Violent conflict and breastfeeding: the case of Iraq

Quality of maternal and newborn health care at private hospitals in Iraq: a cross-sectional study

BACKGROUND

Approximately 25% of facility births take place in private health facilities. Recent national studies of maternal and newborn health (MNH) service availability and quality have focused solely on the status of public sector facilities, leaving a striking gap in information on the quality of maternal and newborn care services.

METHODS

A rapid cross-sectional assessment was conducted in November 2022 to assess the quality of MNH services at private hospitals in Iraq. Multi-stage sampling was used to select 15% of the country's 164 private hospitals. Assessment tools included a facility assessment checklist, a structured health worker interview tool, and a structured client exit interview tool. Data collection was conducted using KoboToolbox software on Android tablets, and analysis conducted using SPSS v28.

RESULTS

All hospitals visited provided MNH services and had skilled personnel present or on-call 24 h/day, 7 days/week. Most births (88%) documented between January and June 2022 were cesarean births. Findings indicate that nearly all hospitals have the human resources, equipment, medicines and supplies necessary for quality antenatal, intrapartum and early essential newborn care, and many are also equipped with special units and resources needed to care for small and sick babies. However, while resources are in place for basic and advanced care, there are gaps in knowledge and practice of high-impact interventions that require few or no resources to perform, including skin-to-skin thermal care and support for early initiation of breastfeeding. Person-centered maternity care scores suggest that private hospitals offer a positive experience of care for all clients, however there is room for improvement in provider-client communication.

CONCLUSIONS

This assessment highlights the need for deeper dives into factors that underly decisions about how and where to give birth, and both understanding and practice of early essential newborn care and pre-discharge examinations and counseling at private healthcare facilities in Iraq. Engaging private health facility staff in efforts to monitor and improve the quality of maternal and newborn care, with a focus on early essential newborn care and provider-client communication for all clients, will ensure that women and newborns benefit from the best care possible with available resources.

Linking armed conflict to malnutrition during pregnancy, breastfeeding, and childhood

BACKGROUND

Women in LMICs are important agricultural actors; however, these same women, and with their children, suffer high rates of acute malnutrition during armed conflicts.

METHODS AND FINDINGS

A review was undertaken of peer-reviewed literature to describe how armed conflict drives acute malnutrition in pregnant and breastfeeding women and their children. Armed conflict factors driving malnutrition were conceptualized as belonging to one of eight overarching drivers.

CONCLUSION

Future research must examine the effect of specific drivers on acute malnutrition in order to improve predictive models; emphasize inclusion of pregnant and breastfeeding participants in studies; elucidate the role of peacekeepers in mitigating the risk of acute malnutrition; explore how to support breastfeeding women living in armed conflict situations; and explore how displaced populations affect host communities' food systems.

Systematic review of infant and young child feeding practices in conflict areas: what the evidence advocates

BACKGROUND

Breast feeding in conflict settings is known to be the safest way to protect infant and young children from malnourishment and increased risk of infections. This systematic review assesses the evidence on infant and young child feeding (IYCF) practices in conflict settings.

METHODOLOGY

We conducted a search in PubMed and CENTRAL and also searched for grey literature from the year 1980 to August 2019. We included studies conducted in settings inflicted with armed conflict; which comprised settings undergoing conflict, as well as, those within 5 years of its cessation. Studies were included if they discussed IYCF practices, barriers, programmes and guidelines to promote and improve IYCF practices. Two review authors independently evaluated and screened studies for eligibility and extracted data; followed by a descriptive and thematic analysis.

RESULTS

We included 56 studies in our review including 11 published articles and 45 reports from grey literature and broadly classified into four predetermined sections: epidemiology (n=24), barriers/enablers (n=18), programmes/interventions (n=15) and implementation guidelines (n=30). Epidemiological evidence shows that IYCF practices were generally poor in conflict settings with median prevalence of exclusive breast feeding at 25%, continued breast feeding at 29%, bottle feeding at 58.3%, introduction to solid, semisolid or soft foods at 71.1% and minimum dietary diversity at 60.3%.IYCF practices were affected by displacement, stress, maternal malnutrition and mental health, family casualties and free distribution of breast milk substitutes. To improve IYCF, several interventions were implemented; including, training of health workers, educating mothers, community networking and mobilisation, lactation-support service, baby friendly hospital initiative, mother-baby friendly spaces and support groups.

CONCLUSION

The evidence suggests that IYCF practices are generally poor in conflict inflicted settings. However, there is potential for improvement by designing effective interventions, responsibly disseminating, monitoring and implementing IYCF guidelines as prescribed by WHO development partners, government and non-government organisations with dedicated funds and investing in capacity development.

Women, children and adolescents in conflict countries: an assessment of inequalities in intervention coverage and survival

Introduction

Conflict adversely impacts health and health systems, yet its effect on health inequalities, particularly for women and children, has not been systematically studied. We examined wealth, education and urban/rural residence inequalities for child mortality and essential reproductive, maternal, newborn and child health interventions between conflict and non-conflict low-income and middle-income countries (LMICs).

Methods

We carried out a time-series multicountry ecological study using data for 137 LMICs between 1990 and 2017, as defined by the 2019 World Bank classification. The data set covers approximately 3.8 million surveyed mothers (15-49 years) and 1.1 million children under 5 years including newborns (<1 month), young children (1-59 months) and school-aged children and adolescents (5-14 years). Outcomes include annual maternal and child mortality rates and coverage (%) of family planning services, 1+antenatal care visit, skilled attendant at birth (SBA), exclusive breast feeding (0-5 months), early initiation of breast feeding (within 1 hour), neonatal protection against tetanus, newborn postnatal care within 2 days, 3 doses of diphtheria, pertussis and tetanus vaccine, measles vaccination, and careseeking for pneumonia and diarrhoea.

Results

Conflict countries had consistently higher maternal and child mortality rates than non-conflict countries since 1990 and these gaps persist despite rates continually declining for both groups. Access to essential reproductive and maternal health services for poorer, less educated and rural-based families was several folds worse in conflict versus non-conflict countries.

Conclusions

Inequalities in coverage of reproductive/maternal health and child vaccine interventions are significantly worse in conflict-affected countries. Efforts to protect maternal and child health interventions in conflict settings should target the most disadvantaged families including the poorest, least educated and those living in rural areas.