Abstract
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.
Discussion
Efforts are needed at the community-level to facilitate care-seeking and raise awareness
of stillbirth risk factors and the facility-level to strengthen antenatal and childbirth
care quality, ensure culturally appropriate and respectful care, and reduce treatment
delays.
Keywords
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References
- Stillbirths: ending an epidemic of grief.Lancet. 2016; 387: 515
- Stillbirths: where? when? why? how to make the data count?.Lancet. 2011; 377: 1448-1463
- Neonatal and perinatal mortality: country.Regional and Global Estimates. World Health Organization (WHO), Geneva, Switzerland2007
- Stillbirths: rates, risk factors, and acceleration towards 2030.Lancet. 2016; 387: 587-603
- Stillbirths: what difference can we make and at what cost?.Lancet. 2011; 377: 1523-1538
- Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?.Lancet. 2014; 384: 347-370
- Too far to walk: maternal mortality in context.Soc. Sci. Med. 1994; 38: 1091-1110
- Understanding careseeking for child illness in sub-Saharan Africa: a systematic review and conceptual framework based on qualitative research of household recognition and response to child diarrhoea, pneumonia and malaria.Soc. Sci. Med. 2013; 86: 66-78
- The anthropology of pregnancy loss: comparative studies in miscarriage.Stillbirth and Neonatal Death. Berg Publishers, Oxford, UK1996
- Achieving maternal and child health gains in Afghanistan: a Countdown to 2015 country case study.Lancet Glob. Health. 2016; 4: e395-413
- Levels and Trends in Child Mortality Report 2019: Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation.UNICEF, New York2019
- Afghanistan Demographic and Health Survey 2015.Central Statistics Organization (CSO), Kabul, Afghanistan2017
- National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis.Lancet Glob. Health. 2016; 4: e98-e108
- Afghanistan’s Basic Package of Health Services: its development and effects on rebuilding the health system.Glob. Public Health. 2014; 9: S6-S28
- Success in reducing maternal and child mortality in Afghanistan.Glob. Public Health. 2014; (9 Suppl 1): S29-42
- Barriers to appropriate care for mothers and infants during the perinatal period in rural Afghanistan: a qualitative assessment.Glob. Public Health. 2013; 9: S93-S109
- Availability and quality of emergency obstetric and neonatal care services in Afghanistan.Int. J. Gynaecol. Obstet. 2012; 116: 192-196
- Afghanistan’s national strategy for improving quality in health care.Int. J. Qual. Health Care. 2013; 25: 270-276
- Quality of care in early detection and management of pre-eclampsia/eclampsia in health facilities in Afghanistan.BMC Pregnancy Childbirth. 2019; 19: 36
- Monitoring perinatal outcomes in hospitals in Kabul, Afghanistan: the first step of a quality assurance process.J. Matern. Fetal. Neonatal. Med. 2009; 22: 285-292
- National reproductive, maternal, newborn, child and adolescent health (RMNCAH) strategy 2017-2021. Kabul: ministry of public health (MoPH).Islamic Republic of Afghanistan. 2017
- Understanding country-specific determinants of stillbirth using household surveys: the case of Afghanistan.Paediatr. Perinat. Epidemiol. 2019; 33: 28-44
- Weeping in silence: community experiences of stillbirths in rural eastern Uganda.Glob. Health Action. 2015; 8: 24011
- "These are not good things for other people to know": how rural Tanzanian women’s experiences of pregnancy loss and early neonatal death may impact survey data quality.Soc Sci Med. 2010; 71: 1764-1772
- A qualitative study of attitudes and values surrounding stillbirth and neonatal mortality among grandmothers, mothers, and unmarried girls in rural Amhara and Oromiya regions, Ethiopia: unheard souls in the backyard.J. Midwifery Womens Health. 2014; 59: S110-7
- Social autopsy for maternal and child deaths: a comprehensive literature review to examine the concept and the development of the method.Popul. Health Metr. 2011; 9: 45
- Social autopsy for maternal and perinatal deaths in Bangladesh: a tool for community dialog and decision making.Public Health Rev. 2018; 39: 16
- Using social autopsy to understand maternal, newborn, and child mortality in low-resource settings: a systematic review of the literature.Glob. Health Action. 2017; 101413917
- Afghanistan: Protection of Civilians in Armed Conflict Annual Report 2017.United Nations Assistance Mission in Afghanistan (UNAMA), Kabul, Afghanistan2018
- Estimated Population of Afghanistan 2017-18.Central Statistics Organization (CSO), Kabul, Afghanistan2017
- Afghanistan: A Cultural and Political History.Princeton University Press, Princeton, New Jersey2010
- How many interviews are enough? An experiment with data saturation and variability.Field methods. 2006; 18: 59-82
- Using thematic analysis in psychology.Qual. Res. Psychol. 2006; 3: 77-101
- Still too far to walk: literature review of the determinants of delivery service use.BMC Pregnancy Childbirth. 2009; 9
- Poverty and access to health care in developing countries.Ann. N. Y. Acad. Sci. 2008; 1136: 161-171
- Patient-centred access to health care: conceptualising access at the interface of health systems and populations.Int. J. Equity Health. 2013; 12: 18
- Community health workers of Afghanistan: a qualitative study of a national program.Confl. Health. 2014; 8: 26
- Antenatal and obstetric care in Afghanistan--a qualitative study among health care receivers and health care providers.BMC Health Serv. Res. 2013; 13: 166
- Parallel worlds: an ethnography of care in an Afghan maternity hospital.Soc Sci Med. 2018; 216: 33-40
- Bypassing primary care facilities for childbirth: findings from a multilevel analysis of skilled birth attendance determinants in Afghanistan.J. Midwifery Womens Health. 2016; 61: 185-195
- Afghanistan Mortality Survey 2010.Afghan National Public Health Institute, Ministry of Public Health (ANPHI/MoPH), Calverton, Maryland, USA2011
- Barriers associated with care-seeking for institutional delivery among rural women in three provinces in Afghanistan.BMC Pregnancy Childbirth. 2018; 18: 246
- Causes of and factors associated with stillbirth in low- and middle-income countries: a systematic literature review.BJOG. 2014; 121: 141-153
- Stillbirth among women in nine states in India: rate and risk factors in study of 886,505 women from the annual health survey.BMJ Open. 2018; 8e022583
- Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries.Health Policy Plan. 2012; 27: 288-300
- Understanding Afghan healthcare providers: a qualitative study of the culture of care in a Kabul maternity hospital.BJOG. 2015; 122: 260-267
- Group antenatal care models in low- and middle-income countries: a systematic evidence synthesis.Reprod. Health. 2018; 15: 38
- Exploring perceptions of group antenatal care in urban India: results of a feasibility study.Reprod. Health. 2018; 15: 57
- Improving health literacy through group antenatal care: a prospective cohort study.BMC Pregnancy Childbirth. 2017; 17: 228
- Using direct clinical observation to assess the quality of cesarean delivery in Afghanistan: an exploratory study.BMC Pregnancy Childbirth. 2014; 14: 176
- Standards for Improving Quality of Maternal and Newborn Care in Health Facilities.World Health Organisation, Geneva, Switzerland2016
- WHO Recommendations: Intrapartum Care for a Positive Childbirth Experience.World Health Organization (WHO), Geneva2018
- WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience.World Health Organization, Geneva2016
- Social autopsy of maternal, neonatal deaths and stillbirths in rural Bangladesh: qualitative exploration of its effect and community acceptance.BMJ Open. 2016; 6e010490
- Social autopsy: INDEPTH Network experiences of utility, process, practices, and challenges in investigating causes and contributors to mortality.Popul. Health Metr. 2011; 9: 44
Article info
Publication history
Published online: February 21, 2020
Accepted:
February 12,
2020
Received in revised form:
January 20,
2020
Received:
August 29,
2019
Identification
Copyright
© 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
