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      Determinants of delays in travelling to an emergency obstetric care facility in Herat, Afghanistan: an analysis of cross-sectional survey data and spatial modelling


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          Women’s delays in reaching emergency obstetric care (EmOC) facilities contribute to high maternal and perinatal mortality and morbidity in low-income countries, yet few studies have quantified travel times to EmOC and examined delays systematically. We defined a delay as the difference between a woman’s travel time to EmOC and the optimal travel time under the best case scenario. The objectives were to model travel times to EmOC and identify factors explaining delays. i.e., the difference between empirical and modelled travel times.


          A cost-distance approach in a raster-based geographic information system (GIS) was used for modelling travel times. Empirical data were obtained during a cross-sectional survey among women admitted in a life-threatening condition to the maternity ward of Herat Regional Hospital in Afghanistan from 2007 to 2008. Multivariable linear regression was used to identify the determinants of the log of delay.


          Amongst 402 women, 82 (20%) had no delay. The median modelled travel time, reported travel time, and delay were 1.0 hour [Q1-Q3: 0.6, 2.2], 3.6 hours [Q1-Q3: 1.0, 12.0], and 2.0 hours [Q1-Q3: 0.1, 9.2], respectively. The adjusted ratio (AR) of a delay of the “one-referral” group to the “self-referral” group was 4.9 [95% confidence interval (CI): 3.8-6.3]. Difficulties obtaining transportation explained some delay [AR 2.1 compared to “no difficulty”; 95% CI: 1.5-3.1]. A husband’s very large social network (> = 5 people) doubled a delay [95% CI: 1.1-3.7] compared to a moderate (3-4 people) network. Women with severe infections had a delay 2.6 times longer than those with postpartum haemorrhage (PPH) [95% CI: 1.4-4.9].


          Delays were mostly explained by the number of health facilities visited. A husband’s large social network contributed to a delay. A complication with dramatic symptoms (e.g. PPH) shortened a delay while complications with less-alarming symptoms (e.g. severe infection) prolonged it. In-depth investigations are needed to clarify whether time is spent appropriately at lower-level facilities. Community members need to be sensitised to the signs and symptoms of obstetric complications and the urgency associated with them. Health-enhancing behaviours such as birth plans should be promoted in communities.

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          Too far to walk: maternal mortality in context.

          The Prevention of Maternal Mortality Program is a collaborative effort of Columbia University's Center for Population and Family Health and multidisciplinary teams of researchers from Ghana, Nigeria and Sierra Leone. Program goals include dissemination of information to those concerned with preventing maternal deaths. This review, which presents findings from a broad body of research, is part of that activity. While there are numerous factors that contribute to maternal mortality, we focus on those that affect the interval between the onset of obstetric complication and its outcome. If prompt, adequate treatment is provided, the outcome will usually be satisfactory; therefore, the outcome is most adversely affected by delayed treatment. We examine research on the factors that: (1) delay the decision to seek care; (2) delay arrival at a health facility; and (3) delay the provision of adequate care. The literature clearly indicates that while distance and cost are major obstacles in the decision to seek care, the relationships are not simple. There is evidence that people often consider the quality of care more important than cost. These three factors--distance, cost and quality--alone do not give a full understanding of decision-making process. Their salience as obstacles is ultimately defined by illness-related factors, such as severity. Differential use of health services is also shaped by such variables as gender and socioeconomic status. Patients who make a timely decision to seek care can still experience delay, because the accessibility of health services is an acute problem in the developing world. In rural areas, a woman with an obstetric emergency may find the closest facility equipped only for basic treatments and education, and she may have no way to reach a regional center where resources exist. Finally, arriving at the facility may not lead to the immediate commencement of treatment. Shortages of qualified staff, essential drugs and supplies, coupled with administrative delays and clinical mismanagement, become documentable contributors to maternal deaths. Findings from the literature review are discussed in light of their implications for programs. Options for health programs are offered and examples of efforts to reduce maternal deaths are presented, with an emphasis on strategies to mobilize and adapt existing resources.
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            Social capital and self-rated health: a contextual analysis.

            Social capital consists of features of social organization--such as trust between citizens, norms of reciprocity, and group membership--that facilitate collective action. This article reports a contextual analysis of social capital and individual self-rated health, with adjustment for individual household income, health behaviors, and other covariates. Self-rated health ("Is your overall health excellent, very good, good, fair, or poor?") was assessed among 167,259 individuals residing in 39 US states, sampled by the Behavioral Risk Factor Surveillance System. Social capital indicators, aggregated to the state level, were obtained from the General Social Surveys. Individual-level factors (e.g., low income, low education, smoking) were strongly associated with self-rated poor health. However, even after adjustment for these proximal variables, a contextual effect of low social capital on risk of self-rated poor health was found. For example, the odds ratio for fair or poor health associated with living in areas with the lowest levels of social trust was 1.41 (95% confidence interval = 1.33, 1.50) compared with living in high-trust states. These results extend previous findings on the health advantages stemming from social capital.
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              The prevalence of maternal near miss: a systematic review.

              Severe maternal morbidity or 'near miss' is a promising indicator to improve quality of obstetric care. To systematically review all available studies on 'near miss'. Following a pre-defined protocol, our review covered articles between January 2004 and December 2010. We used a combination of the following terms: near miss morbidity, severe maternal morbidity, severe acute maternal morbidity, obstetric near-miss, maternal near miss, obstetric near miss, emergency hysterectomy, emergency obstetric hysterectomy, maternal complications, pregnancy complications, intensive care unit. Nearly 4000 articles were screened by title and abstract, and 153 articles were retrieved for full text evaluation. There were no language restrictions. Data extraction was performed using an instrument that included sections on study characteristics, quality of reporting, prevalence/incidence and the definition and identification criteria. Univariate analysis and meta-analysis for sub-groups were performed. A total of 82 studies from 46 countries were included. Criteria for identification of cases varied widely. Prevalence rates varied between 0.6 and 14.98% for disease-specific criteria, between 0.04 and 4.54% for management-based criteria and between 0.14 and 0.92% for organ-based dysfunction based on Mantel criteria. The rates are higher in low-income and middle-income countries of Asia and Africa. Based on meta-analysis, the estimate of near miss was 0.42% (95% CI 0.40-0.44%) for the Mantel (organ dysfunction) criteria and 0.039% (95% CI 0.037-0.042%) for emergency hysterectomy. Our meta-regression results indicate that emergency hysterectomy rates have been increasing by about 8% per year. There is growing interest in the application of the maternal near-miss concept as an adjunct to maternal mortality. However, in the literature published before 2011 there was still important variation in the criteria used to identify maternal near-miss cases. The World Health Organization recently published criteria based on markers of management and of clinical and organ dysfunction which would enable systematic data collection on near miss and development of summary estimates. Comparing the rates over time and across regions, it is clear that different approaches are needed to lower the rates of near miss and that interventions must be developed with the local context in mind. © 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.

                Author and article information

                BMC Pregnancy Childbirth
                BMC Pregnancy Childbirth
                BMC Pregnancy and Childbirth
                BioMed Central (London )
                5 February 2015
                5 February 2015
                : 15
                : 14
                [ ]PhD programme, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
                [ ]Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
                [ ]Institute of Tropical Medicine and International Health, Charité – Universitätsmedizin, Berlin, Germany
                [ ]Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
                [ ]World Vision International, Herat, Afghanistan
                © Hirose et al.; licensee BioMed Central. 2015

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                : 16 October 2014
                : 12 January 2015
                Research Article
                Custom metadata
                © The Author(s) 2015

                Obstetrics & Gynecology
                afghanistan,delays,emergency obstetric care,referrals,maternal health,near-miss,geographic information systems,social network,transportation


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