Neonatal survival in complex humanitarian emergencies: setting an evidence-based research agenda

The impacts of the Syrian conflict on child and adolescent health: a scoping review

BACKGROUND

The Syrian conflict has had a profound impact on Syrian children and adolescents. We sought to determine the extent and range of literature on the conflict's health effects on this vulnerable population.

METHODS

A scoping review describing the impact of the Syrian conflict on children was undertaken while utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews methodology. Qualitative thematic analyses were undertaken to both identify patterns of morbidity and mortality and gaps in evidence.

RESULTS

A total of 982 articles meeting search criteria were identified between 1 January 2011 and 30 April 2021. After iterative screening, 12 were identified from academic databases and 4 were identified from grey literature and hand searching, yielding a total of 16 studies for final, full-text analysis. Four distinct themes recurred in the literature; these include children suffering from violent injury, a resurgence of communicable diseases, malnutrition and micronutrient deficiency and impacts on their mental health.

CONCLUSIONS

The health of children and adolescents in Syria has been significantly impacted by the indiscriminate attacks against civilians, flagrant human rights violations and the disintegration of the national health care system. Neonates were largely absent from the literature. The themes from this scoping review can inform health programming priorities by aid organizations.

Implementation of maternal and perinatal death surveillance and response (MPDSR) in humanitarian settings: insights and experiences of humanitarian health practitioners and global technical expert meeting attendees

BACKGROUND

Maternal and perinatal death surveillance and response (MPDSR) is a system of identifying, analysing and learning lessons from such deaths in order to respond and prevent future deaths, and has been recommended by WHO and implemented in many low-and-middle income settings in recent years. However, there is limited documentation of experience with MPDSR in humanitarian settings. A meeting on MPDSR in humanitarian settings was convened by WHO, UNICEF, CDC and Save the Children, UNFPA and UNHCR on 17th-18th October 2019, informed by semi-structured interviews with a range of professionals, including expert attendees.

CONSULTATION FINDINGS

Interviewees revealed significant obstacles to full implementation of the MPDSR process in humanitarian settings. Many obstacles were familiar to low resource settings in general but were amplified in the context of a humanitarian crisis, such as overburdened services, disincentives to reporting, accountability gaps, a blame approach, and politicisation of mortality. Factors more unique to humanitarian contexts included concerns about health worker security and moral distress. There are varying levels of institutionalisation and implementation capacity for MPDSR within humanitarian organisations. It is suggested that if poorly implemented, particularly with a punitive or blame approach, MPDSR may be counterproductive. Nevertheless, successes in MPDSR were described whereby the process led to concrete actions to prevent deaths, and where death reviews have led to improved understanding of complex and rectifiable contextual factors leading to deaths in humanitarian settings.

CONCLUSIONS

Despite the challenges, examples exist where the lessons learnt from MPDSR processes have led to improved access and quality of care in humanitarian contexts, including successful advocacy. An adapted approach is required to ensure feasibility, with varying implementation being possible in different phases of crises. There is a need for guidance on MPDSR in humanitarian contexts, and for greater documentation and learning from experiences.

Health research in humanitarian crises: an urgent global imperative

Globally, humanitarian crises—such as armed conflict, forced displacement, natural disasters and major disease outbreaks—affect more people today than at any point in recorded history. These crises have immense acute and long-term health impacts on hundreds of millions of people, predominantly in low and middle-income countries (LMIC), yet the evidence base that informs how humanitarian organisations respond to them is weak. Humanitarian crises are often treated as an outlier in global health. However, they are an increasingly common and widespread driver of health that should be integrated into comprehensive approaches and strategies, especially if we hope to achieve ambitious global health targets such as the Sustainable Development Goals. The academic research community can play an important role in addressing the evidence gap in humanitarian health. There are important scientific questions of high public health relevance that can only be addressed by conducting research in humanitarian settings. While working in these settings is uniquely challenging, there are effective strategies that can be employed, such as using flexible and adaptive research methodologies, partnering with non-governmental organisations and other humanitarian actors, and devoting greater attention to issues of research ethics, community engagement, local LMIC-based partners, building humanitarian research capacity and collaborating across disciplines.

Effects of armed conflict on child health and development: A systematic review

BACKGROUND

Armed conflicts affect more than one in 10 children globally. While there is a large literature on mental health, the effects of armed conflict on children's physical health and development are not well understood. This systematic review summarizes the current and past knowledge on the effects of armed conflict on child health and development.

METHODS

A systematic review was performed with searches in major and regional databases for papers published 1 January 1945 to 25 April 2017. Included studies provided data on physical and/or developmental outcomes associated with armed conflict in children under 18 years. Data were extracted on health outcomes, displacement, social isolation, experience of violence, orphan status, and access to basic needs. The review is registered with PROSPERO: CRD42017036425.

FINDINGS

Among 17,679 publications screened, 155 were eligible for inclusion. Nearly half of the 131 quantitative studies were case reports, chart or registry reviews, and one-third were cross-sectional studies. Additionally, 18 qualitative and 6 mixed-methods studies were included. The papers describe mortality, injuries, illnesses, environmental exposures, limitations in access to health care and education, and the experience of violence, including torture and sexual violence. Studies also described conflict-related social changes affecting child health. The geographical coverage of the literature is limited. Data on the effects of conflict on child development are scarce.

INTERPRETATION

The available data document the pervasive effect of conflict as a form of violence against children and a negative social determinant of child health. There is an urgent need for research on the mechanisms by which conflict affects child health and development and the relationship between physical health, mental health, and social conditions. Particular priority should be given to studies on child development, the long term effects of exposure to conflict, and protective and mitigating factors against the harmful effects of armed conflict on children.

Opportunities and Challenges in Global Perinatal Research

BACKGROUND

The global plight of stillbirths and neonatal mortality is concentrated in low- and middle-income countries. The ambitious targets introduced by the World Health Organization in the Every Newborn Action Plan demand a commitment to research that promotes equitable perinatal outcomes.

OBJECTIVES

The aim of this review was to understand the opportunities for global perinatal research and the accompanying challenges.

METHODS

We conducted a literature search to identify research prioritization exercises from 2014 to 2018 pertaining to global perinatal health. The top 50 questions with the highest research prioritization scores were extracted and analyzed.

RESULTS

The greatest priorities centered on community-based, implementation research targeting major causes of stillbirth and neonatal mortality in low-resource settings. The priorities are saddled with prerequisite conditions, design obstacles, and ethical considerations that require attention.

CONCLUSIONS

While the challenges are undeniable, the need to make the perinatal period healthier for babies worldwide has never been clearer.

"You have to take action": changing knowledge and attitudes towards newborn care practices during crisis in South Sudan

Highest rates of neonatal mortality occur in countries that have recently experienced conflict. International Medical Corps implemented a package of newborn interventions in June 2016, based on the Newborn health in humanitarian settings: field guide, targeting community- and facility-based health workers in displaced person camps in South Sudan. We describe health workers' knowledge and attitudes toward newborn health interventions, before and after receiving clinical training and supplies, and recommend dissemination strategies for improved uptake of newborn guidelines during crises. A mixed methods approach was utilised, including pre-post knowledge tests and in-depth interviews. Study participants were community- and facility-based health workers in two internally displaced person camps located in Juba and Malakal and two refugee camps in Maban from March to October 2016. Mean knowledge scores for newborn care practices and danger signs increased among 72 community health workers (pre-training: 5.8 [SD: 2.3] vs. post-training: 9.6 [SD: 2.1]) and 25 facility-based health workers (pre-training: 14.2 [SD: 2.7] vs. post-training: 17.4 [SD: 2.8]). Knowledge and attitudes toward key essential practices, such as the use of partograph to assess labour progress, early initiation of breastfeeding, skin-to-skin care and weighing the baby, improved among skilled birth attendants. Despite challenges in conflict-affected settings, conducting training has the potential to increase health workers' knowledge on neonatal health post-training. The humanitarian community should reinforce this knowledge with key actions to shift cultural norms that expand the care provided to women and their newborns in these contexts.

How Schools Can Promote Healthy Development for Newly Arrived Immigrant and Refugee Adolescents: Research Priorities

BACKGROUND

The US education system must find creative and effective ways to foster the healthy development of the approximately 2 million newly arrived immigrant and refugee adolescents, many of whom contend with language barriers, limited prior education, trauma, and discrimination. We identify research priorities for promoting the school success of these youth.

METHODS

The study used the 4-phase priority-setting method of the Child Health and Nutrition Research Initiative. In the final stage, 132 researchers, service providers, educators, and policymakers based in the United States were asked to rate the importance of 36 research options.

RESULTS

The highest priority research options (range 1 to 5) were: evaluating newcomer programs (mean = 4.44, SD = 0.55), identifying how family and community stressors affect newly arrived immigrant and refugee adolescents' functioning in school (mean = 4.40, SD = 0.56), identifying teachers' major stressors in working with this population (mean = 4.36, SD = 0.72), and identifying how to engage immigrant and refugee families in their children's education (mean = 4.35, SD = 0.62).

CONCLUSION

These research priorities emphasize the generation of practical knowledge that could translate to immediate, tangible benefits for schools. Funders, schools, and researchers can use these research priorities to guide research for the highest benefit of schools and the newly arrived immigrant and refugee adolescents they serve.

Setting an implementation research agenda for Canadian investments in global maternal, newborn, child and adolescent health: a research prioritization exercise

BACKGROUND

Improving global maternal, newborn, child and adolescent health (MNCAH) is a top development priority in Canada, as shown by the $6.35 billion in pledges toward the Muskoka Initiative since 2010. To guide Canadian research investments, we aimed to systematically identify a set of implementation research priorities for MNCAH in low- and middle-income countries.

METHODS

We adapted the Child Health and Nutrition Research Initiative method. We scanned the Child Health and Nutrition Research Initiative literature and extracted research questions pertaining to delivery of interventions, inviting Canadian experts on MNCAH to generate additional questions. The experts scored a combined list of 97 questions against 5 criteria: answerability, feasibility, deliverability, impact and effect on equity. These questions were ranked using a research priority score, and the average expert agreement score was calculated for each question.

RESULTS

The overall research priority score ranged from 40.14 to 89.25, with a median of 71.84. The average expert agreement scores ranged from 0.51 to 0.82, with a median of 0.64. Highly-ranked research questions varied across the life course and focused on improving detection and care-seeking for childhood illnesses, overcoming barriers to intervention uptake and delivery, effectively implementing human resources and mobile technology, and increasing coverage among at-risk populations. Children were the most represented target population and most questions pertained to interventions delivered at the household or community level.

INTERPRETATION

Investing in implementation research is critical to achieving the Sustainable Development Goal of ensuring health and well-being for all. The proposed research agenda is expected to drive action and Canadian research investments to improve MNCAH.

Evidence to inform the future for maternal and newborn health

Despite the impressive progress gains for maternal and child health during the Millennium Development Goals era, over 5.6 million women and babies died in 2015 due to complications during pregnancy, birth and in the first month of life. In order to achieve the new mortality targets set out in the Sustainable Development Goals, there needs to be intentional efforts to maintain and accelerate action to end preventable maternal and newborn deaths and stillbirths. This paper outlines what progress is required to meet these new 2030 targets based on patterns of progress in the recent past; where the burden is the greatest; when to focus attention along the continuum of care; and what causes of death require concerted efforts. Priority actions include intentional and intensified political attention and investment in maternal-newborn health with particular focus on improving quality and experience of care around the time of birth with implementation at scale of integrated maternal-newborn health interventions across the continuum of care with commensurate investment targeted at the most vulnerable populations. Looking forward, improved data for decision making and accountability will be required. The health and survival of babies and their mothers are inextricably linked, and calls for coordinated efforts and innovation before and during pregnancy, in childbirth, and postnatally, in order to end preventable maternal, neonatal deaths and stillbirths.

Barriers in the Delivery of Emergency Obstetric and Neonatal Care in Post-Conflict Africa: Qualitative Case Studies of Burundi and Northern Uganda

Objectives

Maternal and neonatal mortality and morbidity rates are particularly grim in conflict, post-conflict and other crisis settings, a situation partly blamed on non-availability and/or poor quality of emergency obstetric and neonatal care (EmONC) services. The aim of this study was to explore the barriers to effective delivery of EmONC services in post-conflict Burundi and Northern Uganda, in order to provide policy makers and other relevant stakeholders context-relevant data on improving the delivery of these lifesaving services.

Methods

This was a qualitative comparative case study that used 42 face-to-face semi-structured in-depth interviews and 4 focus group discussions for data collection. Participants were 32 local health providers and 37 staff of NGOs working in the area of maternal health. Data was analysed using the framework approach.

Results

The availability, quality and distribution of EmONC services were major challenges across the sites. The barriers in the delivery of quality EmONC services were categorised into two major themes; human resources-related challenges, and systemic and institutional failures. While some of the barriers were similar, others were unique to specific sites. The common barriers included shortage of qualified staff; lack of essential installations, supplies and medications; increasing workload, burn-out and turnover; and poor data collection and monitoring systems. Barriers unique to Northern Uganda were demoralised personnel and lack of recognition; poor referral system; inefficient drug supply system; staff absenteeism in rural areas; and poor coordination among key personnel. In Burundi, weak curriculum; poor harmonisation and coordination of training; and inefficient allocation of resources were the unique challenges. To improve the situation across the sites, efforts are ongoing to improve the training and recruitment of more staff; harmonise and strengthen the curriculum and training; increase the number of EmONC facilities; and improve staff supervision, monitoring and support.

Conclusions

Post-conflict health systems face different challenges in the delivery of EmONC services and as such require context-specific interventions to improve the delivery of these services.

Confronting stillbirths and newborn deaths in areas of conflict and political instability: a neglected global imperative

BACKGROUND

Despite considerable improvements in reproductive and newborn health throughout the world, relatively poor outcomes persist in areas plagued by conflict or political instability.

OBJECTIVES

To assess the contribution of areas of conflict and instability to global patterns of stillbirths and newborn deaths and to identify opportunities for effective intervention in these areas.

METHODS

Analysis of the available data on stillbirths and neonatal mortality in association with conflict and governance indicators, and review of epidemiological and political literature pertaining to the provision of health and public services in areas of conflict and instability.

RESULTS

Of the 15 countries with the highest neonatal mortality rates in the world, 14 are characterized by chronic conflict or political instability. If India and China are excluded, countries experiencing chronic conflict or political instability account for approximately 42% of all neonatal deaths worldwide. Efforts to address adverse reproductive and newborn outcomes in these areas must adapt recommended intervention protocols to the special security and governance conditions associated with unstable political environment.

CONCLUSION

Despite troubling relative and absolute indicators, the special requirements of improving reproductive and neonatal outcomes in areas affected by conflict and political instability have not received adequate attention. New integrated political and technical strategies will be required. This should include moving beyond traditional approaches concerned with complex humanitarian emergencies. Rather, global efforts must be based on a deeper understanding of the specific governance requirements associated with protracted and widespread health requirements. A focus on women's roles, regional strategies which take advantage of relative stability and governance capacity in neighbouring states, virtual infrastructure, and assistance regimens directed specifically to unstable areas may prove useful.

Progress and gaps in reproductive health services in three humanitarian settings: mixed-methods case studies

Background

Reproductive health (RH) care is an essential component of humanitarian response. Women and girls living in humanitarian settings often face high maternal mortality and are vulnerable to unwanted pregnancy, unsafe abortion, and sexual violence. This study explored the availability and quality of, and access barriers to RH services in three humanitarian settings in Burkina Faso, Democratic Republic of the Congo (DRC), and South Sudan.

Methods

Data collection was conducted between July and October 2013. In total, 63 purposively selected health facilities were assessed: 28 in Burkina Faso, 25 in DRC, and nine in South Sudan, and 42 providers completed a questionnaire to assess RH knowledge and attitudes. Thirty-four focus group discussions were conducted with 29 members of the host communities and 273 displaced married and unmarried women and men to understand access barriers.

Results

All facilities reported providing some RH services in the prior three months. Five health facilities in Burkina Faso, six in DRC, and none in South Sudan met the criteria as a family planning service delivery point. Two health facilities in Burkina Faso, one in DRC, and two in South Sudan met the criteria as an emergency obstetric and newborn care service delivery point. Across settings, three facilities in DRC adequately provided selected elements of clinical management of rape. Safe abortion was unavailable. Many providers lacked essential knowledge and skills. Focus groups revealed limited knowledge of available RH services and socio-cultural barriers to accessing them, although participants reported a remarkable increase in use of facility-based delivery services.

Conclusion

Although RH services are being provided, the availability of good quality RH services was inconsistent across settings. Commodity management and security must be prioritized to ensure consistent availability of essential supplies. It is critical to improve the attitudes, managerial and technical capacity of providers to ensure that RH services are delivered respectfully and efficiently. In addition to ensuring systematic implementation of good quality RH services, humanitarian health actors should meaningfully engage crisis-affected communities in RH programming to increase understanding and use of this life-saving care.