Abstract
BackgroundAlthough there have been notable improvements in availability and utilization of maternal health care in Afghanistan over the last few decades, risk of maternal mortality remains very high. Previous studies have highlighted gaps in quality of emergency obstetric and newborn care practices, however, little is known about the quality of routine intrapartum care at health facilities in Afghanistan.MethodsWe analyzed a subset of data from the 2016 Afghanistan Maternal and Newborn Health Quality of Care Assessment that comprised of observations of labor, delivery and immediate post-partum care, as well as health facility assessments and provider interviews across all accessible public health facilities with an average of five or more births per day in the preceding year (N = 77). Using the Quality of the Process of Intrapartum and Immediate Postpartum Care index, we calculated a quality of care score for each observation. We conducted descriptive and bivariate analyses and built a multivariate linear regression model to identify facility-level factors associated with quality of care scores.ResultsAcross 665 childbirth observations, low quality of care was observed such that no health facility type received an average quality score over 56%. The multivariate regression model indicated that availability of routine labor and delivery supplies, training in respectful maternity care, perceived gender equality for training opportunities, recent supervision, and observation during supervision have positive, statistically significant associations with quality of care.ConclusionsQuality of routine intrapartum care at health facilities in Afghanistan is concerningly low. Our analysis suggests that multi-faceted interventions are needed to address direct and indirect contributors to quality of care including clinical care practices, attention to client experiences during labor and childbirth, and attention to staff welfare and opportunities, including gender equality within the health workforce.
Highlights
There have been notable improvements in availability and utilization of maternal health care in Afghanistan over the last few decades, risk of maternal mortality remains very high
A couple of the quality of care (QoC) index items were widely implemented such that a uterotonic drug was prepared for use in active management of the third stage (AMTSL) of labor for 90% of women, and newborns were immediately dried with a towel in 87% of cases
While this study has demonstrated the clinical quality improvements related to respectful maternity care training and gender equality among providers, there is a need to explore these relationships in other contexts and through more rigorous study designs
Summary
There have been notable improvements in availability and utilization of maternal health care in Afghanistan over the last few decades, risk of maternal mortality remains very high. There has been an important shift in maternal health efforts in recent decades, expanding in focus from access to facility-based care to encompass quality of care. Lydon et al BMC Pregnancy Childbirth (2021) 21:438 calls for a focus on quality of care in fragile and conflict-affected areas [3]. As such, it is critical for maternal health programs in conflict-affected areas to assess quality gaps and develop strategic plans to address them. Accessible, quality, and equitable health services were severely lacking [4] At this time, Afghanistan logged the highest maternal mortality ratio on record [5]. In a society where it is considered inappropriate to seek obstetric care from a male provider, this gap in female providers left many women without culturally appropriate options for skilled birth attendance [5, 6]
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