title: A case-control study of correlates of severe acute maternal morbidity in Kabul, Afghanistan.
abstract: OBJECTIVE
  To identify correlates of severe acute maternal morbidity (SAMM) in Kabul, Afghanistan.
  
  
  METHODS
  The present case-control study enrolled postpartum couples at four public maternity hospitals between September 2007 and December 2009. Eligibility was determined by: spousal consent; SAMM criteria from chart review for cases; and matching by age, parity, and time since previous delivery for controls (uncomplicated deliveries). Staff administered questionnaires to women and their husbands separately. SAMM correlates were analyzed with conditional logistic regression in models including (proximate) and excluding (distal) care factors.
  
  
  RESULTS
  Among 285 case and 285 control couples, the most frequent SAMM diagnoses were obstructed labor (104 [36.5%]) and hemorrhage requiring transfusion (102 [35.8%]). In both models, SAMM was associated with the husband having more than one wife (distal: adjusted odds ratio [aOR] 48.6, 95% CI 5.4-436.5; proximate: 141.8, 3.5-5819.0), prior stillbirth(s) (distal: 16.2, 6.1-42.9; proximate: 8.0, 2.9-22.4), and complications in a prior pregnancy (distal: 5.4, 95% CI 2.5-12.1; proximate: 7.1, 2.5-20.4). In the proximate model, SAMM was associated with visiting another facility before hospitalization (aOR 7.5, 95% CI 3.1-17.9), male-reported planned home delivery (5.5, 1.5-20.0), and provider-determined care-seeking (4.8, 1.6-14.9).
  
  
  CONCLUSIONS
  Planned home delivery and referral to multiple facilities or by providers are factors associated with SAMM that are potentially amenable to intervention in Afghanistan.
authors.affiliation: Department of Obstetrics and Gynecology and Heilbrunn Department of Population and Family Health, Columbia University, New York, NY, USA. Electronic address: ctodd@fhi360.org.
authors.forename: Catherine S
authors.initials: CS
authors.lastname: Todd
authors.affiliation: Health Protection and Research Organisation, Kabul, Afghanistan.
authors.forename: Ghulam Farooq
authors.initials: GF
authors.lastname: Mansoor
authors.affiliation: Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Sadia
authors.initials: S
authors.lastname: Haider
authors.affiliation: Health Protection and Research Organisation, Kabul, Afghanistan.
authors.forename: Pashtoon
authors.initials: P
authors.lastname: Hashimy
authors.affiliation: Health Protection and Research Organisation, Kabul, Afghanistan.
authors.forename: Nazifa
authors.initials: N
authors.lastname: Mustafavi
authors.affiliation: Health Protection and Research Organisation, Kabul, Afghanistan.
authors.forename: Abdul
authors.initials: A
authors.lastname: Nasir
authors.affiliation: Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
authors.forename: Suellen
authors.initials: S
authors.lastname: Miller
mesh_terms: D000328:Adult; D000346:Afghanistan / Q000453:epidemiology; D016022:Case-Control Studies; D005260:Female; D006700:Home Childbirth / Q000706:statistics & numerical data; D006771:Hospitals, Maternity; D006801:Humans; D016015:Logistic Models; D008393:Marriage / Q000706:statistics & numerical data; D008875:Middle Aged; D007744:Obstetric Labor Complications / Q000453:epidemiology*; D006473:Postpartum Hemorrhage / Q000453:epidemiology*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology*; D012017:Referral and Consultation / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: Afghanistan; Maternal morbidity; Maternal mortality; Pregnancy complications