title: Afghan migrants face more suboptimal care than natives: a maternal near-miss audit study at university hospitals in Tehran, Iran.
abstract: Women from low-income settings have higher risk of maternal near miss (MNM) and suboptimal care than natives in high-income countries. Iran is the second largest host country for Afghan refugees in the world. Our aim was to investigate whether care quality for MNM differed between Iranians and Afghans and identify potential preventable attributes of MNM.
  
  
  
  An MNM audit study was conducted from 2012 to 2014 at three university hospitals in Tehran. Auditors evaluated the quality of care by reviewing the hospital records of 76 MNM cases (54 Iranians, 22 Afghans) and considering additional input from interviews with patients and professionals. Main outcomes were frequency of suboptimal care and the preventable attributes of MNM. Crude and adjusted odds ratios with confidence intervals for the independent predictors were examined.
  
  
  
  Afghan MNM faced suboptimal care more frequently than Iranians after adjusting for educational level, family income, and insurance status. Above two-thirds (71%, 54/76) of MNM cases were potentially avoidable. Preventable factors were mostly provider-related (85%, 46/54), but patient- (31%, 17/54) and health system-related factors (26%, 14/54) were also important. Delayed recognition, misdiagnosis, inappropriate care plan, delays in care-seeking, and costly care services were the main potentially preventable attributes of MNM.
  
  
  
  Afghan mothers faced inequality in obstetric care. Suboptimal care was provided in a majority of preventable near-miss events. Improving obstetric practice and targeting migrants' specific needs during pregnancy may avert near-miss outcomes.
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska sjukhuset, Uppsala University , Uppsala, SE-751 85, Sweden. soheila.mohammadi@kbh.uu.se.|Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. soheila.mohammadi@kbh.uu.se.
authors.forename: Soheila
authors.initials: S
authors.lastname: Mohammadi
authors.affiliation: Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Soraya
authors.initials: S
authors.lastname: Saleh Gargari
authors.affiliation: Infertility and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Masoumeh
authors.initials: M
authors.lastname: Fallahian
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska sjukhuset, Uppsala University , Uppsala, SE-751 85, Sweden.
authors.forename: Carina
authors.initials: C
authors.lastname: Källestål
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska sjukhuset, Uppsala University , Uppsala, SE-751 85, Sweden.
authors.forename: Shirin
authors.initials: S
authors.lastname: Ziaei
authors.affiliation: Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Akademiska sjukhuset, Uppsala University , Uppsala, SE-751 85, Sweden.
authors.forename: Birgitta
authors.initials: B
authors.lastname: Essén
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D006785:Hospitals, University / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D007492:Iran / Q000453:epidemiology; D008330:Management Audit / Q000379:methods*; D008427:Maternal Health Services / Q000458:organization & administration*; D008428:Maternal Mortality / Q000639:trends; D000067491:Near Miss, Healthcare / Q000458:organization & administration*; D016017:Odds Ratio; D011247:Pregnancy; D011248:Pregnancy Complications / Q000208:ethnology*; D011295:Prenatal Care / Q000379:methods*; D012307:Risk Factors; D014171:Transients and Migrants; D055815:Young Adult
keywords: Afghan migrants; Audit; Iran; Maternal near miss; Preventability; Quality of care