Association Between Gender, Surgery and Mortality for Patients Treated at Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan

Our main findings suggest that female trauma patients arrived later than men, had a different injury pattern and were less likely to undergo surgery. The cause of hospitalization showed a surprisingly small proportion of conflict-related injuries in this high-intense conflict area. One explanation could be that patients in challenging contexts may hesitate to report their injuries as being due to assault but it could also be explained by impaired access and that patients might have died before arrival. Our results also showed that the proportion of conflict-related injuries in females was half compared to males. This could be explained by the way of warfare where females are less involved. However, although “Accident–Others” is not a group of violent trauma, the largeness and width of the group add uncertainty to all results under “cause of hospitalisation” and no certain conclusion can therefore be drawn based on this category. The differences in injury patterns between genders were consistent with other studies from similar as well as different settings to Kunduz [7, 12, 29]. However, overall, gender differences in categories describing injury pattern, i.e. nature of injury and body region of injury, were small.

Due to local traditions prevailing in Afghanistan, females have limited movement outside the household and depend on males for transportation to KTC. These factors might explain why fewer females visited the ED, as well as the differences in injury pattern (double the percentage of burns could be explained by them doing more of the cooking), and it might also explain why females arrived later than men to the hospital. However, only 24.1% of all patients arrived at KTC within an hour of injury, indicating that there were significant limitations in the overall access to KTC. Another factor that indicates impaired access in Kunduz is the very low mortality of 0.6% which is only a third of the median mortality rate demonstrated in a WHO systematic review of EDs in LMICs (1.8%, IQR 0.2–5.1) [30]. To enable comparison with trauma care studies, the in-patient hospital mortality was calculated and found to be 2.8% (see Table 6). However, beyond ascertaining that a death had occurred in the ED, or following admittance to the hospital, the data did not provide sufficient detail to calculate 24 h- and 30-day mortality. The in-patient hospital mortality of 2.8% is significantly lower than the mortality rates described in a US military medical facility in Afghanistan, where non-war-related conditions had a 3.6% mortality and war-related mortality was 5.11% [31]. Moreover, the in-hospital mortality in KTC is almost three times lower than the in-hospital mortality of 18 level 1 trauma centres in the USA [32]. This implies that the most critically injured patients in Kunduz may have died prior to reaching KTC, indicating a significant gap in prehospital care and availability of rapid transport.

The adjusted odds of surgery remained significantly lower in females as compared to males. This finding suggests that females were less likely to undergo surgery even if they had as severe trauma and the same type of injuries as their male counterparts. Our data do not allow us to determine the cause of this difference, but future prospective research should attempt to assess this. We can only speculate to why the OR is lower for females after adjustment. It could be that all indicators for severity were not considered during the adjusted analysis for risk of surgery or that the adjustment itself had flaws. The literature reveals conflicting conclusions with respect to surgical interventions for females. In our study, females represented 16.3% of all surgeries. This is in accordance with a study by Forrester et al. [23] where females in a number of MSF hospitals around the world accounted for between 16 and 41% of the operative interventions. Andersson et al. [24] found that females tended to be younger and required more surgeries than male patients when assessing at the female surgical outcome rather than the female percentage of all surgeries. However, our results still indicate a lower surgical rate for females.

This study is subject to a number of limitations. First, since the study was retrospective, it was limited to existing data with risk of bias and unmeasured confounding, as well as errors in data entry. Second, the unknown causes of injury in the group “Accident–Others” are a source of inaccuracy. Third, given the austere environment in which this facility operated, transcription errors may have occurred. However, due to the random nature of this type of error, any impact on the results of this study is likely to be limited. Fourth, no measurement for injury severity was used due to limitations in our data. Fifth, two different triage systems were used, SATS regularly and START when there were mass casualty incidents (MCI). Only approximately 100 patients were MCI’s and therefore triaged using START minor errors in our results cannot be excluded. Lastly, there was no provision made in the data regarding whether patients are civilian or combatant, which could have provided additional insight concerning reasons for gender differences. Despite above, we still think the results are accurate and provide essential information that may help to improve trauma care for females in conflict settings.

Further research into what particular risks females are subject to is essential to guide preventative measures. The extent to which our results are generalizable is uncertain, and our understanding of female trauma patients in conflicts would therefore gain from additional studies in this setting. Moreover, working to improve systematic trauma surveillance in-country will allow for future retrospective studies to determine the epidemiology of female trauma patients. These are all crucial to guide public health interventions to improve the situation for females in conflict areas. The issue of systematic, high-quality data collection which enables both programmatic and scientific research in conflict environments is an urgent one. To enable quality studies yielding actionable results to the benefit of civilians in conflict environments, the authors recommend implementing data collection systems which provide more detailed patient data. However, merely including more variables is of little value if data collection routines are not followed. Therefore, any measure to improve systematic data collection must be coupled with the incentives, manpower and IT infrastructure needed to ensure consistent data collection. MSF is aware of this and efforts are constantly being done to improve the reliability and the accuracy of collected data [33].