Impact of secondary and tertiary neonatal interventions on neonatal mortality in a low- resource limited setting hospital in Uganda: a retrospective study.

OBJECTIVE: To assess the impact of secondary and tertiary level neonatal interventions on neonatal mortality over a period of 11 years. DESIGN: Interrupted time series analysis. SETTING: Nsambya Hospital, Uganda. INTERVENTIONS: Neonatal secondary interventions (phase I, 2007-2014) and tertiary level interventions (phase II, 2015-2020). PARTICIPANTS: Neonates. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome: neonatal mortality. SECONDARY OUTCOME: case fatality rate (CFR) for prematurity, neonatal sepsis and asphyxia. RESULTS: During the study period, a total of 25 316 neonates were admitted, of which 1853 (7.3%) died. The average inpatient mortality reduced from 8.2% during phase I to 5.7% during phase II (p=0.001). The CFR for prematurity reduced from 16.2% to 9.2% (p=0.001). There was a trend in reduction for the CFR of perinatal asphyxia from 14.9% to 13.0% (p=0.34). The CFR for sepsis had a more than a twofold increase (3%-6.8% p=0.001) between phase I and phase II. CONCLUSION: Implementation of secondary and tertiary neonatal care in resource-limited settings is feasible. This study shows that these interventions can significantly reduce the neonatal mortality, with the largest impact seen in the reduction of deaths from perinatal asphyxia and prematurity. An increase in sepsis related deaths was observed, suggesting emphasis on infection control is key.

Childbearing and contraceptive decision making amongst Afghan men and women: a qualitative analysis.

Afghanistan has one of the highest maternal mortality ratios and lowest contraceptive prevalence rates globally. Limited information is known regarding Afghan men and women's attitudes toward childbearing, child spacing, and contraceptive use, which is essential for delivery of appropriate services. We conducted a qualitative study among postpartum couples enrolled at maternity hospitals in Kabul, Afghanistan. We identified important themes that highlight the complex inter-relationship between acknowledged risks of childbearing, desire for family planning, rationales for limited contraceptive use, and sociocultural barriers to contraceptive use. We offer practical recommendations for application of findings toward family planning and maternal mortality reduction programs.

Attitudes and practices of obstetric care providers in Kabul, Afghanistan regarding antenatal testing for sexually transmitted infection.

OBJECTIVE: To determine attitudes toward and utilization of testing for HIV, syphilis, and hepatitis B among obstetric care providers in Kabul, Afghanistan. DESIGN: Cross-sectional survey. SETTING: Three public maternity hospitals in Kabul, Afghanistan. PARTICIPANTS: One hundred and fourteen (114) doctors and midwives. MAIN OUTCOME MEASURE: Prevalence and correlates of ever having tested patients for HIV, syphilis, and hepatitis B and agreement with statements concerning attitudes toward testing and care. RESULTS: Less than half of the patient care providers surveyed had previously tested a patient for HIV, syphilis, or hepatitis B. Presumed rarity of these infections in Afghanistan was the most frequently stated reason for not testing, although many midwives stated that they did not have the authority to order tests. Most providers supported testing to promote neonatal health, but some midwives expressed concern regarding patient and family perceptions. CONCLUSIONS: Due to logistical and cultural barriers, obstetric care providers underutilize testing for antenatal patients in Afghanistan. Improved training, empowerment of female providers, and availability of rapid testing are needed.

Seroprevalence and correlates of HIV, syphilis, and hepatitis B and C virus among intrapartum patients in Kabul, Afghanistan.

BACKGROUND: Little current information is available for prevalence of vertically-transmitted infections among the Afghan population. The purpose of this study is to determine prevalence and correlates of human immunodeficiency virus (HIV), syphilis, and hepatitis B and C infection among obstetric patients and model hepatitis B vaccination approaches in Kabul, Afghanistan. METHODS: This cross-sectional study was conducted at three government maternity hospitals in Kabul, Afghanistan from June through September, 2006. Consecutively-enrolled participants completed an interviewer-administered survey and whole blood rapid testing with serum confirmation for antibodies to HIV, T. pallidum, and HCV, and HBsAg. Descriptive data and prevalence of infection were calculated, with logistic regression used to identify correlates of HBV infection. Modeling was performed to determine impact of current and birth dose vaccination strategies on HBV morbidity and mortality. RESULTS: Among 4452 women, prevalence of HBsAg was 1.53% (95% CI: 1.18 - 1.94) and anti-HCV was 0.31% (95% CI: 0.17 - 0.53). No cases of HIV or syphilis were detected. In univariate analysis, HBsAg was associated with husband's level of education (OR = 1.13, 95% CI: 1.01 - 1.26). Modeling indicated that introduction of birth dose vaccination would not significantly reduce hepatitis-related morbidity or mortality for the measured HBsAg prevalence. CONCLUSION: Intrapartum whole blood rapid testing for HIV, syphilis, HBV, and HCV was acceptable to patients in Afghanistan. Though HBsAg prevalence is relatively low, periodic assessments should be performed to determine birth dose vaccination recommendations for this setting.

Cross-sectional analysis of factors associated with prior contraceptive use among hospitalized obstetric patients in Kabul, Afghanistan.

OBJECTIVE: This study was conducted to assess prevalence and correlates of prior contraceptive use among hospitalized obstetric patients in Kabul, Afghanistan. STUDY DESIGN: Medically eligible (e.g., conditions not requiring urgent medical attention, such as eclampsia, or not imminently delivering [dilation > or =8 cm]) obstetric patients admitted to three Kabul public hospitals were consecutively enrolled in this cross-sectional study. An interviewer-administered questionnaire assessed demographic information, health utilization history, including prior contraceptive use, and intent to use contraception. Correlates of prior contraceptive use were determined with logistic regression. RESULTS: Of 4452 participants, the mean age was 25.7 years (SD, +/-5.7 years), 66.4% reported pregnancy before the presenting gestation, 88.4% had > or =1 prenatal care visit and 82.4% reported the current pregnancy was desired. Most (67.4%) had no formal education. One fifth (22.8%) reported using contraception before this pregnancy. Among women with any pregnancy before the current gestation (98.6% of prior users), prior contraceptive use was independently associated with having lived outside Afghanistan in the last 5 years (adjusted odds ratio [AOR], 1.35; 95% confidence interval [CI], 1.12-1.63), having a skilled attendant at the last birth (AOR, 1.35; 95% CI, 1.07-1.71), having a greater number of living children (AOR, 1.30; 95% CI, 1.20-1.41), longer mean birth interval (years) (AOR, 1.21; 95% CI, 1.11-1.38) and higher educational level (AOR, 1.16; 95% CI, 1.09-1.22). Immediate desire for another pregnancy and spousal disapproval were the most common reasons for not utilizing contraception. CONCLUSION: Prior contraceptive use is low among the women in Kabul, Afghanistan, particularly for younger less educated women. Programming in Kabul to strengthen postpartum contraceptive counseling should address barriers to contraceptive use, including immediate desire for pregnancy and spousal attitudes.