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). Conclusion Planned home delivery and referral to multiple facilities or by providers are factors associated with SAMM that are potentially amenable to intervention in Afghanistan.