Revising the WHO verbal autopsy instrument to facilitate routine cause-of-death monitoring.

OBJECTIVE: Verbal autopsy (VA) is a systematic approach for determining causes of death (CoD) in populations without routine medical certification. It has mainly been used in research contexts and involved relatively lengthy interviews. Our objective here is to describe the process used to shorten, simplify, and standardise the VA process to make it feasible for application on a larger scale such as in routine civil registration and vital statistics (CRVS) systems. METHODS: A literature review of existing VA instruments was undertaken. The World Health Organization (WHO) then facilitated an international consultation process to review experiences with existing VA instruments, including those from WHO, the Demographic Evaluation of Populations and their Health in Developing Countries (INDEPTH) Network, InterVA, and the Population Health Metrics Research Consortium (PHMRC). In an expert meeting, consideration was given to formulating a workable VA CoD list [with mapping to the International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) CoD] and to the viability and utility of existing VA interview questions, with a view to undertaking systematic simplification. FINDINGS: A revised VA CoD list was compiled enabling mapping of all ICD-10 CoD onto 62 VA cause categories, chosen on the grounds of public health significance as well as potential for ascertainment from VA. A set of 221 indicators for inclusion in the revised VA instrument was developed on the basis of accumulated experience, with appropriate skip patterns for various population sub-groups. The duration of a VA interview was reduced by about 40% with this new approach. CONCLUSIONS: The revised VA instrument resulting from this consultation process is presented here as a means of making it available for widespread use and evaluation. It is envisaged that this will be used in conjunction with automated models for assigning CoD from VA data, rather than involving physicians

Global Role and Burden of Influenza in Pediatric Respiratory Hospitalizations, 1982-2012:A Systematic Analysis

BACKGROUND:The global burden of pediatric severe respiratory illness is substantial, and influenza viruses contribute to this burden. Systematic surveillance and testing for influenza among hospitalized children has expanded globally over the past decade. However, only a fraction of the data has been used to estimate influenza burden. In this analysis, we use surveillance data to provide an estimate of influenza-associated hospitalizations among children worldwide. METHODS AND FINDINGS:We aggregated data from a systematic review (n = 108) and surveillance platforms (n = 37) to calculate a pooled estimate of the proportion of samples collected from children hospitalized with respiratory illnesses and positive for influenza by age group (<6 mo, <1 y, <2 y, <5 y, 5-17 y, and <18 y). We applied this proportion to global estimates of acute lower respiratory infection hospitalizations among children aged <1 y and <5 y, to obtain the number and per capita rate of influenza-associated hospitalizations by geographic region and socio-economic status. Influenza was associated with 10% (95% CI 8%-11%) of respiratory hospitalizations in children <18 y worldwide, ranging from 5% (95% CI 3%-7%) among children <6 mo to 16% (95% CI 14%-20%) among children 5-17 y. On average, we estimated that influenza results in approximately 374,000 (95% CI 264,000 to 539,000) hospitalizations in children <1 y-of which 228,000 (95% CI 150,000 to 344,000) occur in children <6 mo-and 870,000 (95% CI 610,000 to 1,237,000) hospitalizations in children <5 y annually. Influenza-associated hospitalization rates were more than three times higher in developing countries than in industrialized countries (150/100,000 children/year versus 48/100,000). However, differences in hospitalization practices between settings are an important limitation in interpreting these findings. CONCLUSIONS:Influenza is an important contributor to respiratory hospitalizations among young children worldwide. Increasing influenza vaccination coverage among young children and pregnant women could reduce this burden and protect infants <6 mo

Male involvement in Spacing births, Afghanistan

Involvement of men in supporting women for fertility control, safe pregnancy, and child bearing has been recognized as an important element of reproductive health in International Conference on Population and Development (ICPD) held in Cairo in 1994. In male dominant society such as Afghanistan, the role of men in supporting reproductive health and the use of birth spacing methods is essential. Early marriages, low contraceptive prevalence rate, and short inter-pregnancy intervals are the explanations for the high fertility, maternal and infant mortality in Afghanistan. Few studies have been conducted to provide information about Afghan men\u27s perception and behavior regarding use of birthspacing methods. Successful interventions to reduce maternal and infants mortality requires a better understanding of awareness, attitude and practices of men towards the use of family planning methods. This study aimed to assess the knowledge, attitude, and behavior of Afghan men towards birth spacing methods; and to look into factors influencing men to adopt such methods. This was a cross-sectional survey that used both qualitative (formative research) and quantitative tools. Initially a formative research in the form of six in-depth interviews was carried out, with the purpose to identify barriers to the implementation of the cross sectional survey and to finalize the response categories of the data collection tool. The cross sectional study was conducted from July to September 2006 in the district Tagab-e Keshem, Badakhshan province Afghanistan. We were able to complete interviews on 309 married men aged 18-60 years. Unadjusted Odds ratios were used to determine the factors that influence Afghan men to practice birth spacing methods. The contraceptive prevalence rate (both men and wives) was 8.4 %. Only 28.5% of the respondents had heard about the contraceptive methods. Educational status (OR=2.7), access to radio (OR=6.36), income (OR=9.8), and couple\u27s discussion (OR-1.00) about birth spacing were the main factors influencing men to use any contraceptive method. Our study findings reveal that nearly 72 % of the men had no knowledge about the family planning even though majority can read and write; moreover, a fraction of men or their spouses were using any method at the time of the interview. Broad and effective information, education, and communication strategies should be undertaken to promote awareness regarding birthspacing and its advantages. In addition, family planning programs in Afghanistan should involve men and particularly invite couple discussion as a key strategy. Inter spousal communication should be made part of national family planning program

Opium trade and the spread of HIV in the Golden Crescent

The Golden Crescent region of South Asia-comprising Afghanistan, Iran, and Pakistan-is a principal global site for opium production and distribution. Over the past few decades, war, terrorism, and a shifting political landscape have facilitated an active heroin trade throughout the region. Protracted conflict has exacerbated already dire socio-economic conditions and political strife within the region and contributed to a consequent rise in opiate trafficking and addiction among the region\u27s inhabitants. The worsening epidemic of injection drug use has paralleled the rising incidence of HIV and other blood-borne infections in the region and drawn attention to the broader implications of the growing opiate trade in the Golden Crescent. The first step in addressing drug use is to recognize that it is not a character flaw but a form of mental illness, hence warranting humane treatment of drug users. It is also recommended that the governments of the Golden Crescent countries encourage substitution of opium with licit crops and raise awareness among the general public about the perils of opium use

‘I should have seen her face at least once’: parent’s and healthcare providers’ experiences and practices of care after stillbirth in Kabul province, Afghanistan

Objective This study aimed to explore bereaved parents’ and healthcare providers experiences of care after stillbirth. Study design Qualitative in-depth interviews with 55 women, men, female elders, healthcare providers and key informants in Kabul province, Afghanistan between October and November 2017. Results Inadequate and insensitive communication and practices by healthcare providers, including avoiding or delaying disclosing the stillbirth were recurring concerns. There was a disconnect between parents’ desires and healthcare provider’s perceptions. The absence of shared decision-making on seeing and holding the baby and memory-making, manifested as profound regret. Health providers’ reported hospitals were not equipped to separate women who had a stillbirth and acknowledged that psychological support would be beneficial. However, the absence of trained personnel and resource constraints prevented provision of such support. Conclusion Findings can inform future provision of perinatal bereavement care. Given resource constraints, communication training can be considered with longer term goals to develop context-appropriate bereavement care guidelines

Explanatory models of stillbirth among bereaved parents in Afghanistan: Implications for stillbirth prevention

Local perceptions and understanding of the causes of ill health and death can influence health-seeking behaviour and practices in pregnancy. We aimed to understand individual explanatory models for stillbirth in Afghanistan to inform future stillbirth prevention. This was an exploratory qualitative study of 42 semi-structured interviews with women and men whose child was stillborn, community elders, and healthcare providers in Kabul province, Afghanistan between October-November 2017. We used thematic data analysis framing the findings around Kleinman’s explanatory framework. Perceived causes of stillbirth were broadly classified into four categories–biomedical, spiritual and supernatural, extrinsic factors, and mental wellbeing. Most respondents attributed stillbirths to multiple categories, and many believed that stillbirths could be prevented. Prevention practices in pregnancy aligned with perceived causes and included engaging self-care, religious rituals, superstitious practices and imposing social restrictions. Symptoms preceding the stillbirth included both physical and non-physical symptoms or no symptoms at all. The impacts of stillbirth concerned psychological effects and grief, the physical effect on women’s health, and social implications for women and how their communities perceive them. Our findings show that local explanations for stillbirth vary and need to be taken into consideration when developing health education messages for stillbirth prevention. The overarching belief that stillbirth was preventable is encouraging and offers opportunities for health education. Such messages should emphasise the importance of care-seeking for problems and should be delivered at all levels in the community. Community engagement will be important to dispel misinformation around pregnancy loss and reduce social stigma

Explanatory models of stillbirth among bereaved parents in Afghanistan: Implications for stillbirth prevention.

Local perceptions and understanding of the causes of ill health and death can influence health-seeking behaviour and practices in pregnancy. We aimed to understand individual explanatory models for stillbirth in Afghanistan to inform future stillbirth prevention. This was an exploratory qualitative study of 42 semi-structured interviews with women and men whose child was stillborn, community elders, and healthcare providers in Kabul province, Afghanistan between October-November 2017. We used thematic data analysis framing the findings around Kleinman's explanatory framework. Perceived causes of stillbirth were broadly classified into four categories-biomedical, spiritual and supernatural, extrinsic factors, and mental wellbeing. Most respondents attributed stillbirths to multiple categories, and many believed that stillbirths could be prevented. Prevention practices in pregnancy aligned with perceived causes and included engaging self-care, religious rituals, superstitious practices and imposing social restrictions. Symptoms preceding the stillbirth included both physical and non-physical symptoms or no symptoms at all. The impacts of stillbirth concerned psychological effects and grief, the physical effect on women's health, and social implications for women and how their communities perceive them. Our findings show that local explanations for stillbirth vary and need to be taken into consideration when developing health education messages for stillbirth prevention. The overarching belief that stillbirth was preventable is encouraging and offers opportunities for health education. Such messages should emphasise the importance of care-seeking for problems and should be delivered at all levels in the community. Community engagement will be important to dispel misinformation around pregnancy loss and reduce social stigma

Understanding pathways leading to stillbirth: the role of care-seeking and care received during pregnancy and childbirth in Kabul province, Afghanistan

Background: The underlying pathways leading to stillbirth in low- and middle-income countries are not well understood. Context-specific understanding of how and why stillbirths occur is needed to prioritise interventions and identify barriers to their effective implementation and uptake. Aim: To explore the contribution of contextual, individual, household-level and health system factors to stillbirth in Afghanistan. Methods: Using a qualitative approach, we conducted semi-structured in-depth interviews with women and men that experienced stillbirth, female elders, community health workers, healthcare providers, and government officials in Kabul province, Afghanistan between October-November 2017. We used thematic analysis to identify contributing factors and developed a conceptual map describing possible pathways to stillbirth. Findings: We found that low utilisation and access to healthcare was a key contributing factor, as were unmanaged conditions in pregnancy that increased women’s risk of complications and stillbirth. Sociocultural factors related to the treatment of women and perceptions about medical interventions deprived women of interventions that could potentially prevent stillbirth. The quality of care from public and private providers during pregnancy and childbirth was a recurring concern exacerbated by health system constraints that led to unnecessary delays; while environmental factors linked to the ongoing conflict were also perceived to contribute to stillbirth. These pathways were underscored by social, cultural, economic factors and individual perceptions that contributed to the three-delays

Understanding country-specific determinants of stillbirth using household surveys: The case of Afghanistan

Background: Stillbirth rates in Afghanistan have declined little in the past decade with no data available on key risk factors. Health care utilisation and maternal com- plications are important factors influencing pregnancy outcomes but rarely captured for stillbirth in national surveys from low‐ and middle‐income countries. The 2010 Afghanistan Mortality Survey (AMS) is one of few surveys with this information. Methods: We used data from the 2010 AMS that included a full pregnancy history and verbal autopsy. Our sample included the most recent live birth or stillbirth of 13 834 women aged 12‐49 years in the three years preceding the survey. Multivariable Poisson regression was used to identify sociodemographic, maternal, and health care utilisation risk factors for stillbirth. Results: The risk of stillbirth was increased among women in the Central Highlands (aRR: 3.01, 95% CI 1.35, 6.70) and of Nuristani ethnicity (aRR: 9.15, 95% CI 2.95, 28.74). Women who did not receive antenatal care had three times increased risk of stillbirth (aRR: 3.03, 95% CI 1.73, 5.30), while high‐quality antenatal care was impor- tant for reducing the risk of intrapartum stillbirth. Bleeding, infection, headache, and reduced fetal movements were antenatal complications strongly associated with stillbirth. Reduced fetal movements in the delivery period increased stillbirth risk by almost seven (aRR: 6.82, 95% CI 4.20, 11.10). Facility births had a higher risk of still- births overall (aRR: 1.55, 95% CI 1.12, 2.16), but not for intrapartum stillbirths. Conclusions: Targeted interventions are needed to improve access and utilisation of services for high‐risk groups. Early detection of complications through improved quality of antenatal and obstetric care is imperative. We demonstrate the potential of household surveys to provide country‐specific evidence on stillbirth risk factors for LMICs where data are lacking