Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Lancet Glob Health. 2017 May;5(5):e545-e555. doi: 10.1016/S2214-109X(17)30139-0.
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.
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.
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.
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.
United States Agency for International Development (USAID).
阿富汗的孕产妇死亡率高居世界前列，但该国国内的风险情况仍不明确。需要对亚省级别的孕产妇死亡率进行估计，并深入了解决定因素，以指导未来的孕产妇健康计划。在此，我们旨在研究国内的孕产妇死亡风险和原因、寻求医疗服务的模式以及成本。
我们在喀布尔市城区和巴达赫尚省拉格县农村地区进行了一项家庭调查（RAMOS-II）。高级女性家庭成员填写问卷，由接受过中等教育的女性访谈员团队收集数据。信息包括所有孕产妇死亡、活产、死产、卫生保健获取和成本、家庭收入和资产。利用妊娠史记录分娩情况。自 2008 年 1 月以来，我们通过死因推断调查了所有年龄在 12-49 岁的育龄期女性死亡病例。社区成员、服务提供者以及每个区的地区、省和国家官员都接受了访谈，以了解孕产妇死亡风险和卫生服务提供方面的变化，以及孕产妇保健覆盖范围的方案和政策文件。
数据于 2011 年 3 月 2 日至 10 月 16 日期间在 130688 名参与者中收集：喀布尔 63329 人，拉格 67359 人。拉格的孕产妇死亡率是喀布尔的四倍（每 10 万活产儿中有 713 人死亡，95%置信区间为 553-873，喀布尔为 166 人，95%置信区间为 0.2-0.3）。其他所有孕产妇死亡指标也呈现出类似的模式，包括孕产妇死亡率（每 1000 名育龄妇女中有 1.7 人死亡，95%置信区间为 1.3-2.1，喀布尔为 0.2，95%置信区间为 0.1-0.3）。这两个地区的婴儿死亡率也存在显著差异（每 1000 例活产儿中有 115.5 例死亡，95%置信区间为 108.6-122.3，喀布尔为 24.8，95%置信区间为 20.5-29.0）。在喀布尔，6789 名妇女中有 5594 名（82%）报告在最近分娩时有熟练助产士，而在拉格的 11366 名妇女中只有 381 名（3%）。喀布尔约 85%的妇女和拉格约 47%的妇女承担了分娩费用（喀布尔的平均费用为 66.20 美元，中值为 61.30 美元；拉格的费用为 9.89 美元，中值为 11.87 美元）。孕产妇并发症是喀布尔育龄妇女死亡的第三大主要原因，也是拉格的主要原因，主要由妊娠高血压疾病引起。2002 年至 2011 年，喀布尔（下降 71%）和拉格（下降 84%）的孕产妇死亡率以及拉格的所有其他孕产妇死亡率指标均显著下降。
阿富汗的孕产妇和其他死亡率显著下降，但城乡地区之间的差距令人震惊，拉格的所有孕产妇死亡率指标均明显高于喀布尔。需要提供定制化的服务，以确保不同地理和安全环境的公平性。
美国国际开发署（USAID）。
