Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999-2002.

BACKGROUND: Maternal mortality in Afghanistan is uniformly identified as an issue of primary public-health importance. To guide the implementation of reproductive-health services, we examined the numbers, causes, and preventable factors for maternal deaths among women in four districts. METHODS: We did a retrospective cohort study of women of reproductive age (15-49 years) who died between March 21, 1999, and March 21, 2002, in four selected districts in four provinces: Kabul city, Kabul province (urban); Alisheng district, Laghman province (semirural); Maywand, Kandahar province (rural); and Ragh, Badakshan province (rural, most remote). Deaths among women of reproductive age were identified through a survey of all households in randomly selected villages and investigated through verbal-autopsy interviews of family members. FINDINGS: In a population of 90 816, 357 women of reproductive age died; 154 deaths were related to complications during pregnancy, childbirth, or the puerperal period. Most maternal deaths were caused by ante-partum haemorrhage, except in Ragh, where a greater proportion of women died of obstructed labour. All measures of maternal risk were high, especially in the more remote areas; the maternal mortality ratio (per 100,000 livebirths) was 418 (235-602) in Kabul, 774 (433-1115) in Alisheng, 2182 (1451-2913) in Maywand, and 6507 (5026-7988) in Ragh. In the two rural sites, no woman who died was assisted by a skilled birth attendant. INTERPRETATION: Maternal mortality in Afghanistan is high and becomes significantly greater with increasing remoteness. Deaths could be averted if complications were prevented through optimisation of general health status and if complications that occurred were treated to reduce their severity--efforts that require a multisectoral approach to increase availability and accessibility of health care.

A comparison of morbidity rates attributable to conditions originating in the perinatal period among newborns discharged from United States hospitals, 1989-90 and 1999-2000.

Perinatal conditions account for 60% of US neonatal deaths, yet little is known about rates of morbidity attributable to these conditions. To estimate these rates, we analysed newborn hospital discharges from the National Hospital Discharge Survey. We used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to classify discharge diagnoses among a weighted, nationally representative sample of newborns discharged from short-stay, non-federal US hospitals. We compared overall and cause-specific morbidity rates attributable to perinatal conditions (ICD-9-CM 760.0-779.9), as well as the average length of hospital stay among newborn discharges during 1989-90 and 1999-2000. The overall newborn morbidity rate declined from 36.3% in 1989-90 to 33.7% in 1999-2000 (P < 0.01), despite significant increases in high-risk births. The decline can be attributed to significant decreases in the reported rates of jaundice, fetal distress, birth trauma and birth asphyxia. Rates of jaundice decreased from 15.7% to 13.4% (P < 0.01). The average length of stay decreased among newborns with no morbid condition (2.37-2.04 days, P < 0.001) and among those with one perinatal condition (3.11-2.51, P < 0.001), but increased among those with multiple perinatal conditions (8.43-9.98, P < 0.05). Morbidity rates among newborns discharged from US hospitals declined. Shorter newborn hospital stays may have resulted in fewer cases of jaundice being diagnosed before discharge. Stricter diagnostic criteria and changes in obstetric practices may have led to a decline in the rates of fetal distress, birth trauma and birth asphyxia.

Pregnancy-associated hospitalizations in the United States, 1999-2000.

OBJECTIVE: The purpose of this study was to examine nondelivery, pregnancy-associated hospitalizations in the United States and the factors associated with them. STUDY DESIGN: Population-based nondelivery hospitalizations during pregnancy were obtained from the 1999 and 2000 National Hospital Discharge Survey. Ratios of hospitalizations per 100 deliveries were calculated and analyzed by age, race, and payment source. RESULTS: The pregnancy-associated hospitalization ratio for 1999 through 2000 was 12.8 per 100 deliveries (95% CI, 11.8-13.8). Hospitalizations were highest among young women, African American women, and women without private insurance. Preterm labor, nausea and/or vomiting, and genitourinary complications accounted for one half of antenatal hospitalizations. CONCLUSION: Pregnancy-associated hospitalizations declined during the 1990s. This may represent a decline in maternal morbidity or a change in management of pregnancy complications. Future research should be expanded to assess trends in morbidity treated in settings outside of hospitals.

A determination of the prevalence of gender-based violence among conflict-affected populations in East Timor.

The Reproductive Health Response in Conflict (RHRC) Consortium designed a standardised questionnaire to measure gender-based violence (GBV) prevalence in conflict-affected settings. A preliminary field test was undertaken July-August 2002 in one urban and one rural district in East Timor to assess the prevalence of GBV among women 18-49 years of age during and after conflict. The field test used a cross-sectional survey design with a two-stage random selection process. During the year preceding East Timor's 1999 crisis, 23.8 per cent of respondents reported physical assault by an intimate partner; this rate was not significantly different in the year preceding the survey (24.8 per cent). Assault by perpetrators outside the family declined significantly from 24.2 per cent during the crisis to 5.8 per cent post-crisis for physical assault (p<.001) and 22.7 per cent during the crisis to 9.7 per cent post-crisis for sexual assault (p=0.046). The field test stimulated and informed additional research in East Timor, and the complementary findings of these research initiatives continue to be used to develop local policies and programming to prevent and address GBV.