Association of hormone receptors and human epidermal growth factor receptor-2/neu expressions with clinicopathologic factors of breast carcinoma: a cross-sectional study in a tertiary care hospital, Kabul, Afghanistan.

BACKGROUND: Breast cancer (BC) is one of the major causes of death worldwide. It is the most common cause of death before the age of 70 years. The incidence and mortality of BC are rapidly increasing, posing great challenges to the health system and economy of every nation. METHODOLOGY: A cross-sectional analytical study was conducted at the Department of Pathology and Clinical Laboratory of the French Medical Institute for Mothers and Children (FMIC) to demonstrate the association of human epidermal growth factor receptor 2 (Her2/Neu) and estrogen receptor (ER)/ progesterone receptor (PR) with clinical as well as pathological parameters among women with BC. A consecutive nonprobability sampling method was used for this study over a span of one and a half years. RESULTS: One hundred twenty participants diagnosed with breast cancer were included in the study. The mean age at diagnosis was 44.58 ± 11.16 years. Out of the total patients, 68 (56.7%) were above 40 years old, 108 (90%) were married, 94 (78.3%) were multiparous, and 88 (73.3%) had a history of breastfeeding. 33.3% of cases were within the age range of menopause (40-50 years). The positive expression rates of ER, PR, and Her2/neu were found to be 48.8%, 44.6%, and 44.6%, respectively, and Her2/neu overexpression was found to be higher among ER/PR-negative cases. CONCLUSION: In our study, we demonstrated that among Afghan women, grade II invasive ductal carcinoma, not otherwise specified, was the most common type of BC and frequently affected women above the age of 40. We also revealed that the percentage of negative ER (50.4%), negative PR (54.4%), and concordant ER/PR-negative cases were high compared to other possibilities. Additionally, the study revealed that expression of Her2/neu was in contrast with the expression of ER and PR receptors. The findings of our study still support the importance of performing immunohistochemical stains for hormonal receptor classification in terms of better clinical outcomes and prognosis.

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.

'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.

How community and healthcare provider perceptions, practices and experiences influence reporting, disclosure and data collection on stillbirth: Findings of a qualitative study in Afghanistan.

Quality concerns exist with stillbirth data from low- and middle-income countries including under-reporting and misclassification which affect the reliability of burden estimates. This is particularly problematic for household survey data. Disclosure and reporting of stillbirths are affected by the socio-cultural context in which they occur and societal perceptions around pregnancy loss. In this qualitative study, we aimed to understand how community and healthcare providers' perceptions and practices around stillbirth influence stillbirth data quality in Afghanistan. We collected data through 55 in-depth interviews with women and men that recently experienced a stillbirth, female elders, community health workers, healthcare providers, and government officials in Kabul province, Afghanistan between October-November 2017. The results showed that at the community-level, there was variation in local terminology and interpretation of stillbirth which did not align with the biomedical categories of stillbirth and miscarriage and could lead to misclassification. Specific birth attendant practices such as avoiding showing mothers their stillborn baby had implications for women's ability to recall skin appearance and determine stillbirth timing; however, parents who did see their baby, had a detailed recollection of these characteristics. Birth attendants also unintentionally misclassified birth outcomes. We found several practices that could potentially reduce under-reporting and misclassification of stillbirth; these included the cultural significance of ascertaining signs of life after birth (which meant families distinguished between stillbirths and early neonatal deaths); the perceived value and social recognition of a stillborn; and openness of families to disclose and discuss stillbirths. At the facility-level, we identified that healthcare provider's practices driven by institutional culture and demands, family pressure, and socio-cultural influences, could contribute to under-reporting or misclassification of stillbirths. Data collection methodologies need to take into consideration the socio-cultural context and investigate thoroughly how perceptions and practices might facilitate or impede stillbirth reporting in order to make progress on data quality improvements for stillbirth.

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 complications 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 important 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 stillbirths 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.