Barriers and associated factors for adequate antenatal care among Afghan women in Iran; findings from a community-based survey

Barriers and enabling factors for utilizing physical rehabilitation services by Afghan immigrants and refugees with disabilities in Iran: a qualitative study

INTRODUCTION

Individuals with a migrant background often underutilize physical rehabilitation services (PRS) compared to the host population. This disparity is attributed to various barriers, including limited access to information, language barriers, illiteracy, and cultural factors. To improve PRS utilization by Afghan immigrants and refugees in Iran, it is crucial to identify these barriers and enabling factors. In response, this study explored the barriers and enabling factors for utilizing PRS among Afghan immigrants and refugees with disabilities in Iran.

METHODS

This qualitative study was conducted in Iran between January and March 2023. Participants were selected through convenient and snowball sampling. Individual, semi-structured interviews were carried out both in face-to-face and online formats. Data analysis occurred concurrently with data collection, using the directed content analysis approach.

RESULTS

Findings from our research indicate that common barriers to PRS utilization among Afghan immigrants and refugees include insufficient insurance coverage, high service costs, expensive transportation and accommodation, limited knowledge about Iran's health system, inadequate awareness of available supports, restricted access to PRS in remote areas, impatience among PRS providers, fear of arrest and deportation, a lack of trust in modern treatments, stringent immigration rules, high inflation rates limiting the ability to pay for PRS, and limited social support. On the other hand, several enabling factors were identified, such as strengthening insurance coverage, utilizing the capacities of charities and NGOs, providing information about available services, promoting respectful behavior by healthcare providers towards patients, facilitating cultural integration, and increasing immigrants' awareness of available services and eligibility criteria.

CONCLUSION

The barriers and enabling factors uncovered in this study offer valuable insights into the complexities surrounding PRS utilization by Afghan immigrants and refugees with disabilities in Iran. Understanding and addressing these factors is essential for developing targeted interventions and policies that can improve access and utilization, ultimately leading to enhanced health outcomes for this vulnerable population.

Awareness of Preeclampsia and Its Associated Factors Among Women in Al Baha Region, Saudi Arabia

BACKGROUND

Preeclampsia is associated with the incidence of common fetal problems including intra-uterine growth restriction (IUGR), premature delivery oligohydramnios, placental abruption, fetal discomfort, and intrauterine fetal death. Pregnant women are not well-informed about preeclampsia, including its symptoms, risk factors, and consequences. The aim of the current study is to evaluate the awareness of preeclampsia and its associated factors among women in the Al Baha region, Saudi Arabia.

METHODOLOGY

An observational cross-sectional design was employed to assess the awareness of preeclampsia and its associated factors among women in the Al Baha region of Saudi Arabia. Data was collected from April 2023 to September 2023. A questionnaire was designed to gather information on participants' sociodemographic characteristics (such as age, educational level, and residency) and their awareness of preeclampsia, including knowledge about signs/symptoms, risk factors, and complications.

RESULTS

In the current study, we included 485 pregnant women. The majority of participants were aged 40 years or older (37.5%), followed by those aged 35-39 (20.4%). Among the participants, 70.9% confirmed that they had heard about pre-eclampsia before. The most common signs and symptoms were high blood pressure (47.4%), increased protein in urine (40.2%), continuous headache (39.2%), and vomiting/nausea (40.0%). Participants demonstrated awareness of obesity (29.7%), diabetes mellitus (35.5%), chronic hypertension (47.0%), and chronic kidney disease (31.3%) as major risk factors. Participants were aware of potential risks such as kidney disorders (34.6%), heart disorders (23.7%), and preterm delivery (50.9%). The analysis reveals that younger participants below 20 years old (3.3%) and lower educational levels (5.6%) had lower awareness of preeclampsia compared to older age groups.

CONCLUSION

The findings of this study highlight a reasonable level of preeclampsia awareness and knowledge among Saudi Arabian women residing in the Al Baha region. While the majority of participants were familiar with preeclampsia, there were significant knowledge gaps regarding the precise symptoms, risk factors, and consequences of the condition.

Double burden of vulnerability for refugees: conceptualization and policy solutions for financial protection in Iran using systems thinking approach

INTRODUCTION

Iran is host to one of the world's largest and longest-standing refugee populations. Although Iran has initiated a basic health insurance scheme for refugees throughout the country since September 2015, the population coverage of this scheme is very low, and various factors have caused a significant percentage of refugees to still lack insurance coverage and often face financial hardships when receiving health services. In response, this study aimed to understand barriers to insurance coverage among refugees in Iran and propose effective policies that can address persistent gaps in financial protection.

METHODS

This qualitative study was conducted in two phases. First, a review of policy documents and interviews with participants were conducted to investigate the common barriers and facilitators of effective insurance coverage for refugees in Iran. Then, a systems thinking approach was applied to visualize the common variables and interactions on the path to achieving financial protection for refugees.

RESULTS

Findings showed that various factors, such as (1) household-based premium for refugees, (2) considering a waiting time to be eligible for insurance benefits, (3) determining high premiums for non-vulnerable groups and (4) a deep difference between the health services tariffs of the public and private service delivery sectors in Iran, have caused the coverage of health insurance for non-vulnerable refugees to be challenging. Furthermore, some policy solutions were found to improve the health insurance coverage of refugees in Iran. These included removing household size from premium calculations, lowering current premium rates and getting monthly premiums from non-vulnerable refugees.

CONCLUSIONS

A number of factors have caused health insurance coverage to be inaccessible for refugees, especially non-vulnerable refugees in Iran. Therefore, it is necessary to adopt effective policies to improve the health financing for the refugee with the aim of ensuring financial protection, taking into account the different actors and the interactions between them.

Effectiveness of a telehealth patient education intervention for breast cancer awareness and screening uptake among Afghan refugee women: a cross-sectional survey and feasibility study

Background

Refugee populations have low levels of cancer awareness, low cancer screening rates, and a high rate of advanced or metastatic cancer at diagnosis. Educational interventions to improve cancer awareness and screening have been successful in other nationality refugee populations but have never been implemented in Afghan refugee populations. We aimed to estimate the level of breast cancer awareness among Afghan refugee women and test the feasibility of a telehealth breast cancer educational intervention to increase breast cancer awareness in this population.

Methods

A cross-sectional survey of Afghan refugee women residing in Istanbul, Türkiye who had no personal history of breast cancer and who presented to outpatient primary clinics for care between August 1, 2022, and February 10, 2023 was performed. Participant awareness of breast cancer (BC) was assessed using the validated BC awareness tool, Breast Cancer Awareness Measure (BCAM), during a telehealth encounter. After this baseline assessment, a BC educational intervention was administered to each participant during the telehealth encounter. Six months after the initial assessment and education, a follow-up BCAM was administered via telehealth in order to determine the effectiveness of the education intervention.

Findings

One hundred participants were accrued to the study. Median age was 49 years (range: 40-64). All participants had no formal education, were married, and were not employed. Prior to the educational intervention, BC awareness was low; none of the participants were able to identify some common signs/symptoms and risk factors for BC. Prior to the educational intervention, zero participants had ever had a mammogram or seen a physician for a breast-related concern. Six months after the educational intervention, up to 99 percent of participants (99 of 100 participants) were able to correctly identify common signs or symptoms and risk factors for BC. Six months after the educational intervention, all one hundred participants had accepted the offer of a screening mammogram.

Interpretation

A telehealth BC education intervention meaningfully increased BC awareness in Afghan refugee women. This increase in BC awareness was associated with a strong increase in completion of BC screening. Further implementation of educational interventions is warranted in order to increase participant awareness and improve screening rates.

Funding

Dana Farber Cancer Institute Jay Harris Junior Faculty Research Grant.

Financing of health services for undocumented immigrants in Iran: common challenges and potential solutions

INTRODUCTION

Iran is host to one of the largest urban refugee populations worldwide, about two million of whom are undocumented immigrants (UIs). UIs are not eligible to enroll in the Iranian health insurance scheme and have to pay out-of-pocket to access most health services. This increases the likelihood that they will delay or defer seeking care, or incur substantial costs if they do seek care, resulting in worse health outcomes. This study aims to improve understanding of the financial barriers that UIs face in utilizing health services and provide policy options to ensure financial protection to enhance progress towards UHC in Iran.

METHODS

This qualitative study was conducted in 2022. A triangulation approach, including interviews with key informants and comparing them with other informative sources to find out the complementary findings, was applied to increase data confirmability. Both purposive and snowball sampling approaches were used to select seventeen participants. The data analysis process was done based on the thematic content analysis approach.

RESULTS

The findings were explained under two main themes: the financial challenges in accessing health services and the policy solutions to remove these financial barriers, with 12 subthemes. High out-of-pocket payments, high service prices for UIs, fragmented financial support, limited funding capacity, not freeing all PHC services, fear of deportation, and delayed referral are some of the barriers that UIs face in accessing health care. UIs can get insurance coverage by using innovative ways to get money, like peer financing and regional health insurance, and by using tools that make it easier, like monthly premiums without policies that cover the whole family.

CONCLUSION

The formation of a health insurance program for UIs in the current Iranian health insurance mechanism can significantly reduce management costs and, at the same time, facilitate risk pooling. Strengthening the governance of health care financing for UIs in the form of network governance may accelerate the inclusion of UIs in the UHC agenda in Iran. Specifically, it is necessary to enhance the role of developed and rich regional and international countries in financing health services for UIs.

Single-Centre Retrospective Cohort Study of Demographic Characteristics and Perinatal Outcomes in Pregnant Refugee Patients in Toronto, Canada

Pregnant refugee patients are especially vulnerable to adverse perinatal outcomes. Detailed characterization of this heterogenous population will identify risk factors and thus guide contextualized initiatives for improved patient care. A retrospective cohort study of obstetrical refugee patients at a tertiary-care hospital in Toronto, Ontario. Of 196 pregnant refugees, 48% were fluent English speaking, 57% had poor social support, and 42% lived in a shelter. Eighty-seven percent started prenatal care after the first trimester, which was associated with delivery of a large-for-gestational-age infant (p = 0.043). Sixteen percent experienced family violence, which was associated with poor fetal aggregate outcomes (p = 0.03). There were significantly higher rates of pre-eclampsia and Cesarean sections in refugee versus non-refugee patients (p < 0.05). Pregnant refugees are at risk for psychosocial challenges and experience significantly worse obstetrical outcomes compared with non-refugees. Quality improvement initiatives should focus on access to early prenatal care, stable housing, and support for victims of family violence.

The association of child marriage with morbidities and mortality among children under 5 years in Afghanistan: findings from a national survey

BACKGROUND

There is still a gap in knowledge of the impact that child marriage could have on the mortality and morbidity of children in Afghanistan. This study used the data from the latest Afghanistan demographic health survey conducted in 2015 (ADHS) to address this gap and advance the current knowledge.

METHODS

A secondary analysis of the 2015 ADHS, including the births in the past 5 years to ever-married women aged 15-24 years old, was carried out. Logistic regression analyses were employed to examine the association of child marriage (< 18y) with morbidities (diarrhea, acute respiratory infection, and fever in the last 2 weeks), mortality (neonatal, infant, child), and size at birth among the children under 5 born to women aged 15-24 years, before and after adjusting for the effect of sociodemographic and structural inequalities.

RESULTS

Approximately two-thirds of births in the past 5 years belong to 15-24 years old mothers who married at ages < 18. The majority of them were born to mothers residing in rural areas (75.67%) with no education (51.68%) from poor households (39.39%). As compared to the births to women married at ages ≥ 18, there was a significantly higher likelihood of neonatal mortality among births to women married at ages < 18 (crude OR = 2.30, 95% CI: 1.52-3.49 & adjusted OR = 1.94, 95% CI: 1.25-3.01) and higher infant mortality among the births to the women married at ages ≤ 14y (crude OR = 1.94, 95% CI: 1.06-3.53). However, it disappeared for neonatal mortality after adjustment for adequacy of antenatal care (ANC) and infant mortality after adjustment for sociodemographic inequalities.

CONCLUSION

Although the births to women married as a child (< 18) were more likely to die at an early age, this association disappeared after adjustment for the adequacy of ANC. Given the unavoidable practice of child marriage in Afghanistan, this finding emphasizes the importance of providing adequate ANC for young brides to prevent child mortality. In addition, strong global advocacy is required to empower and support young Afghan women in negotiating their reproductive and maternity rights with their partners by reducing social and gender-based inequalities.

Internal migration and utilization of reproductive and maternity care among women in Pakistan: evidence from a recent National Survey

Background

During the last decades, migratory behavior has had a key role in population growth and redistribution in Pakistan. Migration has far-reaching socioeconomic implications for individuals and society at large that could influence the health integrity of Pakistani women. This study aimed to describe the migration patterns and drivers as well as their association with adequate access to reproductive and maternal care among married Pakistani women aged 15-49.

Methods

The data from the 2017-18 Pakistan Demographic Health Survey (PDHS) was used to extract the information on the explanatory (sociodemographic and migration backgrounds) and outcome variables (unmet needs for family planning, adequate antenatal care, and delivery at health facilities). Bivariate and multivariate logistic regression analyses were employed to examine the relationship between these explanatory and outcome variables before and after adjustment for sociodemographic inequalities.

Results

In unadjusted models, the odds of having adequate ANC and delivery at health facilities were approximately 2 to 4 times higher in those living (urban non-migrant), moving to (urban to urban, rural to urban), or leaving the urban areas (rural to urban) as compared to rural non-migrants; likewise, the odds of the unmet needs for family planning was about 20-50% lower in the same migration streams compared to rural non-migrant. However, after adjustment for sociodemographic inequalities, most of these associations attenuated and only the association of urban to urban migration with unmet needs for family planning and the association of urban non-migrant with delivery at health facilities remained significant.

Conclusion

Although the findings suggest that Internal migration flows, particularly those to urban areas (urban to urban and rural to urban), could be associated with better access to reproductive and maternity care among married Pakistani women aged 15-49 years; adjustment for sociodemographic inequalities, particularly education and wealth, nullified this association to a great extent. This has important implications for current policies and interventions in Pakistan and calls for policy reform and women's rights advocacy to enhance the literacy level of young Pakistani girls through well-tailored interventions, maintaining them at school.

Input, process, and output factors contributing to quality of antenatal care services: a scoping review of evidence

BACKGROUND

High-quality antenatal care (ANC) provides a lifesaving opportunity for women and their newborns through providing health promotion, disease prevention, and early diagnosis and treatment of pregnancy-related health issues. However, systematically synthesised evidence on factors influencing the quality of ANC services is lacking. This scoping review aims to systematically synthesize the factors influencing in provision and utilisation of quality ANC services.

METHODS

We conducted a scoping review of published evidence on the quality of ANC services. We searched records on four databases (PubMed, Scopus, Embase, and Google scholar) and grey literature from 1 to 2011 to 30 August 2021. We analysed data using Braun and Clarke's thematic analysis approach. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline for the review. We explained themes using the Donabedian healthcare quality assessment model (input-process-output).

RESULTS

Several inputs- and process-related factors contributed to suboptimal quality of ANC in many low and lower- or middle-income countries. Input factors included facility readiness (e.g., lack of infrastructure, provision of commodities and supplies, health workforce, structural and intermediary characteristics of pregnant women, and service delivery approaches). Processes-related factors included technical quality of care (e.g., lack of skilled adequate and timely care, and poor adherence to the guidelines) and social quality (lack of effective communication and poor client satisfaction). These input and process factors have also contributed to equity gaps in utilisation of quality ANC services.

CONCLUSION

Several input and process factors influenced the provision and utilization of optimum quality ANC services. Better health system inputs (e.g., availability of trained workforces, commodities, guidelines, context-specific programs) are essential to creating enabling facility environment for quality ANC services. Care processes can be improved by ensuring capacity-building activities for workforces (training, technical support visits), and mentoring staff working at peripheral facilities. Identifying coverage of quality ANC services among disadvantaged groups could be the initial step in designing and implementing targeted program approaches.

Health Status of Afghan Refugees in Europe: Policy and Practice Implications for an Optimised Healthcare

Four decades of civil war, violence, and destabilisation have forced millions of Afghans to flee their homes and to move to other countries worldwide. This increasing phenomenon may challenge physicians unfamiliar with the health status of this population, which may be markedly different from that of the host country. Moreover, several factors during their migration, such as transport in closed containers, accidental injuries, malnutrition, and accommodation in detention centres and refugee camps have a major influence on the health of refugees. By taking into account the variety of the specific diseases among migrant groups, the diversity of the origins of refugees and asylum seekers, and the increasing numbers of Afghan refugees, in this review we focus on the population of Afghans and describe their health status with the aim of optimising our medical approach and management. Our literature review shows that the most prevalent reported infections are tuberculosis and other respiratory tract infections and parasitic diseases, for example leishmaniasis, malaria, and intestinal parasitic infections. Anaemia, hyperlipidaemia, arterial hypertension, diabetes, smoking, overweight, malnutrition, low socioeconomic status, and poor access to healthcare facilities are additional risk factors for non-communicable diseases among Afghan refugees. With regards mental health issues, depression and post-traumatic stress disorder (PTSD) are the most common diagnoses and culture shock and the feeling of being uprooted modulate their persistence. Further research is needed in order to provide us with extensive, high-quality data about the health status of Afghan refugees. The main objective of this review is to identify protective factors which could ensure key health concepts and good clinical practice.

Number of antenatal care visits and associated factors among reproductive age women in Sub-Saharan Africa using recent demographic and health survey data from 2008-2019: A multilevel negative binomial regression model

BACKGROUND

Antenatal care is one of the best strategies for maternal and neonatal mortality reduction. There is a paucity of evidence on the mean number of ANC visits and associated factors in Sub-Saharan Africa (SSA). This study aimed to investigate the mean number of ANC visits and associated factors among reproductive-age women in Sub-Saharan Africa using the Demographic and Health Survey conducted from 2008 to 2019.

METHOD

A total of 256,425 weighted numbers of women who gave birth five years before the survey were included. We used STATA version 14 for data management and analysis. A multilevel negative binomial regression model was fitted. Finally, the Adjusted Incident Rate Ratio (AIRR) with its 95% CI confidence interval was reported. Statistical significance was declared at P-value < 0.05.

RESULTS

The mean number of ANC visits among women who gave birth five years before the survey in SSA was 3.83 (95% CI = 3.82, 3.84) Individual-level factors such as being aged 36-49 years (AIRR = 1.20, 95% CI = 1.18,1.21), having secondary education &above (AIRR = 1.44, 95% CI = 1.42, 1.45), having rich wealth status (AIRR = 1.08, 95% CI = 1.07, 1.09), media exposure (AIRR = 1.10, 95% CI = 1.09,1.11), and grand multiparity (AIRR = 0.90, 95% CI = 0.89, 0.91) were significantly associated with the number of ANC visits. Furthermore, rural residence (AIRR = 0.90, 95% CI = 0.89, 0.91), Western SSA region (AIRR = 1.19, 95% CI = 1.18, 1.20) and being from a middle-income country (AIRR = 1.09, 95% CI = 1.08, 1.10) were community-level factors that had a significant association with the number of ANC visits.

CONCLUSION

The mean number of ANC visits in SSA approximates the minimum recommended number of ANC visits by the World Health Organization. Women's educational status, women's age, media exposure, parity, planned pregnancy, wealth status, residence, country's income, and region of SSA had a significant association with the frequency of ANC visits. This study suggests that addressing geographical disparities and socio-economic inequalities will help to alleviate the reduced utilization of ANC services.

A Systematic review of sexual and reproductive health needs, experiences, access to services, and interventions among the rohingya and the afghan refugee women of reproductive age in Asia

INTRODUCTION

Approximately 9.2 million refugees live in Asia, with most originating from Afghanistan and Myanmar, and half of them are women, girls, and children. Humanitarian crises disrupt the existing health-care system, limiting access to sexual and reproductive health (SRH) services. This review explores the SRH status of Afghan and Rohingya refugee women of reproductive age in Asia and their needs and experiences in accessing these services and commodities.

MATERIALS AND METHODS

We used the PRISMA checklist and searched for qualitative and quantitative peer-reviewed studies from five online bibliographic databases, SCOPUS, EMBASE (Ovid), MEDLINE (Ovid), CINAHL, and PROQUEST, from January 2000 to April 2021. Content analysis was undertaken following the minimum initial service package objectives.

RESULTS

Fifteen studies were included in this review from four countries: Bangladesh (5), Pakistan (5), Iran (4), and Malaysia (1). Approximately 50.91% of Rohingya and 54% of Afghan refugee women used contraceptives. About 56.6% of Afghan refugee mothers experienced pregnancy-related complications, one-third received antenatal care, and low birth weight was 2.6 times higher among infants born to Afghan refugee mothers than to Pakistani-born mothers. One out of five Rohingya women received delivery-related care. Approximately 72% of Rohingya and 79.8% of Afghan refugee women had experienced gender-based violence, and 56.5% of Rohingya women engaged in unwanted sexual intercourse with their husbands.

CONCLUSION

Social norms, stigma, cultural values, distrust of providers, inadequate staff, and prohibition by family members limit their access to SRH services and influence their needs, knowledge, and perceptions regarding SRH.

Long-term effects of a lay health advisor intervention on immigrant children's dental caries and maternal preventive behaviour: A randomized controlled trial

OBJECTIVES

An oral health disparity exists between native and immigrant children in Taiwan. This study evaluated the long-term effectiveness of a lay health advisor (LHA) intervention on immigrant children's dental caries and maternal preventive behaviours.

METHODS

Fifty-one immigrant mother-child pairs were randomly assigned to LHA intervention (n = 23) and control (n = 28) groups. Mothers in the LHA group received a four-chapter one-on-one lesson plan, which included dental caries-related knowledge, brushing techniques, caries prevention and free preventive services, from the LHA over 4 weeks. Mothers in the control group received only a health brochure. Baseline and 1-week, 2-month, and 8-month follow-up information was collected using dental examinations and questionnaires.

RESULTS

The mean ages of the children in the LHA and control groups were 4.0 ± 1.4 and 4.2 ± 1.5, respectively. The decayed, missing due to caries, filled teeth (dmft) index in the LHA and control groups was 4.8 ± 6.0 and 5.4 ± 5.4, respectively, at baseline. At the 8-month postintervention follow-up, the number of filled teeth (ft) in the LHA group was higher than that in the control group (β = 8.3, P = .033). The effect size (ES) demonstrated an upward trend at 1-week, 2-month and 8-month follow-ups in ft (ES = 0.21, 0.50 and 0.59, respectively) and a decrease in the number of decayed teeth (dt) (ES = 0.30, 0.43 and 0.57, respectively). The mothers in the LHA group were observed to be 10.9 times more likely than control mothers to assist their children in toothbrushing for 3 min at the 1-week follow-up (95% CI = 1.98-59.40, P = .006).

CONCLUSIONS

The LHA intervention strategy had positive effects on the immigrant children's new dt and ft and on maternal preventive behaviour, such as assisting their children in toothbrushing.

The prevalence and associated factors of adverse pregnancy outcomes among Afghan women in Iran; Findings from community-based survey

Backgrounds

An estimated 2.5 million Afghans are living in the Iran and almost half of them are young women at the childbearing ages. Although the evidence indicates lower rates of antenatal care and higher incidence of pregnancy complications in Afghan compared to Iranian women, the underlying reasons are not well defined. Therefore, in the present study, we aimed to explore the prevalence and associated sociodemographic factors of adverse pregnancy outcomes and examine the impact of intimate partner violence, food insecurity, poor mental health, and housing issues on pregnancy outcome in Afghan women living in Iran.

Methods

In July 2019, we enrolled 424 Afghan women aged 18–44 years old using the time-location sampling at three community health centers in the south region of Tehran province. The data was collected through face to face interviews using the researcher-developed questionnaire. Using bivariate and multivariate analysis, the impact of poor antenatal care, intimate partner violence, food insecurity, and poor mental health was assessed on the incidence of adverse pregnancy outcome.

Results

More than half (56.6%) of Afghan women reported at least one pregnancy complication in their recent pregnancy. The results showed that undocumented, illiterate, and unemployed Afghan women with lower socioeconomic status are more likely to experience adverse pregnancy outcomes. Furthermore, we observed lower prevalence of adverse pregnancy outcomes among documented immigrants with health insurance compared to those with no health insurance. It is also been found that the food insecurity [Adjusted OR = 3.35, 95% CI (1.34–8.36)], poor antenatal care [Adjusted OR = 10.50, 95% CI (5.40–20.39)], intimate partner violence [Adjusted OR = 2.72, 95% CI (1.10–6.77)], and poor mental health [Adjusted OR = 4.77, 95% CI (2.54–8.94)] could adversely impact the pregnancy outcome and we observed higher incidence of adverse outcomes among those suffering from these situations.

Conclusion

To our knowledge, this is the first study that explored the prevalence and associated factors of adverse pregnancy outcomes and the impact of intimate partner violence, food insecurity, poor mental health on pregnancy outcome among Afghan women in Iran. Enhancing the psychosocial support and empowering Afghan women through expanding the social network and safety net should be a priority for the central government and international parties. Psychological counseling should be incorporated into routine maternity care for Afghan refugees. Access to free antenatal care is a right for all Afghan women and it should be facilitated by universal health insurance for all Afghans regardless of their legal status.