Association of Exposure to Civil Conflict With Maternal Resilience and Maternal and Child Health and Health System Performance in Afghanistan
Association of Exposure to Civil Conflict With Maternal Resilience and Maternal and Child Health and Health System Performance in Afghanistan
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DOI：
10.1001/jamanetworkopen.2019.14819
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发表时间：
2019-11-01
影响因子：
13.8
通讯作者：
Bhutta, Zulfiqar A.
中科院分区：
文献类型：
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作者：
Akseer, Nadia;Rizvi, Arjumand;Bhutta, Zulfiqar A.
重要性目前的研究检查阿富汗的冲突过渡对卫生系统的性能，卫生服务的提供，和健康结果的影响是过时的，规模小，并没有涵盖所有必要的生殖，孕产妇，新生儿和儿童健康干预措施。2003年至2018年重建期间阿富汗儿童营养状况。设计，环境，这项基于人群的调查研究包括对2个时期的个人水平面板数据进行连续横断面分析（2003 - 2010年和2010 - 2018年）和差异中的差异设计。调查包括2003年至2004年和2010年至2011年的多指标类集调查以及2018年阿富汗健康调查。阿富汗2013年全国营养调查被用来评估营养结果，年度平衡计分卡数据集被用来评价卫生系统的业绩。参与者包括完成全国代表性住户调查的12至49岁的女孩和妇女以及5岁以下的儿童。所有分析均在2019年1月1日至4月30日期间进行。EXPOSURES使用乌普萨拉冲突数据计划中与战斗有关的死亡数据，将各省分为经历轻微，中度和严重强度冲突的省份。主要结果和指标使用10个标准指标检查健康干预覆盖率：避孕方法（任何一种或现代的）;熟练保健专业人员的产前护理;设施分娩;熟练助产;卡介苗接种;白喉、百日咳和破伤风疫苗（三联疫苗）或三联疫苗加B型肝炎和脊髓灰质炎疫苗（五联疫苗）;麻疹疫苗接种;急性呼吸道感染求医;腹泻口服补液疗法;以及综合覆盖指数。使用以下标准的平衡计分卡复合域的卫生系统的性能进行了分析：客户和社区，人力资源，物理能力，服务质量的提供，管理系统，和整体使命。儿童发育迟缓，消瘦，体重不足，并共同发生的发育迟缓和消瘦估计usingWorld Health Organization growth reference cutoffs.Results64 815名妇女（平均[SD]年龄，31.0 [8.5]岁）的反应进行了分析。冲突强度最小的省份在避孕药具使用方面取得了更大的进展（平均年百分点变化[MAPC]，1.3% vs 0.5%; P <.001），SBA（MAPC，2.7% vs 1.5%; P = 0.005），卡介苗接种（MAPC，3.3% vs-0.5%; P =.002），麻疹疫苗接种（MAPC，1.9%对-1.0%; P = 0.01）和DPT3/五联疫苗接种（MAPC，1.0%对-2.0%; P <0.001）与控制混杂因素后中度至重度冲突的省份相比。调整混杂因素后，冲突强度严重的省份在功能基础设施（MAPC，-1.6%<$95% CI，-2.4%至-0.8%]）和客户背景和身体评估指数（MAPC，-1.0%<$95% CI，-0.8%至2.7%]）方面的表现明显差于冲突强度最小的省份。在冲突严重程度较高的地区，（战斗相关死亡对数与消瘦之间关联的完全校正β，0.33 [95% CI，0.01 - 0.66];结论和相关性阿富汗冲突与孕产妇和儿童健康之间的关联因卫生保健干预和交付领域而异，在冲突激烈程度较高的地区，若干关键指标落后。这些发现可能有助于规划和优先考虑在阿富汗实现联合国可持续发展目标的努力。
IMPORTANCE Current studies examining the effects of Afghanistan's conflict transition on the performance of health systems, health service delivery, and health outcomes are outdated and small in scale and do not span all essential reproductive, maternal, newborn, and child health interventions.OBJECTIVE To evaluate associations of conflict severity with improvement of health system performance, use of health services, and child nutrition outcomes in Afghanistan during the 2003 to 2018 reconstruction period.DESIGN, SETTING, AND PARTICIPANTS This population-based survey study included a sequential cross-sectional analysis of individual-level panel data across 2 periods (2003-2010 and 2010-2018) and a difference-in-differences design. Surveys included the 2003 to 2004 and 2010 to 2011 Multiple Indicator Cluster Surveys and the 2018 Afghanistan Health Survey. Afghanistan's 2013 National Nutrition Survey was used to assess nutritional outcomes, and the annual Balanced Scorecard data sets were used to evaluate health system performance. Participants included girls and women aged 12 to 49 years and children younger than 5 years who completed nationally representative household surveys. All analyses were conducted from January 1 through April 30, 2019.EXPOSURES Provinces were categorized as experiencing minimal-, moderate-, and severe-intensity conflict using battle-related death data from the Uppsala Conflict Data Program.MAIN OUTCOMES AND MEASURES Health intervention coverage was examined using 10 standard indicators: contraceptive method (any or modern); antenatal care by a skilled health care professional; facility delivery; skilled birth attendance (SBA); bacille Calmette-Guerin vaccination (BCG); diphtheria, pertussis, and tetanus vaccination (DPT3) or DPT3 plus hepatitis B and poliomyelitis (penta); measles vaccination; care-seeking for acute respiratory infection; oral rehydration therapy for diarrhea; and the Composite Coverage Index. The health system performance was analyzed using the following standard Balanced Scorecard composite domains: client and community, human resources, physical capacity, quality of service provision, management systems, and overall mission. Child stunting, wasting, underweight, and co-occurrence of stunting and wasting were estimated usingWorld Health Organization growth reference cutoffs.RESULTS Responses from 64 815 women (mean [SD] age, 31.0 [8.5] years) were analyzed. Provinces with minimal-intensity conflict had greater gains in contraceptive use (mean annual percentage point change [MAPC], 1.3% vs 0.5%; P < .001), SBA (MAPC, 2.7% vs 1.5%; P = .005), BCG vaccination (MAPC, 3.3% vs -0.5%; P = .002), measles vaccination (MAPC, 1.9% vs -1.0%; P = .01), and DPT3/penta vaccination (MAPC, 1.0% vs -2.0%; P < .001) compared with provinces with moderate- to severe-intensity conflict after controlling for confounders. Provinces with severe-intensity conflict fared significantly worse than those with minimal-intensity conflict in functioning infrastructure (MAPC, -1.6%[95% CI, -2.4% to -0.8%]) and the client background and physical assessment index (MAPC, -1.0%[95% CI, -0.8% to 2.7%]) after adjusting for confounders. Child wasting was significantly worse in districts with greater conflict severity (full adjusted beta for association between logarithm of battle-related deaths and wasting, 0.33 [95% CI, 0.01-0.66]; P = .04).CONCLUSIONS AND RELEVANCE Associations between conflict and maternal and child health in Afghanistan differed by health care intervention and delivery domain, with several key indicators lagging behind in areas with higher-intensity conflict. These findings may be helpful for planning and prioritizing efforts to reach the United Nations' Sustainable Development Goals in Afghanistan.