摘要：Objectives. We sought to identify characteristics associated with use of skilled birth attendants where health services exist in Afghanistan. Methods. We conducted a cross-sectional study in all 33 provinces in 2004, yielding data from 617 health facilities and 9917 women who lived near the facilities and had given birth in the past 2 years. Results. Only 13% of respondents had used skilled birth attendants. Women from the wealthiest quintile (vs the poorest quintile) had higher odds of use (odds ratio [OR] = 6.3; 95% confidence interval [CI] = 4.4, 8.9). Literacy was strongly associated with use (OR = 2.5; 95% CI = 2.0, 3.2), as was living less than 60 minutes from the facility (OR = 1.5; 95% CI = 1.1, 2.0) and residing near a facility with a female midwife or doctor (OR = 1.4; 95% CI = 1.1, 1.8). Women living near facilities that charged user fees (OR = 0.8; 95% CI = 0.6, 1.0) and that had male community health workers (OR = 0.6; 95% CI = 0.5, 0.9) had lower odds of use. Conclusions. In Afghanistan, the rate of use of safe delivery care must be improved. The financial barriers of poor and uneducated women should be reduced and culturally acceptable alternatives must be considered. Reduction of maternal and neonatal mortality are global priorities that are particularly relevant in Afghanistan, where the maternal mortality ratio (1600 per 100 000 live births) is one of the highest in the world. 1 Reliable estimates for neonatal mortality in Afghanistan do not exist, but available evidence indicates that 74% of infants born to women who died of maternal causes also died. 1 Causes of maternal death in Afghanistan include hemorrhage, obstructed labor, sepsis, pregnancy-induced hypertension, and indirect causes—diseases that reduce resilience of pregnant women—such as tuberculosis, malnutrition, and malaria. 1 Neonatal deaths in developing countries are caused by prematurity, congenital anomalies, birth asphyxia, and infections. 2 Increasing the proportion of births assisted by skilled birth attendants—doctors, nurses, or midwives trained in safe care during delivery—is a central strategy for improving maternal and child health in Afghanistan. If 80% of pregnant Afghan women were assisted by skilled birth attendants, an estimated 10 000 maternal deaths and 40 000 neonatal deaths would have been prevented in 2002. 1 , 3 – 5 Several barriers to utilization of health services contribute to Afghanistan's high maternal mortality; these include decisionmaking processes related to care seeking, availability of skilled female health workers and supplies, and other geographical, financial, and cultural factors. 1 , 6 In 2002, Afghanistan's health care system, destroyed after 25 years of conflict, had few trained health workers and little remaining infrastructure. 7 , 8 The lifetime risk of maternal death for women was 1 in 9; 78% of maternal deaths were from causes that could have been prevented had adequate obstetrical care been received. 1 , 3 At that time, only 9% of women were assisted by a skilled birth attendant, 8% of women received antenatal care, 10% of hospitals provided caesarean sections, and one third of women were vaccinated against tetanus. 7 , 9 Challenges to health care provision are compounded by the fact that 77% of Afghans live in sparsely populated areas separated by large expanses of difficult terrain and poor transportation infrastructure. 3 For women in some remote areas, more than 2 weeks of travel time is required to access a skilled birth attendant 1 , 10 ; this is important because both infant and maternal deaths have been found to vary with distance from urban centers. 1 , 9 , 11 Use of skilled birth attendants is a central part of the Basic Package of Health Services (BPHS), a set of essential health services designed by the Afghan Ministry of Public Health to be provided to all Afghans. The BPHS addresses maternal and newborn health, child health and immunizations, nutrition, tuberculosis, malaria, mental health, disabilities, and the supply of essential medicines. 12 We sought to assess the extent to which women residing in facility catchment areas in Afghanistan use skilled birth attendants and to identify the household, community, and health facility characteristics associated with skilled birth attendant use, in the hopes of informing maternal health programs and policies. We conducted our study in 2004 among households residing in the catchment areas of facilities implementing the BPHS, defined as within a 90-minute walking distance from the facility.
