|Understanding country-specific determinants of stillbirth using household surveys: The case of Afghanistan|
||Aliki Christou, Michael J. Dibley, Mohammad Hafiz Rasooly, Adela Mubasher, Sayed Murtaza Sadat Hofiani, Mohammad Khakerah Rashidi, Patrick J. Kelly, and Camille Raynes-Greenow
||Paediatric & Perinatal Epidemiology, 33(1): 28-44; DOI: 10.1111/ppe.12530
||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.
K E Y W O R D S
Afghanistan, Demographic and Health Survey, fetal death, household surveys, low- and
middle-income country, perinatal death, risk factor, stillbirth