Humanitarian and primary healthcare needs of refugee women and children in Afghanistan

Mobile outreach health services for mothers and children in conflict-affected and remote areas: a population-based study from Afghanistan

OBJECTIVE

To assess whether sustained, scheduled mobile health team (MHT) services increase antenatal care (ANC), postnatal care (PNC) and childhood immunisation in conflict-affected and remote regions of Afghanistan.

DESIGN

Cross-sectional, population-based study from 2013 to 2017. Proportions were compared using multivariable linear regression adjusted for clustering and socio-demographic variables.

SETTING

54 intervention and 56 control districts in eight Afghanistan provinces.

PARTICIPANTS

338 796 pregnant women and 1 693 872 children aged under 5 years.

INTERVENTIONS

'Intervention districts' that received MHT services for 3 years compared with 'control districts' in the same province without any MHT services over the same period.

MAIN OUTCOME MEASURES

District-level and clinic-level ANC, PNC, childhood immunisation (pentavalent 3, measles 1), integrated management of childhood immunisation services.

RESULTS

Proportion of pregnant women receiving at least one ANC visit was higher in intervention districts (83.6%, 161 750/193 482) than control districts (61.3%, 89 077/145 314) (adjusted mean difference (AMD) 14.8%;95% CI: 1.6% to 28.0%). Proportion of children under 1 year receiving their first dose of measles vaccine was higher in intervention (73.8%, 142 738/193 412) than control districts (57.3%, 83 253/145 293) (AMD 12.8;95% CI: 2.1% to 23.5%). There was no association with PNC (AMD 2.8%;95% CI: -5.1% to 10.7%). MHTs did not increase clinic-level service provision for ANC (AMD 41.32;95% CI: -52.46 to 135.11) or any other outcomes.

CONCLUSIONS

Sustained, scheduled MHT services to conflict-affected and remote regions were associated with improved coverage of important maternal and child health interventions. Outreach is an essential service and not just an 'optional extra' for the most deprived mothers and children.

Home-based records for poor mothers and children in Afghanistan, a cross sectional population based study

BACKGROUND

No studies have examined distribution, retention and use of maternal and child health (MCH) home-based records (HBRs) in the poorest women in low income countries. Our primary objective was to compare distribution of the new Afghanistan MCH HBR (the MCH handbook) to the poorest women (quintiles 1-2) with the least poor women (quintiles 3-5). Secondary objectives were to assess distribution, retention and use of the handbook across wealth, education, age and parity strata.

METHODS

This was a population based cross sectional study set in Kama and Mirbachakot districts of Afghanistan from August 2017 to April 2018. Women were eligible to be part of the study if they had a child born in the last 6 months. Multivariable logistic regression models were constructed to adjust for clustering by district and potential confounders decided a priori (maternal education, maternal age, parity, age of child, sex of child) and to calculate adjusted odds ratios (aOR), 95% confidence intervals (95% CI) and corresponding p values. Principal components analysis was used to create the wealth quintiles using standard methods. Wealth categories were 'poorest' (quintiles 1,2) and 'least poor' (quintiles 3,4,5).

RESULTS

1728/1943 (88.5%) mothers received a handbook. The poorest women (633, 88.8%) had similar odds of receiving a handbook compared to the least poor (990, 91.7%) (aOR 1.26, 95%CI [0.91-1.77], p value 0.165). Education status (aOR 1.03, 95%CI [0.63-1.68], p value 0.903) and age (aOR 1.39, 95%CI [0.68-2.84], p value 0.369) had little effect. Multiparous women (1371, 91.5%) had a higher odds than primiparous women (252, 85.7%) (aOR 1.83, 95%CI [1.16-2.87], p value 0.009). Use of the handbook by health providers and mothers was similar across quintiles. Ten (0.5%) women reported that they received a book but then lost it.

CONCLUSIONS

We were able to achieve almost universal coverage of our new MCH HBR in our study area in Afghanistan. The handbook will be scaled up over the next three years across all of Afghanistan and will include close monitoring and assessment of coverage and use by all families.

Conditional cash transfers to improve use of health facilities by mothers and newborns in conflict affected countries, a prospective population based intervention study from Afghanistan

BACKGROUND

The effects of conditional cash transfer (CCT) programs on maternal and child health (MCH) service use in conflicted affected countries such as Afghanistan are not known.

METHODS

We conducted a non-randomised population based intervention study in six Afghanistan districts from December 2016 to December 2017. Six control districts were purposively matched. Women were eligible to be included in the baseline and endline evaluation surveys if they had given birth to one or more children in the last 12 months. The intervention was a CCT program including information, education, communication (IEC) program about CCT to community members and financial incentives to community health workers (CHWs) and families if mothers delivered their child at a health facility. Control districts received standard care. The primary objective was to assess the effect of CCT on use of health facilities for delivery. Secondary objectives were to assess the effect of CCT on antenatal care (ANC), postnatal care (PNC) and CHW motivation to perform home visits. Outcomes were analysed at 12 months using multivariable difference-in-difference linear regression models adjusted for clustering and socio demographic variables.

RESULTS

Overall, facility delivery increased in intervention villages by 14.3% and control villages by 8.4% (adjusted mean difference [AMD] 3.3%; 95% confidence interval [- 0.14 to 0.21], p value 0.685). There was no effect in the poorest quintile (AMD 0.8% [- 0.30 to 0.32], p value 0.953). ANC (AMD 45.0% [0.18 to 0.72] p value 0.004) and PNC (AMD 31.8% [- 0.05 to 0.68] p value 0.080) increased in the intervention compared to the control group. CHW home visiting changed little in intervention villages (- 3.0%) but decreased by - 23.9% in control villages (AMD 12.2% [- 0.27 to 0.51], p value 0.508). CCT exposure was 27.3% (342/1254) overall and 10.2% (17/166) in the poorest quintile.

CONCLUSIONS

Our study demonstrated that a CCT program provided to women aged 16-49 years can be implemented in a highly conservative conflict affected population. CCT should be scaled up for the poorest women in Afghanistan.

Universal health coverage for refugees and migrants in the twenty-first century

Migration is a determinant of health. Tackling the health needs of migrants and refugees will require action at the local, national, and global levels. Over the past 12 months, BMC Medicine has published a collection of articles under the title Migrant and Refugee Health ( https://www.biomedcentral.com/collections/migrant-and-refugee-health ) addressing a range of health issues affecting refugees and migrants in their countries of origin, on transit, and in their destination countries. In light of these articles, we herein discuss the complex and wide-ranging healthcare needs of different refugee groups in their destination countries as well as the need for accessible and culturally appropriate health services.