragh. The maternal mortality ratio in Ragh was quadruple that in Kabul (713 per 100 000 livebirths, 95% CI 553–873 in Ragh vs 166, 63–270 in Kabul). We recorded similar patterns for all other maternal death indicators, including the maternal mortality rate (1·7 per 1000 women of reproductive age, 95% CI 1·3–2·1 in Ragh vs 0·2, 0·1–0·3 in Kabul). Infant mortality also differed significantly between the two areas (115·5 per 1000 livebirths, 95% CI 108·6–122·3 in Ragh vs 24·8, 20·5–29·0 in Kabul). In Kabul, 5594 (82%) of 6789 women reported a skilled attendant during recent deliveries compared with 381 (3%) of 11 366 women in Ragh. An estimated 85% of women in Kabul and 47% in Ragh incurred delivery costs (mean US$66·20, IQR$61·30 in Kabul and $9·89,$11·87 in Ragh). Maternal complications were the third leading cause of death in women of reproductive age in Kabul, and the leading cause in Ragh, and were mainly due to hypertensive diseases of pregnancy. The maternal mortality rate decreased significantly between 2002 and 2011 in both Kabul (by 71%) and Ragh (by 84%), plus all other maternal mortality indicators in Ragh. Interpretation Remarkable maternal and other mortality reductions have occurred in Afghanistan, but the disparity between urban and rural sites is alarming, with all maternal mortality indicators significantly higher in Ragh than in Kabul. Customised service delivery is needed to ensure parity for different geographic and security settings

Associations between Indoor Air Pollution and Acute Respiratory Infections among Under-Five Children in Afghanistan: Do SES and Sex Matter?

Background: Low-income families often depend on fuels such as wood, coal, and animal dung for cooking. Such solid fuels are highly polluting and are a primary source of indoor air pollutants (IAP). We examined the association between solid fuel use (SFU) and acute respiratory infection (ARI) among under-five children in Afghanistan and the extent to which this association varies by socioeconomic status (SES) and gender. Materials and Methods: This is a cross-sectional study based on de-identified data from Afghanistan’s first standard Demographic and Health Survey (DHS) conducted in 2015. The sample consists of ever-married mothers with under-five children in the household (n = 27,565). We used mixed-effect Poisson regression models with robust error variance accounting for clustering to examine the associations between SFU and ARI among under-five children after adjusting for potential confounders. We also investigated potential effect modification by SES and sex. Additional analyses were conducted using an augmented measure of the exposure to IAP accounting for both SFU and the location of cooking/kitchen (High Exposure, Moderate, and No Exposure). Results: Around 70.2% of households reported SFU, whereas the prevalence of ARI was 17.6%. The prevalence of ARI was higher in children living in households with SFU compared to children living in households with no SFU (adjusted prevalence ratio (aPR) = 1.10; 95% CI: (0.98, 1.23)). We did not observe any effect modification by SES or child sex. When using the augmented measure of exposure incorporating the kitchen’s location, children highly exposed to IAP had a higher prevalence of ARI compared to unexposed children (aPR = 1.17; 95% CI: (1.03, 1.32)). SES modified this association with the strongest associations observed among children from the middle wealth quintile. Conclusion: The findings have significant policy implications and suggest that ARI risk in children may be reduced by ensuring there are clean cookstoves as well as clean fuels and acting on the socio-environmental pathways

Diabetes Mellitus Among Adults in Herat, Afghanistan: A Cross-Sectional Study

Introduction: Diabetes is reaching epidemic levels in Afghanistan. This study identifies the risk factors associated with diabetes in Herat City, Afghanistan, and explores the prevalence of previously undiagnosed diabetes.Methods: A cross-sectional study was conducted using multistage cluster sampling by adopting the World Health Organization’s (WHO) STEPwise approach to Surveillance (STEPS). We enrolled 1129 participants aged 25-70 years between May and June of 2015 (47.4% males, 52.6% females). A structured questionnaire was used for data collection of demographic, socioeconomic, and behavioral factors. Investigators collected anthropometric measurements and blood samples from study participants. A multivariable logistic regression model was used to identify factors associated with diabetes prevalence.Results: We found that the prevalence of diabetes in Herat City was 9.9% (9.8% in males and 10.1% in females). Of the 1129 respondents, only 3.3% were previously diagnosed with diabetes or were under treatment, whereas 6.6% of respondents were previously undiagnosed. The multivariable analyses showed that age, frequency of rice consumption, type of cooking oil, and systolic blood pressure were associated with diabetes. Conclusions: This is one of the first studies to discuss the high prevalence of undiagnosed diabetes in Herat, Afghanistan. This study found several modifiable factors that were associated with diabetes in Herat, Afghanistan. Future reduction of disease burden should focus on these factors in the development of the most optimal diabetes prevention programs

Quality of care in prevention, detection and management of postpartum hemorrhage in hospitals in Afghanistan:an observational assessment

Background: Hemorrhage is the leading cause of maternal mortality worldwide and accounts for 56% of maternal deaths in Afghanistan. Postpartum hemorrhage (PPH) is commonly caused by uterine atony, genital tract trauma, retained placenta, and coagulation disorders. The purpose of this study is to examine the quality of prevention, detection and management of PPH in both public and private hospitals in Afghanistan in 2016, and compare the quality of care in district hospitals with care in provincial, regional, and specialty hospitals. Methods: This study uses a subset of data from the 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment. It covers a census of all accessible public hospitals, including 40 district hospitals, 27 provincial hospitals, five regional hospitals, and five specialty hospitals, as well as 10 purposively selected private hospitals. Results: All public and private hospitals reported 24 h/7 days a week service provision. Oxytocin was available in 90.0% of district hospitals, 89.2% of provincial, regional and specialty hospitals and all 10 private hospitals; misoprostol was available in 52.5% of district hospitals, 56.8% of provincial, regional and specialty hospitals and in all 10 private hospitals. For prevention of PPH, 73.3% women in district hospitals, 71.2% women at provincial, regional and specialty hospitals and 72.7% women at private hospital received uterotonics. Placenta and membranes were checked for completeness in almost half of women in all hospitals. Manual removal of placenta was performed in 97.8% women with retained placenta. Monitoring blood loss during the immediate postpartum period was performed in 48.4% of women in district hospitals, 36.9% of women in provincial, regional and specialty hospitals, and 43.3% in private hospitals. The most commonly observed cause of PPH was retained placenta followed by genital tract trauma and uterine atony. Conclusion: Gaps in performance of skilled birth attendants are substantial across public and private hospitals. Improving and retaining skills of health workers through on-site, continuous capacity development approaches and encouraging a culture of audit, learning and quality improvement may address clinical gaps and improve quality of PPH prevention, detection and management

Hepatitis C and HIV incidence and harm reduction program use in a conflict setting: an observational cohort of injecting drug users in Kabul, Afghanistan

BACKGROUND: Armed conflict may increase the risk of HIV and other pathogens among injecting drug users (IDUs); however, there are few prospective studies. This study aimed to measure incidence and potential predictors, including environmental events and needle and syringe distribution and collection program (NSP) use, of hepatitis C virus (HCV) and HIV among IDUs in Kabul, Afghanistan. METHODS: Consenting adult IDUs completed interviews quarterly in year 1 and semi-annually in year 2 and HCV and HIV antibody testing semi-annually through the cohort period (November 2007–December 2009). Interviews detailed injecting and sexual risk behaviors, NSP service use, and conflict-associated displacement. Quarters with peak conflict or local displacement were identified based on literature review, and key events, including insurgent attacks and deaths, were reported with simple counts. Incidence and predictors of HCV and HIV were measured with Cox proportional hazards models. RESULTS: Of 483 IDUs enrolled, 385 completed one or more follow-up visits (483.8 person-years (p-y)). All participants were male with a median age of 28 years and a median duration of injecting of 2 years. Reported NSP use among the participants ranged from 59.9 to 70.5 % in the first year and was 48.4 and 55.4 % at 18 and 24 months, respectively. There were 41 confirmed deaths, with a crude death rate of 93.4/1000 p-y (95 % confidence interval (CI) 67.9–125) and overdose as the most common cause. HCV and HIV incidence were 35.6/100 p-y (95 % CI 28.3–44.6) and 1.5/100 p-y (95 % CI 0.6–3.3), respectively. Changing from injecting to smoking was protective for HCV acquisition (adjusted hazard ratio (AHR) = 0.53, 95 % CI 0.31–0.92), while duration of injecting (AHR = 1.09, 95 % CI 1.01–1.18/year) and sharing syringes (AHR = 10.09, 95 % CI 1.01–100.3) independently predicted HIV infection. CONCLUSION: There is high HCV incidence and high numbers of reported deaths among male Kabul IDUs despite relatively consistent levels of harm reduction program use; peak violence periods did not independently predict HCV and HIV risk. Programming should increase awareness of HCV transmission and overdose risks, prepare clients for harm reduction needs during conflict or other causes of displacement, and continue efforts to engage community and police force support

Statistical modelling of clustered and incomplete data with applications in population health studies in developing countries

Philosophiae Doctor - PhDThe United Nations (UN) Millennium Development Goals (MDGs) drafted eight goals to be achieved by the year 2015, namely: eradicating extreme poverty and hunger, achieving universal primary education, promoting gender equality and women empowerment, reducing child mortality, improving maternal health, combating HIV/AIDS, malaria and other diseases, ensuring environmental sustainability and lastly developing a global partnership for development. Many public health studies often result in complicated and complex data sets, the nature of these data sets could be clustered, multivariate, longitudinal, hierarchical, spatial, temporal or spatio-temporal. This often results in what is called correlated data, because the assumption of independence among observations may not be appropriate. The shared genetic traits in the studies of illness or shared household characteristics among family members in the studies of poverty are examples of correlated data. In cross-sectional studies, individuals may be nested within sub-clusters (e.g., families) that are nested within clusters (e.g., environment), thus causing correlation within clusters. Ignoring the structure of the data may result in asymptotically biased parameter estimates. Clustered data may also be a result of geographical location or time (spatial and temporal). A crucial step in modelling correlated data is the speci cation of the dependency by choosing the covariance/correlation function. However, often the choice for a particular application is unclear and diagnostic tests will have to be carried out, following tting of a model. This study's view of developing countries investigates the prospects of achieving MDGs through the development of flexible predictor statistical models. The first objective of this study is to explore the existing methods for modelling correlated data sets (hierarchical, multilevel and spatial) and then apply the methods in a novel way to several data sets addressing the underlying MDGs. One of the most challenging issue in spatial or spatio-temporal analysis is the choice of a valid and yet exible correlation (covariance) structure. In cases of high dimensionality of the data, where the number of spatial locations or time points that produced the observations is large, the analysis of such data presents great computational challenges. It is debatable whether some of the classical correlation structures adequately reect the dependency in the data. The second objective is to propose a new flexible technique for handling spatial, temporal and spatio-temporal correlations. The goal of this study is to resolve the dependencies problems by proposing a more robust method for modelling spatial correlation. The techniques are used for di erent correlation structures and then combined to form the resulting estimating equations using the platform of the Generalized Method of Moments. The proposed model will therefore be built on a foundation of the Generalized Estimating Equations; this has the advantage of producing consistent regression parameter estimates under mild conditions due to separation of the processes of estimating the regression parameters from the modelling of the correlation. These estimates of the regression parameters are consistent under mild conditions. Thirdly, to account for spatio-temporal correlation in data sets, a method that decouples the two sources of correlations is proposed. Speci cally, the spatial and temporal e ects were modelled separately and then combined optimally. The approach circumvents the need of inverting the full covariance matrix and simpli es the modelling of complex relationships such as anisotropy, which is known to be extremely di cult or Lastly, large public health data sets consist of a high degree of zero counts where it is very di cult to distinguish between "true zeros" and "imputed" zeros. This can be due to the reporting mechanism as a result of insecurity, technical and logistics issues. The focus is therefore on the implementation of a technique that is capable of handling such a problem. The study will make the assumption that "imputed" zeros are a random event and consider the option of discarding the zeros, and then model a conditional Poisson model, conditioning on all cases greater than 0

Strengthening Afghanistan's Health System to Save Women's Lives: Achievements and Gaps in Scale-Up of Safe Delivery Services

Background: There is global agreement that well-functioning health systems are needed to reduce maternal mortality. There is less agreement, however, on what constitutes a functional health system in fragile states or on how to strengthen the capacity of a health system to ensure that all women have access to safe delivery services and timely emergency obstetric care. This dissertation examines the relationship between implementation of a national primary health care package and coverage of safe delivery services in Afghanistan, and identifies barriers that must be addressed to ensure that all women with obstetric complications have access to good quality medical treatment without delay. Methods: Paper 1 examines the relationship between implementation of Afghanistan’s Basic Package of Health Services and skilled birth attendance using routine data from the Ministry of Public Health from 2006 through 2010 and annual evaluations of health system performance in 29 of the country’s 34 provinces. Paper 2 assesses the contribution of health system factors to skilled birth attendance coverage using data from a 2010 household survey conducted in nine provinces of north-central Afghanistan. Paper 3 analyzes information from government and non-government organization reports, routine health service statistics, in-depth interviews and focus group discussions to compare barriers to scale-up of intrapartum care services in four districts where maternal mortality studies were conducted in 2002 and 2011. Results: Results of Paper 1 show a direct relationship between overall health system performance and skilled birth attendance in Afghanistan. Findings suggest that approximately half of the variation in skilled birth attendance rates across provinces can be explained by health facility density and service package implementation, while the remaining variation is likely associated with provincial characteristics not captured in this study. Paper 2 did not show any direct linkages between health facility characteristics and an individual woman’s likelihood of skilled birth attendance, but provided insights into why studies assuming that women seek care at the nearest primary health care facility may lead to misinterpretation of care-seeking patterns or mask the relationship between perceptions of service quality and skilled birth attendance utilization. Paper 3 illustrated the importance of context when evaluating factors that facilitate and hinder safe delivery and emergency obstetric service coverage. When asked about barriers to utilization of intrapartum care services, three common themes highlighted by national policymakers, provincial and district-level healthcare providers, and community members were: (1) structural barriers such as lack of infrastructure or human resource shortages limiting availability of services, (2) programmatic barriers such as limited technical capacity hindering provision of quality care, and (3) contextual barriers affecting when, where and why women deliver at facilities. Conclusions: Together, the three papers presented in this dissertation show that while there is a strong relationship between primary health care service package implementation and coverage of safe delivery services in Afghanistan, roll-out of this service package may not be an effective approach for scaling up services in extremely remote or insecure settings. Improvements in maternal health services coverage must be measured at a sub-national level, and health care service packages adapted to consider the needs and preferences of households in hard-to reach areas. For example, strategic human resource deployment, investment in referral systems and targeted interventions to strengthen community-facility linkages may be required to extend service coverage in remote areas. Thus, more context specific planning and adaptation of health care service packages at the provincial or district level are recommended. Study findings also illustrate the complexity of health policy planning and resource allocation in conflict-affected settings, and suggest that alternatives to the current service delivery strategy be considered in these areas

A Study of the Influence of Culture and Family on Second Generation Afghan Women Aged 18-25 Living in the United States

Objectives This study aims to increase understanding of Afghan family and culture influence on romantic relationship development and reproductive decisions in second-generation Afghan women living in the United States. Methods Participants were second-generation Afghan-American women between the ages of 18-25, born in the United States, and were not legally married. Data was collected through five semi-structured interviews. Results The study identified several themes: romantic relationships outside of marriage are considered taboo, gender differences in relationships, parental approval is important, limited communication about relationships, and a hesitancy to discuss topics surrounding reproductive health. Conclusions Overall, this study found the influence of Afghan culture was present in regards to relationship development and reproductive decisions among participants; however, religion was identified has having an even larger influence.Master of Public Healt