Women’s access to skilled birth attendance in Afghanistan

Women’s access to skilled birth attendance (SBA) is of major interest and concern in Afghanistan to the public, health professionals and international partners of the vulnerable healthcare in the country. This thesis aims at understanding the situation of SBA through the research work of the author and the available evidence on the subject matter. The theoretical framework used is a modified Tanahashi model that distinguishes various layers of access to SBA including its availability, accessibility, acceptability, utilization and quality. Chapter 1 introduces the unique situation in Afghanistan surrounding SBA necessary for developing a holistic understanding of the Afghan context. Country specific issues such exclusivity of SBA to female midwives and obstetrician/gynecologist, extreme shortage of SBA providers just a couple of decades ago and a rapid increase in the number of midwives in the period, a split healthcare provision system led by Ministry of Public Health, funded by international donors and implemented by non-governmental organizations are highlighted. Finally, the interlinking concepts of health system components, human resources for health and quality of care are described and incorporated in the final research theoretical framework of a modified Tanahashi model. Chapter 2 describes the availability and utilization of Emergency Obstetric and Newborn Care (EmONC) in terms of the defining healthcare package of the seven Basic EmONC (BEmONC) and additional two Comprehensive EmONC (CEmONC) signal functions. The study shows how various signal functions are missing from facilities designated to provide the healthcare. Chapter 3 explores availability and distribution of human resources for provision of CEmONC. Availability of SBA providers is explored at different facility levels and during different days, shifts, and times. The study emphasizes the need for innovative approaches for deployment, skills development, and retention of SBA providers, especially in underserved areas. Chapter 4 is based on the study of midwifery education programs in Afghanistan established to fill the vast gap of availability of SBA in Afghanistan. The study examines two distinctive midwifery education programs established and operating in the country and summarizes lessons learned for future improvement of the systems. Chapter 5 explores the level of trainings received by SBA providers and their level of confidence in providing the healthcare. The study documents and recommends the need for continued in-service training and hands-on practice for all SBA providers in order to ensure its effectiveness. The study specifically demonstrate that midwifes rather than medical doctors are key to reliable SBA in Afghanistan. Chapter 6 presents the findings of a study of the quality of the educational programs in 29 public and private midwifery education programs as a prerequisite for the quality of care of their graduate SBA providers. The study documents the quality of midwifery education with respect to the necessary infrastructure and management, teachers and preceptors, clinical practice sites, curriculum, and support of students. Chapter 7 is based on a qualitative study of women’s experience of care during facility based childbirth healthcare. The study looks at respectful maternity care from the women’s, healthcare providers’ and health managers’ perspectives and highlights key areas of improvement. Chapter 8 synthetizes all of the findings of the research work along with the available local and international evidence into the hierarchical frame of Tanahashi model and from the perspectives of the recipient of the care, the healthcare providers and the health system. The chapter provides a list of recommendations based on the evidence compiled as the outcome of the thesis

PATIENTS WITH PSYCHOTIC DISORDERS RECOGNIZE FACIAL EMOTIONAL EXPRESSION BETTER IN EMOTIONS COMPARED TO IN IMAGES

ABSTRACT Background: One of the well-documented findings in patients with schizophrenia is the deficit in processing facial expressions of emotional states. It is, however, unclear whether these patients are deficient in interpreting the intensity of facial expression or the emotional states altogether. In the current study we examine the ability of patients with a diagnosis of schizophrenia or schizoaffective disorder to identify the facial expression in emoticons and pictures of common emotional expressions. Methods: we recruited 10 normal individuals and 20 patients with diagnoses of schizophrenia and schizoaffective disorders. Individuals were presented with pictures of emotional states and emoticons along with a list of emotions to be matched to the image and emoticons. Results: the patients suffering from schizophrenia and schizoaffective disorders were able to correctly identify emotional expression in emoticons significantly better than in images (91.7% vs 73%, p=0.0001, Fisher's exact test). Conclusion: to our knowledge this is the first study to evaluate the ability of patients with severe psychotic disorders to differentiate between gross and subtle facial changes during expression of emotional states using emoticons. Our findings suggest that patients suffering from schizophrenia and schizoaffective disorders may have difficulty understanding the subtle facial expression of emotions with relative preservation of ability to recognize the stereotypical features of facial emotional expressions. Further research is needed to validate these findings

Readiness of emergency obstetric and newborn care in public health facilities in Afghanistan between 2010 and 2016

OBJECTIVE: To assess changes in readiness to provide emergency obstetric and newborn care (EmONC) in health facilities in Afghanistan between 2010 and 2016. METHODS: A secondary analysis was performed of a subset of data from cross-sectional health facility assessments conducted in December 2009 to February 2010 and May 2016 to January 2017. Interviews with health providers, facility inventory, and record review were conducted in both assessments. Descriptive statistics and χ2 tests were used to compare readiness of EmONC at 59 public health facilities expected to provide comprehensive EmONC. RESULTS: The proportion of facilities reporting provision of uterotonic drugs, anticonvulsants, parenteral antibiotics, newborn resuscitation, and cesarean delivery did not change significantly between 2010 and 2016. Provision of assisted vaginal deliveries increased from 78% in 2010 to 98% in 2016 (P<0.001). Fewer health facilities had amoxicillin (61% in 2016 vs 90% in 2010; P<0.001) and gentamicin (74% in 2016 vs 95% in 2010; P<0.002). The number of facilities with at least one midwife on duty 24 hours a day/7 days a week significantly declined (88% in 2016 vs 98% in 2010; P=0.028). CONCLUSION: Despite a few positive changes, readiness of EmONC services in Afghanistan in 2016 had declined from 2010 levels

Quality of essential newborn care and neonatal resuscitation at health facilities in Afghanistan:a cross-sectional assessment

Objective To assess readiness and quality of essential newborn care and neonatal resuscitation practices in public health facilities in Afghanistan.Design Cross-sectional assessment.Setting 226 public health facilities in Afghanistan, including 77 public health facilities with at least five births per day (high-volume facilities) and 149 of 1736 public health facilities with fewer than five births per day (low-volume facilities).Participants Managers of 226 public health facilities, 734 skilled birth attendants (SBAs) working at these facilities, and 643 women and their newborns observed during childbirth at 77 high-volume health facilities.Outcome measures Availability of knowledgeable SBAs, availability of supplies and compliance with global guidelines for essential newborn care and neonatal resuscitation practices.Results At high-volume facilities, 569/636 (87.9%) of babies were dried immediately after birth, 313/636 (49.2%) were placed in skin-to-skin contact with their mother and 581/636 (89.7%) had their umbilical cord cut with a sterile blade or scissors. A total of 87 newborn resuscitation attempts were observed. Twenty-four of the 87 (27.5%) began to breath or cry after simply clearing the airway or on stimulation. In the remaining 63 (72.5%) cases, a healthcare worker began resuscitation with a bag and mask; however, only 54 (62%) used a correct size of mask and three babies died as their resuscitation with bag and mask was unsuccessful.Conclusions The study indicates room for improvement of the quality of neonatal resuscitation practices at public health facilities in Afghanistan, requiring only strengthening of the current best practices in newborn care. Certain basic and effective aspects of essential newborn care that can be improved on with little additional resources were also missing, such as skin-to-skin contact of the babies with their mother. Improvement of compliance with the standard newborn care practices must be ensured to reduce preventable newborn mortality and morbidity in Afghanistan

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

Quality of care in early detection and management of pre-eclampsia/eclampsia in health facilities in Afghanistan

BackgroundAfghanistan faces a high burden of maternal and neonatal morbidity and mortality. Hypertensive disorders of pregnancy, including pre-eclampsia and eclampsia (PE/E), are among the most common causes of maternal and neonatal complications. Hypertensive disorders of pregnancy can lead to fatal complications for both the mother and fetus. The 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment assessed quality of early detection and management of PE/E in health facilities and skilled birth attendants' (SBAs) perceptions of their working environment.MethodsAll accessible public health facilities with an average of at least five births per day (n=77), a nationally representative sample of public health facilities with less than five births per day (n=149), and 20 purposively selected private health facilities were assessed. Methods included a facility inventory and record review, interviews with SBAs, and direct clinical observation of antenatal care (ANC), intrapartum care and immediate postnatal care (PNC), as well as severe PE/E case management.ResultsMost facilities had supplies and medicines for early detection and management of PE/E.At public health facilities, 357 of 414 (86.2%) clients observed during ANC consultations had their blood pressure checked and 159 (38.4%) were asked if they had experienced symptoms of PE/E. Only 553 of 734 (72.6%) SBAs interviewed were able to correctly identify severe pre-eclampsia described in a case scenario. Of 29 PE/E cases observed, 17 women (59%) received the correct loading dose of magnesium sulfate (MgSO4) and 12 women (41%) received the correct maintenance dose of MgSO4.At private health facilities, 39 of 45 ANC clients had their blood pressure checked and 9 of 45 (20%) were asked about symptoms of PE/E. Fifty-four of 64(84.4%) SBAs in private facilities correctly identified severe pre-eclampsia described in a case scenario.ConclusionNotable gaps in SBAs' knowledge and clinical practices in detection and management of PE/E in various health facilities increase the risk of maternal and perinatal mortality. Continuing education of health care providers and increased investment in focused quality improvement initiatives will be critical to improve the quality of health care services in Afghanistan

Seasonality of Suicidal Behavior

A seasonal suicide peak in spring is highly replicated, but its specific cause is unknown. We reviewed the literature on suicide risk factors which can be associated with seasonal variation of suicide rates, assessing published articles from 1979 to 2011. Such risk factors include environmental determinants, including physical, chemical, and biological factors. We also summarized the influence of potential demographic and clinical characteristics such as age, gender, month of birth, socioeconomic status, methods of prior suicide attempt, and comorbid psychiatric and medical diseases. Comprehensive evaluation of risk factors which could be linked to the seasonal variation in suicide is important, not only to identify the major driving force for the seasonality of suicide, but also could lead to better suicide prevention in general