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Establishing a sample registration site pilot in a conflict zone: Badakhshan, Afghanistan, 2013-2018


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Presentation by Omrana Pasha (Johns Hopkins Bloomberg School of Public Health) at the international conference on innovations in Civil Registration and Vital Statistics (CRVS) systems - Ottawa on 27-28 February 2018. See more at

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Establishing a sample registration site pilot in a conflict zone: Badakhshan, Afghanistan, 2013-2018

  1. 1. Establishing a sample registration site pilot in a conflict zone: Badakhshan, Afghanistan 2013-2018 Parvez Nayani, MBBS, MPH Director, Academic Projects Afghanistan Aga Khan University Kabul, Afghanistan Omrana Pasha, MD, MSPH Senior Scientist Johns Hopkins Bloomberg School of Public Health Baltimore, MD USA
  2. 2. A 2002 survey (RAMOS) conducted in four districts in Afghanistan identified a maternal mortality ratio (per 100,000 livebirths) ranging from 418 in Kabul to 6507 in Ragh district of Badakhshan – the highest ever measured globally Over the MDG period, Afghanistan has made significant progress in improving maternal and newborn outcomes. However, accurate measurement of maternal and newborn outcomes remains a challenge. Estimation of vital statistics remains dependent on other, less reliable, mechanisms, e.g. facility-based statistics. Other sources of data include national or subnational surveys and national estimates are based statistical models. In the case of neonatal mortality, all of these estimates are congruent with each other; however for maternal mortality - surveys and estimated levels less reliable. We have attempted to establish a mechanism for more accurate estimation of maternal and newborn outcomes in Badakhshan province, with support from Global Affairs Canada
  3. 3. The primary purpose of the registry system is to quantify and understand the trends in pregnancy outcomes in defined geographic areas in selected districts of Badakhshan, Afghanistan over time and ascertain population-based statistics on stillbirths, neonatal mortality and maternal deaths through the implementation of a prospective, population-based active surveillance system.
  4. 4. SiteoftheSample RegistrationSystemPilot: Badakhshan,Afghanistan Figure 4 – Map of secure and insecure surveillance areas in Badakhshan Sample Registration System and Security Map
  5. 5. Badakshan Surveillance Sites Population Covered 904,700 182,456 Districts 28 4 No of Villages 1200 253 No of TBAs ------ 421 No of Facilities 100 - 120 41 No of service providers 700 - 800 209
  6. 6. A listing of villages/neighborhoods in each of the selected districts was obtained from the provincial government Field teams visited each village or neighborhood to confirm its location and correct name etc. Location coordinates for each village were marked and compared to satellite maps to ascertain completion of coverage The community leaders in each area were taken into confidence and an assessment was made about the feasibility of gathering information All health care facilities/providers (including TBA’s) that provided MCH services were identified.
  7. 7. Within each village or neighborhood, each household was visited by the field team and basic demographic information about all the household members was gathered. Each married woman of reproductive age was identified and a complete reproductive history was recorded, number of pregnancies, pregnancy outcomes and current status of off-spring. These data formed the baseline for surveillance activities
  8. 8. Each village/neighborhood is visited at least once a month by the field team. The pregnancy status of all MWRA in that area is ascertained All pregnant women are enrolled and pertinent information is gathered. The goal is to enroll all pregnant women in the catchment areas by 20 weeks of gestation. An attempt is made at estimating the expected data of delivery. Registry staff contact women approximately a week prior to delivery. Each delivery is reported by the family, the delivery attendant or the health care facility to registry staff. The registry workers visit women as early as possible after delivery: depending of level of insecurity and weather- related accessibility.
  9. 9. Overview map of surveillance site in Badakhshan: villages and neighborhoods At baseline, within the 253 villages/ neighborhoods, 31 were found to be insecure; this included 1 area in Faizabad, 8 in Kishim, 13 in Baharak and 9 in Shuhada. In 22 of these 31 villages, the security situation was judged to be too precarious for the conduct of the household survey nor could GIS coordinates be gathered. In the remaining 9 areas, the mapping of coordinates and household survey was completed; however, surveillance activities could not be sustained due to the poor law and order situation.
  10. 10. Screened, consented & enrolled N=24919 (100%) Currently pregnant N= 1,667 Delivery outcome captured N=22,885 42 days follow up completed N=22,607 Pregnancy outcome not determined N= 211 Lost prior to delivery (Miscarriage/MTP) N=1091 0 5 10 15 20 25 30 35 40 45 2013-2014 2014-2015 2015-2016 2016-2017 Stillbirthrate (per1000deliveries) Faizabad Baharak Shuhada Kishim 0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 Neonatalmortalityrate (per1000livebirths)
  11. 11. We have been able to actively identify pregnancy and births with substantial efficiency despite ongoing and increasing conflict with buy-in from the local population. Conflict situations are linked to poor pregnancy outcomes: women who deliver on days when there is active fighting around their neighborhoods or villages are 50% more likely to have a poor pregnancy outcome than those who deliver on non-conflict days or in peaceful areas. Delays in registration and poor pregnancy outcomes are closely linked – with both security situations and weather-related delays being linked to poor outcomes for both newborn survival and timely registration
  12. 12. We are grateful for the generous support received from:  Global Affairs Canada  Agence Française de Développement (AFD)  Aga Khan Foundation, Canada