Impact of conflict on maternal and child health service delivery: a country case study of Afghanistan

The tale of two Badakhshans: Determinants of access and utilization of HIV preventive services along the Afghan-Tajik border

BACKGROUND

Injection of opioids has contributed to growing HIV epidemics in Tajikistan and Afghanistan. This qualitative study explored determinants of access to primary prevention and screening for HIV among people who inject drugs (PWID) residing in border communities of Gorno-Badakhshan, Tajikistan and Badakhshan, Afghanistan.

METHODS

Semi-structured interviews were conducted with PWID, community leaders, and healthcare workers. The social-ecological model was used to inform a thematic analysis of determinants of access.

RESULTS

There were no preventive or screening services for HIV in the border districts of Afghanistan. Barriers to accessing HIV-related services in Tajikistan, and to accessing general health services in Afghanistan, included: lack of knowledge about HIV, inaccessible communities with poor infrastructure, discrimination and violence against women, and stigmatization of PWID and people living with HIV. Access to HIV-related and other health services by PWID was facilitated by community leader support, family support, outreach services, and linkage of harm reduction services with HIV testing and care.

CONCLUSION

Urgent interventions are needed to stem the escalating HIV epidemic in Afghanistan and enhance existing services in Tajik border communities. This qualitative study offers insights into barriers and facilitators for accessing HIV prevention and screening services among PWID, suggesting potential interventions.

Armed conflict and maternal health service utilization in Ethiopia's Tigray Region: a community-based survey

BACKGROUND

Evidence generated on utilization of maternal health services during times of conflict can inform the development of targeted interventions. The deadly war in Tigray caused the health system to collapse. However, utilization of maternal health services is not well documented that might help in design effective interventions applicable during armed conflict. Thus, this study aimed to assess maternal health service utilization and bridge the gap in healthcare provision and support during conflict. .

METHODS

A community-based cross-sectional survey was conducted among mothers of children under the age of 1 year in six accessible zones of Tigray from August 4-20, 2021. The study participants were selected through a random sampling method. The study was conducted during the armed conflict where the access to health services was limited due to the damaged and looted health facilities. A descriptive study was used to characterize the study population and data were presented using proportions and percentages. A Chi-square test was used for categorical variables and a P-value of 0.05 was considered significant. .

RESULTS

A total of 4,381 participants were included in the study. Modern contraceptives were used by 1002 (22.9%) of women, and injectable contraceptives were the most common method used by 472 (47.1%) women. Likewise, only 830 (36.5%),1956 (47.1%), and 623 (15.0%) respondents reported the use of optimal antenatal care (ANC), skilled delivery, and postnatal care (PNC) in the first 24 h by mothers, respectively. About 34% of women received comprehensive abortion care services. Most delivery services took place in hospitals. Residence has shown a significant difference in using maternal health services at p-value < 0.001.

CONCLUSION

The conflict in Tigray has had a profound impact on maternal health services, resulting in a significant disruption that is disproportionately high in rural areas. Immediate action is required to provide access to lifesaving interventions for basic maternal health services. The timely initiation of these services is crucial in addressing the pressing needs of pregnant women and their infants. By implementing comprehensive and targeted interventions, we can mitigate the potential long-term consequences and ensure that maternal health services are effectively reinstated.

Uptake of protective tetanus toxoid vaccine doses and maternal associated factors during pregnancy in armed conflict zone, hospital-based cross-sectional study

Background

Vaccinating pregnant women with tetanus toxoid (TT) is crucial to prevent neonatal tetanus, reducing related deaths by 94%. In conflict zones with restricted access to deliveries, neonates face a fatality rate of 80%-100%. This study explores the uptake of protective TT vaccine doses and maternal associated factors during pregnancy in an armed conflict zone.

Methods

A hospital-based, descriptive, cross-sectional study was conducted of 357 pregnant women at delivery using simple random sampling. Data were collected through interviews with a structured questionnaire, and entered using Epi-data version 3.1, and exported using SPSS version 22 for further analysis. Binary and multivariable logistic regression analyses were used to identify significant variables for receiving protective TT doses during pregnancy at P < 0.05.

Result

In this study, 355 pregnant women were included, with response rate of 99.4%. The mean age of the participants was 27.65 ± 6.23 years. During the study period, 67.3% of pregnant women received a protective TT vaccine dose while 33.3% were missed due to escalated armed conflict. The dropout rates were significant from TT5 to TT2 (17.6%), TT5 to TT3 (11.9%), and TT5 to TT4 (6.1%). However, maternal associated factors for the uptake of the TT protective vaccine dose were identified, including being aged 36-49 years [adjusted odds ratio (AOR) = 3.7; 95% confidence interval (CI) 1.54-7.8; P = 0.001], completing high school (AOR = 3.05; 95% CI 1.5-8.9; P = 0.02), having an antenatal care follow-up (AOR = 9.4; 95% CI 2.9-24.3; P = 0.001), previous media exposure (AOR = 15.5; 95% CI 7.5-25.3; P = 0.001), and good maternal knowledge (AOR = 2.7; 95% CI 1.8-4.9; P = 0.02).

Conclusion

The uptake of the protective TT vaccine dose among pregnant women in a continued armed conflict area was low compared with previous study findings. Efforts should be made to increase vaccine uptake and reduce dropout rates by addressing both community and individual-level factors.

The Impact of Armed Conflict on Services and Outcomes Related to Maternal and Reproductive Health in North Wollo, Amhara, Ethiopia: A Qualitative Study

Introduction

Armed conflict is a public health problem that poses a serious challenge to the health system. Maternal and reproductive health is among the most affected areas. Maternal death rates were highest in conflict-affected countries. Sexual violence and rape are commonplaces, which contributes to the rise in the number of unwanted pregnancies. Reliable data related to the health of mothers and reproduction is required to inform public health policies. Therefore, this study aimed to assess the impact of armed conflict on services and outcomes related to maternal and reproductive health.

Objective

To explore the impact of armed conflict on services and outcomes related to maternal and reproductive health in North Wollo, Amhara, and Ethiopia by 2022.

Methods

This study used an institutional and community-based exploratory design. Six focus group discussions and 44 in-depth interviews were conducted with healthcare professionals, administrators, women, and Non Governmental Organization workers. Each item was recorded in audio, verbatim transcription was made and converted into English. By using OpenCode version 4.03 thematic analyses was performed.

Results

Three overarching themes were identified. The first theme was the inadequate standards of maternal and reproductive health services. This includes the breakdown of infrastructure, shortages of medicines and medical supplies, and the lack of sterility of available limited materials and procedures. The second theme was poor maternal and reproductive health status. It includes poor pregnancy, delivery, reproductive and fertility-related health outcomes. The last theme was the limited access to maternal and reproductive services.

Conclusion

Armed conflicts have enormous effects on services and results related to the health of mothers and reproductive processes. Addressing these effects is essential for designing and implementing public health measures to improve services related to the health of mothers and the reproductive system.

Neonatal mortality during the war in Tigray: a cross-sectional community-based study

BACKGROUND

Neonatal mortality is among the key national and international indicators of health services. The global Sustainable Development Goal target for neonatal mortality is fewer than 12 deaths per 1000 livebirths, by 2030. Neonatal mortality estimates in the 2019 Ethiopian Demographic Health Survey found 25·7 deaths per 1000 livebirths. Subnational surveys specific to Tigray, Ethiopia, reported a neonatal mortality lifetime prevalence of 7·13 deaths. Another government report from the Tigray region estimated a neonatal mortality rate of ten deaths per 1000 livebirths in 2020. Despite the numerous interventions in Ethiopia's Tigray region to achieve the Sustainable Development Goals, the war has disrupted most health services, but the effect on neonatal mortality is unknown. Thus, this study aimed to investigate the magnitude and causes of neonatal mortality during the war in Tigray.

METHODS

A cross-sectional community-based study was conducted in Tigray to evaluate neonatal mortality that occurred from Nov 4, 2020, to May 30, 2022. Among the 31 districts, 121 tabias were selected using computer-generated random sampling, and 189 087 households were visited. We adopted a validated WHO 2022 verbal autopsy tool, and data were collected using an interviewer-administrated Open Data Kit. In the absence of the mother, other respondents to the verbal autopsy interview were household members aged 18 years and older who provided care during the final illness that led to death.

FINDINGS

29 761 livebirths were recorded during the screening of 189 087 households. Verbal autopsy was administered for 1158 households with neonatal deaths. 317 neonates were stillborn, and 841 neonatal deaths were recorded with the WHO 2022 verbal autopsy tool from Nov 4, 2020, to May 30, 2022, in 31 districts. The neonatal mortality rate was 28·2 deaths per 1000 livebirths. 476 (57%) of the 841 neonatal deaths occurred at home and 296 (35%) in health facilities. A high rate of neonatal deaths was reported in rural districts (80% [673 of 841]) compared with urban districts (20% [168 of 841]), and 663 (79%) deaths occurred during the early neonatal period, in the first week of life (0-6 days). The leading causes of neonatal death were asphyxia (35% [291 of 834]), prematurity (30% [247 of 834]), and infection (12% [104 of 834]). Asphyxia (37% [246 of 663]) and infection (28% [50 of 178]) were the leading causes of death for early and late neonatal period deaths, respectively.

INTERPRETATION

Neonatal mortality in Tigray is high due to preventable causes. An urgent response is needed to prevent the high number of neonatal deaths associated with the depleted health resources and services resulting from the war, and to achieve the Sustainable Development Goal on neonatal mortality.

FUNDING

UNICEF and United Nations Fund for Population Activities.

TRANSLATION

For the Tigrigna translation of the abstract see Supplementary Materials section.

Patterns and determinants of healthcare utilization and medication use before and during the COVID-19 crisis in Afghanistan, Bangladesh, and India

BACKGROUND

COVID-19 rapidly spread through South Asian countries and overwhelmed the health systems that were unprepared for such an outbreak. Evidence from high-income countries showed that COVID-19 impacted healthcare utilization, including medication use, but empirical evidence is lacking in South Asia. This study aimed to investigate the effect of COVID-19 on healthcare utilization and medication use in South Asia.

METHOD

The current study used longitudinal data from the 'Premise Health Service Disruption Survey' 2020 and 2021. The countries of interest were limited to Afghanistan, Bangladesh, and India. In these surveys, data related to healthcare utilization and medication use were collected for three-time points; 'Pre-COVID phase', 'Initial phase of COVID-19 outbreak', and 'One year of COVID-19 outbreak'. Generalized estimating equation (GEE) along with McNemar's test, Kruskal-Wallis test and χ2 test were applied in this study following the conceptualization of Andersen's healthcare utilization model.

RESULT

The use of healthcare and medication was unevenly impacted by the COVID-19 epidemic in Afghanistan, Bangladesh, and India. Immediately after the COVID-19 outbreak, respondents in Bangladesh reported around four times higher incomplete healthcare utilization compared to pre-COVID phase. In contrast, respondents in Afghanistan reported lower incomplete utilization of healthcare in a similar context. In the post COVID-19 outbreak, non-adherence to medication use was significantly higher in Afghanistan (OR:1.7; 95%CI:1.6,1.9) and India (OR:1.3; 95%CI:1.1,1.7) compared to pre-COVID phase. Respondents of all three countries who sought assistance to manage non-communicable diseases (NCDs) had higher odds (Afghanistan: OR:1.5; 95%CI:1.3,1.8; Bangladesh: OR: 3.7; 95%CI:1.9,7.3; India: OR: 2.3; 95% CI: 1.4,3.6) of non-adherence to medication use after the COVID-19 outbreak compared to pre-COVID phase.

CONCLUSION

The present study documented important evidence of the influence of COVID-19 epidemic on healthcare utilization and medication use in three countries of South Asia. Lessons learned from this study can feed into policy responses to the crisis and preparedness for future pandemics.

Assessing the health consequences of northern Ethiopian armed conflict, 2022

Armed conflict is a complicated topic with multidimensional impact on population health. This study aimed to assess of the health consequences of the northern Ethiopian conflict, 2022. We used a mixed method study design with a retrospective cross-sectional study supplemented by a qualitative study conducted from May to June 2022. We interviewed 1806 individuals from 423 households and conducted 100 in-depth interviews and focused group discussion. We identified 224 people who self-reported cases of illness (124/1000 people) with only 48 (21%) people who fell ill visited a health institution. We also detected 27 cases of deaths (15/1000 people) during the conflict. The collapse of the health system, evacuation of health personnel, and shortage of medical supplies, and instability with a lack of transportation were consequences of the conflict. The northern Ethiopian conflict has greatly affected the community's health through the breakdown of the health system and health-supporting structures.

Barriers to healthcare utilization among married women in Afghanistan: the role of asset ownership and women's autonomy

Women face multiple socio-economic, cultural, contextual, and perceived barriers in health service utilization. Moreover, poor autonomy and financial constraints act as crucial factors to their healthcare accessibility. Therefore, the objective of the present study is to study the association between health care utilization barriers and women empowerment, including asset ownership among currently married women in Afghanistan. Data of 28,661 currently married women from Afghanistan demographic health survey (2015) was used to carry out this study. Barriers to access healthcare were computed based on problems related to permission, money, distance, and companionship, whereas women empowerment and asset ownership were computed as potential covariates along with other socio-economic risk factors. Bivariate and logistic analysis was carried out to study the association and odds of explanatory variables. Our results confirm the significant and strong association between the barriers to access healthcare and various explanatory variables. Women having any decision-making autonomy are less likely to face any odds [(AOR = 0.56, p < 0.001), CI: 0.51-0.61] among the currently married women than those who don't have any decision-making authority. Similarly, women who justify their beating for some specific reasons face the greater difficulty of accessing health care [(AOR = 1.76, p < 0.001), CI: 1.61-1.93]. In terms of asset ownership, women having any asset ownership (land or household) are less likely to face any barriers in health services utilization given the lower odds [(AOR = 0.91, p < 0.001), CI: 0.90-0.98]. Accessing maternal health is a crucial policy challenge in Afghanistan. A substantial proportion of women face barriers related to approval, money, distance, and companionship while accessing the health services utilization in Afghanistan. Similarly, women empowerment and asset ownership are significantly associated with health service accessibility. This paper therefore suggests for some policy interventions to strengthen the healthcare needs of women and ensure healthcare accessibility by scaling down these potential barriers like poor autonomy, asset ownership and domestic violence.

Primary healthcare system and provider responses to the Taliban takeover in Afghanistan

INTRODUCTION

Existing health system challenges in Afghanistan were amplified by the Taliban's August 2021 government takeover during which the country faced an evolving security situation, border closures, banking interruptions, donor funding disruptions and international staff evacuations. We investigated factors that influenced health sector and health service delivery following the takeover.

METHODS

We purposively sampled individuals knowledgeable about Afghanistan's health sector and health professionals working in underserved areas of the country. We identified codes and themes of the data using framework analysis.

RESULTS

Factors identified as supporting continued health service delivery following August 2021 include external funding and operational flexibilities, ongoing care provision by local implementers and providers, health worker motivation, flexible contracting out arrangements and improved security. Factors identified as contributing to disruptions include damaged infrastructure, limited supplies, ineffective government implementation efforts and changes in government leadership and policies resulting in new coordination and capacity challenges. There were mixed views on the role pay-for-performance schemes played. Participants also shared concerns about the new working environment. These included loss of qualified health professionals and the associated impact on quality of care, continued dependency on external funding, women's inability to finish their studies or take on any leadership positions, various impacts of the Mahram policy, mental stress, the future of care provision for female patients and widespread economic hardship which impacts nearly every aspect of Afghan life.

CONCLUSION

Afghanistan's health sector presents a compelling case of adaptability in the face of crisis. Despite the anticipated and reported total collapse due to the country's power shift, various factors enabled health services to continue in some settings while others acted as barriers. The potential role of these factors should be considered in the context of future service delivery in Afghanistan and other settings at risk of political and societal disruption.

Women's experience of childbirth care in health facilities: a qualitative assessment of respectful maternity care in Afghanistan

BACKGROUND

Respectful maternity care (RMC) remains a key challenge in Afghanistan, despite progress on improving maternal and newborn health during 2001-2021. A qualitative study was conducted in 2018 to provide evidence on the situation of RMC in health facilities in Afghanistan. The results are useful to inform strategies to provide RMC in Afghanistan in spite of the humanitarian crisis due to Taliban's takeover in 2021.

METHODS

Focus group discussions were conducted with women (4 groups, 43 women) who had used health facilities for giving birth and with providers (4 groups, 21 providers) who worked in these health facilities. Twenty key informant interviews were conducted with health managers and health policy makers. Motivators for, deterrents from using, awareness about and experiences of maternity care in health facilities were explored.

RESULTS

Women gave birth in facilities for availability of maternity care and skilled providers, while various verbal and physical forms of mistreatment were identified as deterrents from facility use by women, providers and key informants. Low awareness, lack of resources and excessive workload were identified among the reasons for violation of RMC.

CONCLUSION

Violation of RMC is unacceptable. Awareness of women and providers about the rights of women to respectful maternity care, training of providers on the subject, monitoring of care to prevent mistreatment, and conditioning any future technical and financial assistance to commitments to RMC is recommended.

Mortality and disability-adjusted life years in North Africa and Middle East attributed to kidney dysfunction: a systematic analysis for the Global Burden of Disease Study 2019

Background

The study aimed to estimate the attributable burden to kidney dysfunction as a metabolic risk factor in the North Africa and Middle East (NAME) region and its 21 countries in 1990-2019.

Methods

The data used in this study were obtained from the Global Burden of Diseases (GBD) 2019 study, which provided estimated measures of deaths, disability-adjusted life years (DALYs), and other epidemiological indicators of burden. To provide a better insight into the differences in the level of social, cultural, and economic factors, the Socio-Demographic Index (SDI) was used.

Results

In the NAME region in 2019, the number of deaths attributed to kidney dysfunction was 296 632 (95% uncertainty interval: 249 965-343 962), which was about 2.5 times higher than in the year 1990. Afghanistan, Egypt, and Saudi Arabia had the highest, and Kuwait, Turkey, and Iran (Islamic Republic of) had the lowest age-standardized rate of DALYs attributed to kidney dysfunction in the region in 2019. Kidney dysfunction was accounted as a risk factor for ischemic heart disease, chronic kidney disease, stroke, and peripheral artery disease with 150 471, 111 812, 34 068, and 281 attributable deaths, respectively, in 2019 in the region. In 2019, both low-SDI and high-SDI countries in the region experienced higher burdens associated with kidney dysfunction compared to other countries.

Conclusions

Kidney dysfunction increases the risk of cardiovascular diseases burden and accounted for more deaths attributable to cardiovascular diseases than chronic kidney disease in the region in 2019. Hence, policymakers in the NAME region should prioritize kidney disease prevention and control, recognizing that neglecting its impact on other diseases is a key limitation in its management.

The Governance of Childhood Vaccination Services in Crisis Settings: A Scoping Review

The persistence of inadequate vaccination in crisis-affected settings raises concerns about decision making regarding vaccine selection, timing, location, and recipients. This review aims to describe the key features of childhood vaccination intervention design and planning in crisis-affected settings and investigate how the governance of childhood vaccination is defined, understood, and practised. We performed a scoping review of 193 peer-reviewed articles and grey literature on vaccination governance and service design and planning. We focused on 41 crises between 2010 and 2021. Following screening and data extraction, our analysis involved descriptive statistics and applying the governance analysis framework to code text excerpts, employing deductive and inductive approaches. Most documents related to active outbreaks in conflict-affected settings and to the mass delivery of polio, cholera, and measles vaccines. Information on vaccination modalities, target populations, vaccine sources, and funding was limited. We found various interpretations of governance, often implying hierarchical authority and regulation. Analysis of governance arrangements suggests a multi-actor yet fragmented governance structure, with inequitable actor participation, ineffective actor collaboration, and a lack of a shared strategic vision due to competing priorities and accountabilities. Better documentation of vaccination efforts during emergencies, including vaccination decision making, governance, and planning, is needed. We recommend empirical research within decision-making spaces.

Maternal Health Care Service Utilization in the Post-Conflict Democratic Republic of Congo: An Analysis of Health Inequalities over Time

This study assessed inequality in maternal healthcare service utilization in the Democratic Republic of the Congo, using the Demographic and Health Surveys of 2007 and 2013-2014. We assessed the magnitude of inequality using logistical regressions, analyzed the distribution of inequality using the Gini coefficient and the Lorenz curve, and used the Wagstaff method to assess inequality trends. Women were less likely to have their first antenatal care visit within the first trimester and to attend more antenatal care visits when living in eastern Congo. Women in rural areas were less likely to deliver by cesarean section and to receive postnatal care. Women with middle, richer, and richest wealth indexes were more likely to complete more antenatal care visits, to deliver by cesarean section, and to receive postnatal care. Over time, inequality in utilization decreased for antenatal and postnatal care but increased for delivery by cesarean sections, suggesting that innovative strategies are needed to improve utilization among poorer, rural, and underserved women.

Barriers Towards Obstetric Care Service Utilization in Ethiopia: An Explorative Qualitative Study

Background

Obstetric care has been at the center of both global and national agendas. More than 50% of pregnant mothers are still preferring to give birth at home with some even after having full antenatal care. However, a few literatures looked at contributing factors for this problem but they are not conclusive and do not consider different sociocultural context of Ethiopia and different health service related barriers. Hence, the aim of this study was to explore barriers to obstetric care service utilization in Ethiopia using the socio-ecological model.

Methods

Explorative qualitative study was employed involving key-informant interviews, in-depth interviews, and focus group discussions between October and December 2021; Individual, community, health system, and contextual barriers were explored. Atlas ti. Version 9 was used for analysis.

Result

Lack of awareness, unfavorable perception, lack of partner involvement, cultural barrier, shortage of supplies, poor infrastructure, provider-related factors, poor monitoring, and evaluation system, challenging topography, and conflict were the major barriers that hinder mothers from receiving obstetrics service in Ethiopia.

Conclusion

Lack of awareness, unfavorable perception, conflict, problems with health system structure and process, and cultural and geographical conditions were major barriers in Ethiopia. Therefore, packages of intervention is important to avail essential equipment, strengthening follow up system, create awareness, and increase access to health facilities is very important for service improvement by the government and non-governmental organizations. Additionally, implementing conflict resolution mechanism is important for addressing better obstetric service.

Lessons from the development process of the Afghanistan integrated package of essential health services

In 2017, in the middle of the armed conflict with the Taliban, the Ministry of Public Health decided that the Afghan health system needed a well-defined priority package of health services taking into account the increasing burden of non-communicable diseases and injuries and benefiting from the latest evidence published by DCP3. This leads to a 2-year process involving data analysis, modelling and national consultations, which produce this Integrated Package of Essential health Services (IPEHS). The IPEHS was finalised just before the takeover by the Taliban and could not be implemented. The Afghanistan experience has highlighted the need to address not only the content of a more comprehensive benefit package, but also its implementation and financing. The IPEHS could be used as a basis to help professionals and the new authorities to define their priorities.

How is the implementation of empirical research results documented in conflict-affected settings? Findings from a scoping review of peer-reviewed literature

Implementation science scholars argue that knowing 'what works' in public health is insufficient to change practices, without understanding 'how', 'where' and 'why' something works. In the peer reviewed literature on conflict-affected settings, challenges to produce research, make decisions informed by evidence, or deliver services are documented, but what about the understanding of 'how', 'where' and 'why' changes occur? We explored these questions through a scoping review of peer-reviewed literature based on core dimensions of the Extended Normalization Process Theory. We selected papers that provided data on how something might work (who is involved and how?), where (in what organizational arrangements or contexts?) and why (what was done?). We searched the Global Health, Medline, Embase databases. We screened 2054 abstracts and 128 full texts. We included 22 papers (of which 15 related to mental health interventions) and analysed them thematically. We had the results revised critically by co-authors experienced in operational research in conflict-affected settings. Using an implementation science lens, we found that: (a) implementing actors are often engaged after research is produced to discuss feasibility; (b) new interventions or delivery modalities need to be flexible; (c) disruptions affect how research findings can lead to sustained practices; (d) strong leadership and stable resources are crucial for frontline actors; (e) creating a safe learning space to discuss challenges is difficult; (f) feasibility in such settings needs to be balanced. Lastly, communities and frontline actors need to be engaged as early as possible in the research process. We used our findings to adapt the Extended Normalization Process Theory for operational research in settings affected by conflicts. Other theories used by researchers to document the implementation processes need to be studied further.

Does armed conflict lead to lower prevalence of maternal health-seeking behaviours: theoretical and empirical research based on 55 683 women in armed conflict settings

BACKGROUND

Women and children bear a substantial burden of morbidity and mortality due to armed conflict. Life-saving maternal and child health (MCH) services are low-quality in most conflict-affected regions. Previous studies on armed conflict and MCH services have been mostly cross-sectional, and a causal relationship between armed conflict and MCH services utilisation cannot be inferred.

METHODS

First, we constructed a utility equation for maternal health-seeking behaviour. Next, we extracted MCH data from the Multiple Indicator Cluster Survey led by the UNICEF. Armed conflict data were obtained from the Uppsala Conflict Data Programme; 55 683 women aged 15-49 from Chad, the Central African Republic, the Democratic Republic of Congo (DRC) and the Republic of Iraq were selected as participants. We fitted a difference-in-differences (DID) model, taking before or after the conflict started as an exposure variable to estimate the effects of armed conflict on maternal health-seeking behaviours.

RESULTS

According to the results of the DID model, in the regional sample, armed conflict had a positive effect on tetanus vaccination (β=0.055, 95% CI 0.004 to 0.106, p<0.05), and had a negative effect on antenatal care at least eight visits (ANC8+) (β=-0.046, 95% CI -0.078 to -0.015, p<0.01). And, the effects of armed conflict on ANC, ANC4+, institutional delivery and early initiation of breast feeding (EIB) were not statistically significant. As for the country sample, we found that armed conflict had a negative effect on EIB (β=-0.085, 95% CI -0.184 to 0.015, p<0.1) in Chad. In Iraq, armed conflict had positive impacts on ANC (β=0.038, 95% CI -0.001 to 0.078, p<0.1) and tetanus vaccination (β=0.059, 95% CI 0.012 to 0.107, p<0.05), whereas it had a negative effect on ANC8+ (β=-0.039, 95% CI -0.080 to 0.002, p<0.1). No statistically significant associations were discovered in DRC based on the DID model.

CONCLUSIONS

There might be a mixed effect of armed conflict on maternal health-seeking behaviours. In the absence of humanitarian assistance, armed conflict reduces certain maternal health-seeking behaviours, such as ANC8+. When practical humanitarian health assistance is provided, the damage can be alleviated, and even the prevalence of maternal health-seeking behaviours can be improved, such as tetanus vaccination. Providing humanitarian assistance to conflict-affected regions improved the accessibility of MCH services for women living in those areas. However, the goals of saving lives and alleviating suffering still need to be achieved. In conflict-affected regions, humanitarian assistance on ANC, institutional delivery and breast feeding need strengthening.

Institutional delivery service utilization and associated factors in fragile and conflict-affected situations in Sekota town, Northern Ethiopia, 2022: A community-based cross-sectional study

Background

Conflict-affected areas are considered to contribute a substantial proportion of worldwide maternal deaths. However, research on maternal health care in conflict-affected countries is very limited. In the absence of recent data, it is impossible to monitor progress made in mitigating the effect of conflict on maternal survival. As a result, this study targeted to assess institutional delivery services usage and influencing factors in a fragile and conflict-affected situation in Sekota town, Northern Ethiopia.

Methods

A community-based cross-sectional study was employed among 420 mothers in Sekota town, Northern Ethiopia from July 15th to 30th, 2022. The desired sample size was determined using a single population proportion formula. The data were collected by using interviewer administered structured questionnaire; entered via EpiData version 4.6 and analyzed using SPSS version 25 software. To identify the associated factors, a bivariable and multivariable logistic regression model was applied. The level of significance was declared at a p-value of <0.05. An adjusted odds ratio with a 95% confidence interval was considered to see the strength of the association between dependent and independent variables.

Results

Of the total respondent, 202 (48.1%), 95% CI: (43.0%, 53.0%) mothers utilized institutional delivery service. The use of institutional delivery services was associated with the maternal educational level of secondary school and above (AOR = 2.06, 95% CI: 1.08-3.93), antenatal care during the most recent pregnancy (AOR = 5.24, 95% CI: 3.01-9.11), being informed on birth preparedness and complication readiness (AOR = 1.93, 95% CI: 1.23-3.02) and displacement of the respondents from their usual place of residence due to conflict (AOR = 0.41, 95% CI: 0.21-0.68).

Conclusion

Institutional delivery service utilization was very low in the study setting. Healthcare for women in conflict-prone areas requires critical attention and should be given priority during the conflict. More prospective research is needed to fully understand and reduce the impact of conflict on maternal and neonatal health care.

Evolution of assisted deliveries at primary healthcare centres in an unstable security context in Mali

INTRODUCTION

In Mali, healthcare systems are severely affected by conflict. However, several studies suggest a lack of knowledge about its impact on maternal healthcare. Frequent and repeated attacks increase insecurity, limit access to maternal care, and thus represent a barrier to accessing care. The objective of this study is to understand how assisted deliveries are being reorganised at the health centre level, and how they are adapting to the security crisis.

METHOD

This is a mixed sequential and explanatory study. The quantitative approaches combine a spatial scan analysis of assisted deliveries by health centres, an analysis of health centre performance using an ascending hierarchical classification, and a spatial analysis of violent events in two health districts in central Mali: Mopti and Bandiagara. The qualitative phase analyses semidirective and targeted interviews with managers (n=22) of primary healthcare centres (CsCOM) and two agents of international institutions.

RESULTS

The study reveals an important territorial heterogeneity of assisted deliveries. The primary health centres with high rates of assisted deliveries have mainly high-performance levels. This high level of use can be explained by the movement of the population to areas less exposed to attacks. The centres with low rates of assisted deliveries are those where qualified health workers refused to practice, where populations had few financial resources, and where they limited their travel to reduce their exposure to insecurity.

CONCLUSION

This study confirms that combining methodological approaches is essential to explain significant use in the local context. The analysis of the number of assisted deliveries in conflict zones must consider the number of procedures, the nearby security context, the number of internally displaced persons and the presence of camps in which humanitarian organisations offer programmes.

The health consequences of civil wars: evidence from Afghanistan

This study examines the effects of long-run civil wars on healthcare, which is an important component of human capital development and their causality nexus in Afghanistan using the MVAR (modified vector autoregressive) approach and the Granger non-causality model covering data period 2002Q3-2020Q4. The primary results support a significant long-run relationship between variables, while the results of the MVAR model indicate the per capita cost of war, per capita GDP, and age dependency ratio have significantly positive impacts on per capita health expenditures, whereas child mortality rate and crude death rate have negative impacts. The results of the Granger non-causality approach demonstrate that there is a statistically significant bidirectional causality nexus between per capita health expenditure, per capita cost of war, per capita GDP, child mortality rate, crude death rate, and age dependency ratio, while it also supports the existence of strong and significant interconnectivity and multidimensionality between per capita cost of war and per capita health expenditure, with a significantly strong feedback response from the control variables. Important policy implications sourced from the key findings are also discussed.

Beyond gender mainstreaming: transforming humanitarian action, organizations and culture

The United Nations and major humanitarian organizations have made policy commitments to promote gender equality and empower women and girls. This study assesses the extent to which humanitarian responses have met these commitments based on reviews of gender mainstreaming, textual analysis of policy and program cycle documents, and interviews with humanitarian actors. The analysis reveals that while gender mainstreaming may raise awareness and make fixes at the margins, its focus has been limited to altering internal processes rather than emphasizing results for women and men and girls and boys. Our study also analyzes the cultural and institutional context in which gender mainstreaming takes place. The culture of humanitarian organizations has been characterized as hierarchical and driven by a short-term crisis response with a distinctly macho style of functioning, which is misaligned with gender mainstreaming. We propose replacing gender mainstreaming with a results-focused approach rooted in behavioral science that uses evidence of the conscious and non-conscious drivers of human behavior to address problems, alongside other efforts to change the internal culture of humanitarian organizations.

Association between place of delivery, assistance during delivery and fistula occurrence in Afghanistan

BACKGROUND

Obstetric fistula is one of themost serious and devastating childbirth-related injuries women suffer worldwide. This study investigated the association between delivery characteristics and the occurrence of obstetric fistula in Afghanistan.

METHODS

The study analysed data from the 2015 Afghanistan Demographic and Health Survey. The association between place of delivery and assistance during delivery with experience of fistula symptoms was investigated by fitting two binary logistic regression models.

RESULTS

Findings from this study revealed that 23.4% of the women surveyed ever heard about obstetric fistula and 3% reported symptoms of fistula. Women whose deliveries were assisted by traditional birth attendants were significantly more likely to experience fistula compared with those whose deliveries were assisted by doctors. Similarly, women whose deliveries were assisted by others were significantly more likely to experience fistula compared with women whose deliveries were assisted by doctors. Regarding place of delivery, women whose deliveries took place at a government hospital were less likely to experience fistula compared with those whose deliveries took place at home.

CONCLUSIONS

This study highlights the importance of skilled delivery in reducing the risk for obstetric fistula among women in Afghanistan. Therefore, it is important for the various stakeholders in Afghanistan's healthcare delivery system, including healthcare providers, local authorities and international non-governmental organisations, to collaborate and institute measures that will promote health facility deliveries and improve access to skilled delivery.

The development of Afghanistan's Integrated Package of Essential Health Services: Evidence, expertise and ethics in a priority setting process

Health systems in fragile states need to respond to shifting demographics, burden of disease and socio-economic circumstances in the revision of their health service packages. This entails making difficult decisions about what is and is not included therein, especially in resource-constrained settings offering or striving for universal health coverage. In this paper we turn the lens on the 2017-2021 development of Afghanistan's Integrated Package of Essential Health Services (IPEHS) to analyse the dynamics of the priority setting process and the role and value of evidence. Using participant observation of meetings and interviews with 25 expert participants, we conducted a qualitative study of the consultation process aimed at examining the characteristics of its technical, socio-cultural and organisational aspects, in particular data use and expert input, and how they influenced how evidence was discussed, taken up, and used (or not used) in the process. Our analysis proposes that the particular dynamics shaped by the context, information landscape and expert input shaped and operationalized knowledge sharing and its application in such a way to constitute a sort of "vernacular evidence". Our findings underline the importance of paying attention to the constellation of the priority setting processes in order to contribute to an ethical allocation of resources, particularly in contexts of resource scarcity and humanitarian need.

Regional Effects of Maternal Mortality Determinants in Africa and the Middle East: How About Political Risks of Conflicts?

Background

As per the United Nations Women data, the maternal mortality rate in war-affected countries is critical and more than 800 million people live in war-affected countries (ICRC). External and internal conflicts such as foreign pressure, war and cross-border, civil disorder, terrorism, and civil war, are characteristics of Middle Eastern and African countries. Therefore considering the rapid increment of political risks and internal and external conflicts in Africa and the Middle East during the last decade, and considering warfare as a key contributor to maternal mortality; This paper seeks to evaluate the factors that have caused significant rates of maternal mortality in Middle Eastern and African countries by emphasizing the contributions of a number of political risk aspects as Civil Disorder Index, Terrorism Index, Civil War Index, Foreign Pressures Index, Cross-Border Conflict Index, War Index along with other socio-economic factors.

Method

Data were collected from forty-six countries during 2011–2016 to explore the regional contributions of political risk aspects to the maternal mortality rate through spatial approaches.

Results

It was found that GDP per capita, energy intensity, and urbanization strongly impacted maternal mortality. Also, it was observed that natural resource rents and economic growth significantly influenced the reduction of mortality by expanding healthcare services. The urban expansion was found to have elevated maternal mortality. A majority of external and internal conflicts reduced the orientation of production toward healthcare services and thus raised maternal mortality. On the other hand, war and cross-border were found to pose opposite impacts.

Conclusion

The findings revealed that political risks arising from terrorism, foreign pressure, and war in the adjacent countries would elevate the rate of mortality in the original country. This implies the spillover impacts of regional conflicts on maternal mortality elevation at the regional scale.

JEL Classification Codes: C23; I10; I18; N37:

Review of Humanitarian Guidelines to Ensure the Health and Well-being of Afghan Refugees on U.S. Military Bases

INTRODUCTION

The U.S. military has a 50-year history of managing resettlement or refugee camps on bases. In July and August 2021, more than 124,000 persons were evacuated from Afghanistan, with 55,000 Afghans temporarily housed at U.S. military bases around the world during Operation Allies Welcome (OAW) at its peak.

METHODS

PubMed was searched for papers published in English between January 1, 1980, and February 1, 2021, using "Afghanistan" and "health" (including "public health," "maternal health," and "child health"), "maternal, newborn, and child health," and "health situation" as search terms and specific topics of interest. Where scholarly work was unavailable, reports of the United States Agency for International Development, implementing partners, gray literature, donor reports, Afghanistan Ministry of Health documents, national health plans, policies, and strategies, DoD after-action reviews (AARs), and guidance from previous refugee airlifts were also included in the search.

RESULTS

Although AARs may provide some helpful guidance for these refugee settings, a review of open-source AARs and had little to no health guidance, focused primarily on administrative issues, and do not follow humanitarian guidelines. DoD guidance for refugee settings is dated and requires updating to be useful. There is a well-developed body of literature of international standards, guidelines, and best practices for refugee settings. Using the standardized Needs Assessment for Refugee Emergencies checklist as a guide, this review provides a standardized refugee health assessment framework for ensuring the health and well-being of Afghan refugees on U.S. military bases is based on humanitarian response guidelines and best practices to ensure their care meets international standards. All groups, especially minority ethnic groups (e.g., Hazaras), sexual and gender minorities, elderly, disabled, or mentally ill persons, need equal access to protection to ensure they are not targeted. Water, sanitation, and hygiene must be gender-sensitive and inclusive which includes well-lit separate facilities for males and females to decrease vulnerability to violence. The displaced population must be involved in the management of the camp through community participation and representation. All providers in OAW should be briefed on the food security and nutrition context of those in their care. Medical providers are most effective if they have significant experience with the refugee population health context. Understanding refugee medicine, the ability to work with illiterate and uneducated populations and translators are important skills. Abiding by international standards of care and being up-to-date with current guidelines for refugee care is important. Reproductive health must be a core component of the overall health response to decrease mortality, morbidity, and disability among reproductive-age women in crisis situations. Immediate and exclusive breastfeeding and international standards for breastfeeding must be adhered to, especially among nutritionally at-risk Afghans who are part of OAW. Education implementors familiar with education in refugee settings are an important contributor to establish formal, informal, non-formal, accelerated, and essence-based education programs.

CONCLUSIONS

Partners and providers involved in any refugee setting should become familiar with updated guidelines, standards, and best practices and apply them to any operation to ensure a rights-based approach to protection, care, and the health and well-being of refugees.

The delivery of essential newborn care in conflict settings: A systematic review

INTRODUCTION

Although progress has been made over the past 30 years to decrease neonatal mortality rates, reductions have been uneven. Globally, the highest neonatal mortality rates are concentrated in countries chronically affected by conflict. Essential newborn care (ENC), which comprises critical therapeutic interventions for every newborn, such as thermal care, initiation of breathing, feeding support, and infection prevention, is an important strategy to decrease neonatal mortality in humanitarian settings. We sought to understand the barriers to and facilitators of ENC delivery in conflict settings.

METHODS

We systematically searched Ovid/MEDLINE, Embase, CINAHL, and Cochrane databases using terms related to conflict, newborns, and health care delivery. We also reviewed grey literature from the Healthy Newborn Network and several international non-governmental organization databases. We included original research on conflict-affected populations that primarily focused on ENC delivery. Study characteristics were extracted and descriptively analyzed, and quality assessments were performed.

RESULTS

A total of 1,533 abstracts were screened, and ten publications met the criteria for final full-text review. Several barriers emerged from the reviewed studies and were subdivided by barrier level: patient, staff, facility, and humanitarian setting. Patients faced obstacles related to transportation, cost, and access, and mothers had poor knowledge of newborn danger signs. There were difficulties related to training and retaining staff. Facilities lacked supplies, protocols, and data collection strategies.

CONCLUSIONS

Strategies for improved ENC implementation include maternal and provider education and increasing facility readiness through upgrades in infrastructure, guidelines, and health information systems. Community-based approaches may also play a vital role in strengthening ENC.

Combination of Interventions Needed to Improve Maternal Healthcare Utilization: A Multinomial Analysis of the Inequity in Place of Childbirth in Afghanistan

Giving birth with a skilled birth attendant at a facility that provides emergency obstetric care services has better outcomes, but many women do not have access to these services in low- and middle-income countries. Individual, household, and societal factors influence women's decisions about place of birth. Factors influencing birthplace preference by type of provider and level of public facility are not well understood. Applying the Andersen Behavioral Model of healthcare services use, we explored the association between characteristics of women and their choice of childbirth location using a multinomial logistic regression, and conducted a scenario analysis to predict changes in the childbirth location by imposing various interventions. Most women gave birth at home (68.1%), while 15.1% gave birth at a public clinic, 12.1% at a public hospital, and 4.7% at a private facility. Women with higher levels of education, from households in the upper two wealth quintiles, and who had any antenatal care were more likely to give birth in public or private facilities than at home. A combination of multisector interventions had the strongest signals from the model for increasing the predicted probability of in-facility childbirths. This study enhances our understanding of factors associated with the use of public facilities and the private sector for childbirth in Afghanistan. Policymakers and healthcare providers should seek to improve equity in the delivery of health services. This study highlights the need for decisionmakers to consider a combination of multisector efforts (e.g., health, education, and social protection), to increase equitable use of maternal healthcare services.

Afghanistan: Decades of collective trauma, ongoing humanitarian crises, Taliban rulers, and mental health of the displaced population

More than half of the Afghan population suffers from depression, anxiety, and post-traumatic stress disorder, including many survivors of conflict-related violence, yet only about 10 percent receive effective psychosocial therapy from the government. As a result of decades of bloodshed, many Afghans have sustained serious psychological traumas. Due to unfair social standards, women and girls confront additional challenges, and millions of Afghans have suffered psychologically as a result of 41 years of conflict. While effective mental health investment is vital, funds must be spent judiciously to ensure access to adequate assessment while also adhering to human rights standards. The global mental health crises caused by the lengthy political struggle, as well as the COVID-19 pandemic, have collided in Afghanistan, worsening a complex humanitarian disaster and adding to the country's mounting mental health burden. Mental health is an issue that, at least in Afghanistan's current socio-political setting, requires immediate attention. While effective mental health investment is vital, funds must be spent judiciously to ensure access to adequate assessment.

Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000-2019

BACKGROUND

Armed conflicts have major indirect health impacts in addition to the direct harms from violence. They create enduring political instability, destabilise health systems, and foster negative socioeconomic and environmental conditions-all of which constrain efforts to reduce maternal and child mortality. The detrimental impacts of conflict on global maternal and child health are not robustly quantified. This study assesses the association between conflict and maternal and child health globally.

METHODS AND FINDINGS

Data for 181 countries (2000-2019) from the Uppsala Conflict Data Program and World Bank were analysed using panel regression models. Primary outcomes were maternal, under-5, infant, and neonatal mortality rates. Secondary outcomes were delivery by a skilled birth attendant and diphtheria, pertussis, and tetanus (DPT) and measles vaccination coverage. Models were adjusted for 10 confounders, country and year fixed effects, and conflict lagged by 1 year. Further lagged associations up to 10 years post-conflict were tested. The number of excess deaths due to conflict was estimated. Out of 3,718 country-year observations, 522 (14.0%) had minor conflicts and 148 (4.0%) had wars. In adjusted models, conflicts classified as wars were associated with an increase in maternal mortality of 36.9 maternal deaths per 100,000 live births (95% CI 1.9-72.0; 0.3 million excess deaths [95% CI 0.2 million-0.4 million] over the study period), an increase in infant mortality of 2.8 per 1,000 live births (95% CI 0.1-5.5; 2.0 million excess deaths [95% CI 1.6 million-2.5 million]), a decrease in DPT vaccination coverage of 4.9% (95% CI 1.5%-8.3%), and a decrease in measles vaccination coverage of 7.3% (95% CI 2.7%-11.8%). The long-term impacts of war were demonstrated by associated increases in maternal mortality observed for up to 7 years, in under-5 mortality for 3-5 years, in infant mortality for up to 8 years, in DPT vaccination coverage for up to 3 years, and in measles vaccination coverage for up to 2 years. No evidence of association between armed conflict and neonatal mortality or delivery by a skilled birth attendant was found. Study limitations include the ecological study design, which may mask sub-national variation in conflict intensity, and the quality of the underlying data.

CONCLUSIONS

Our analysis indicates that armed conflict is associated with substantial and persistent excess maternal and child deaths globally, and with reductions in key measures that indicate reduced availability of organised healthcare. These findings highlight the importance of protecting women and children from the indirect harms of conflict, including those relating to health system deterioration and worsening socioeconomic conditions.

Exposure to conflicts and the continuum of maternal healthcare: Analyses of pooled cross-sectional data for 452,192 women across 49 countries and 82 surveys

BACKGROUND

Violent conflicts are observed in many parts of the world and have profound impacts on the lives of exposed individuals. The limited evidence available from specific country or region contexts suggest that conflict exposure may reduce health service utilization and have adverse affects on health. This study focused on identifying the association between conflict exposure and continuum of care (CoC) services that are crucial for achieving improvements in reproductive, maternal, newborn, and child health and nutrition (RMNCHN).

METHODS AND FINDINGS

We combined data from 2 sources, the Demographic Health Surveys (DHS) and the Uppsala Conflict Data Program's (UCDP) Georeferenced Event Dataset, for a sample of 452,192 women across 49 countries observed over the period 1997 to 2018. We utilized 2 consistent measures of conflict-incidence and intensity-and analyzed their association with maternal CoC in 4 key components: (i) at least 1 antenatal care (ANC) visit; (ii) 4 or more ANC visits; (iii) 4 or more ANC visits and institutional delivery; and (iv) 4 or more ANC visits, institutional delivery, and receipt of postnatal care (PNC) either for the mother or the child within 48 hours after birth. To identify the association between conflict exposure and components of CoC, we estimated binary logistic regressions, controlling for a large set of individual and household-level characteristics and year-of-survey and country/province fixed-effects. This empirical setup allows us to draw comparisons among observationally similar women residing in the same locality, thereby mitigating the concerns over unobserved heterogeneity. Around 39.6% (95% CI: 39.5% to 39.7%) of the sample was exposed to some form of violent conflict at the time of their pregnancy during the study period (2003 to 2018). Although access to services decreased for each additional component of CoC in maternal healthcare for all women, the dropout rate was significantly higher among women who have been exposed to conflict, relative to those who have not had such exposure. From logistic regression estimates, we observed that relative to those without exposure to conflict, the odds of utilization of each of the components of CoC was lower among those women who were exposed to at least 1 violent conflict. We estimated odds ratios of 0.86 (95% CI: 0.82 to 0.91, p < 0.001) for at least 1 ANC; 0.95 (95% CI: 0.91 to 0.98, p < 0.005) for 4 or more ANC; and 0.92 (95% CI: 0.89 to 0.96, p < 0.001) for 4 or more ANC and institutional delivery. We showed that both the incidence of exposure to conflict as well as its intensity have profound negative implications for CoC. Study limitations include the following: (1) We could not extend the CoC scale beyond PNC due to inconsistent definitions and the lack of availability of data for all 49 countries across time. (2) The measure of conflict intensity used in this study is based on the number of deaths due to the absence of information on other types of conflict-related harms.

CONCLUSIONS

This study showed that conflict exposure is statistically significantly and negatively associated with utilization of maternal CoC services, in each component of the CoC scale. These findings have highlighted the challenges in achieving the Sustainable Development Goal 3 in conflict settings, and the need for more concerted efforts in ensuring CoC, to mitigate its negative implications on maternal and child health.

Does support to Private Health Practitioners increase childhood vaccination coverage? Findings from a comparative study in Afghanistan

INTRODUCTION

In Afghanistan coverage of childhood vaccinations is very low, especially in remote and insecure areas with a weak public health structure. Private health providers (PHPs) in these areas play an important role in health care provision, some of whom have received (para)medical training. In 2009 HealthNet TPO initiated a Public-Private Partnership program in Uruzgan province, training and equipping 34 PHPs in remote and conflict-affected locations to provide quality childhood vaccination services. We aimed to assess the impact of this program on child vaccination coverage.

METHODS

A cross-sectional household survey was performed in three districts of Uruzgan Province from January through April 2013. A stratified cluster sampling approach was used to select villages; in each of the villages 15 households were randomly selected. Vaccination information, based on vaccination cards and mother's recall, was obtained about all children aged 12-23 months in these households.

RESULTS

In total 113 children from 8 PHP villages and 286 children from 18 non-PHP villages were included. A clustered analysis showed that coverage of polio-3, diphtheria-tetanus-pertussis (DTP)-3 and of measles-1 were significantly higher in PHP villages (73.5%, 66.4% and 69.9% respectively) than in non-PHP villages (36.0%, 5.2% and 26.2% respectively; P < 0.0001 for all comparisons). The proportion of children being fully vaccinated (excluding BCG) was 54.9% in the PHP villages and 4.9% in the non-PHP villages (P < 0.0001). Vaccinated children in non-PHP villages were mainly vaccinated during mass vaccination campaigns (92.5%), while in PHP villages this was done by PHPs (47.2%) or a combination of PHPs and mass vaccination campaigns (39.2%).

CONCLUSION

Our study shows that PHPs in remote and conflict affected locations in Afghanistan can play an important role to increase childhood vaccination coverage. Expanding this program to comparable provinces in Afghanistan and to other countries struggling with insecurity and weak public health systems may save much childhood morbidity and mortality.

State fragility and the coronavirus disease 2019 (COVID-19) pandemic: an ecologic analysis of data from 146 countries

BACKGROUND

Global spread and impact of the coronavirus disease 2019 (COVID-19) pandemic are determined to a large extent, by resistance to the pandemic and public response of all countries in the world; while a country's resistance and response are in turn determined by its political and socio economic conditions. To inform future disease prevention and control, we analyzed global data to exam the relationship between state vulnerabilities and COVID-19 incidences and deaths.

METHODS

Vulnerability was measured using the Fragile States Index (FSI). FSI is created by the Fund for Peace to assess levels of fragility for individual countries. Total FSI score and scores for 12 specific indicators were used as the predictor variables. Outcome variables were national cumulative COVID-19 cases and deaths up to September 16, 2020, derived from the World Health Organization. Cumulative incidence rates were computed using 2019 National population derived from the World Bank, and case fatality rates were computed as the ratio of deaths/COVID-19 cases. Countries with incomplete data were excluded, yielding a final sample of 146 countries. Multivariate regression was used to examine the association between the predictor and the outcome measures.

RESULTS

There were dramatic cross-country variations in both FSI and COVID-19 epidemiological measurements. FSI total scores were negatively associated with both COVID-19 cumulative incidence rates (β = -0.0135, P < 0.001) and case fatality rates (β = -0.0147, P < 0.05). Of the 12 FSI indicators, three negatively associated with COVID-19 incidences were E1(Economic Decline and Poverty), E3 (Human Flight and Brain Drain), and S2 (Refugees and Internally Displaced Persons); two positively associated were P1 (State Legitimacy) and X1 (External Intervention). With regard to association with case fatality rates, C1 (Security Apparatus) was positive, and P3 (Human Rights and Rule of Law) and X1 was negative.

CONCLUSION

With FSI measures by the Fund of Peace, overall, more fragile countries are less likely to be affected by the COVID-19 pandemic, and even if affected, death rates were lower. However, poor in state legitimacy and lack of external intervention are risk for COVID-19 infection and lack of security apparatus is risky for COVID-19 death. Implications of the study findings are discussed and additional studies are needed to examine the mechanisms underpinning these relationships.

Delivering health interventions to women, children, and adolescents in conflict settings: what have we learned from ten country case studies?

Armed conflict disproportionately affects the morbidity, mortality, and wellbeing of women, newborns, children, and adolescents. Our study presents insights from a collection of ten country case studies aiming to assess the provision of sexual, reproductive, maternal, newborn, child, and adolescent health and nutrition interventions in ten conflict-affected settings in Afghanistan, Colombia, Democratic Republic of the Congo, Mali, Nigeria, Pakistan, Somalia, South Sudan, Syria, and Yemen. We found that despite large variations in contexts and decision making processes, antenatal care, basic emergency obstetric and newborn care, comprehensive emergency obstetric and newborn care, immunisation, treatment of common childhood illnesses, infant and young child feeding, and malnutrition treatment and screening were prioritised in these ten conflict settings. Many lifesaving women's and children's health (WCH) services, including the majority of reproductive, newborn, and adolescent health services, are not reported as being delivered in the ten conflict settings, and interventions to address stillbirths are absent. International donors remain the primary drivers of influencing the what, where, and how of implementing WCH interventions. Interpretation of WCH outcomes in conflict settings are particularly context-dependent given the myriad of complex factors that constitute conflict and their interactions. Moreover, the comprehensiveness and quality of data remain limited in conflict settings. The dynamic nature of modern conflict and the expanding role of non-state armed groups in large geographic areas pose new challenges to delivering WCH services. However, the humanitarian system is creative and pluralistic and has developed some novel solutions to bring lifesaving WCH services closer to populations using new modes of delivery. These solutions, when rigorously evaluated, can represent concrete response to current implementation challenges to modern armed conflicts.

Researching the delivery of health and nutrition interventions for women and children in the context of armed conflict: lessons on research challenges and strategies from BRANCH Consortium case studies of Somalia, Mali, Pakistan and Afghanistan

Background

The BRANCH Consortium recently conducted 10 mixed-methods case studies to investigate the provision of health and nutrition interventions for women and children in conflict-affected countries, aiming to better understand the dominant influences on humanitarian health actors’ programmatic decision-making and how such actors surmount intervention delivery barriers. In this paper, the research challenges encountered and the mitigating strategies employed by the case study investigators in four of the BRANCH case study contexts are discussed: Somalia, Mali, Pakistan and Afghanistan.

Discussion

Many of the encountered research challenges were anticipated, with investigators adopting mitigation strategies in advance or early on, but others were unexpected, with implications for how studies were ultimately conducted and how well the original study aims were met. Insecurity was a fundamental challenge in all study contexts, with restricted geographical access and concerns for personal safety affecting sampling and data collection plans, and requiring reliance on digital communications, remote study management, and off-site team meetings wherever possible. The need to navigate complex local sociopolitical contexts required maximum reliance on local partners’ knowledge, expertise and networks, and this was facilitated by early engagement with a wide range of local study stakeholders. Severe lack of reliable quantitative data on intervention coverage affected the extent to which information from different sources could be triangulated or integrated to inform an understanding of the influences on humanitarian actors’ decision-making.

Conclusion

Strong local partners are essential to the success of any project, contributing not only technical and methodological capacity but also the insight needed to truly understand and interpret local dynamics for the wider study team and to navigate those dynamics to ensure study rigour and relevance. Maintaining realistic expectations of data that are typically available in conflict settings is also essential, while pushing for more resources and further methodological innovation to improve data collection in such settings. Finally, successful health research in the complex, dynamic and unpredictable contexts of conflict settings requires flexibility and adaptability of researchers, as well as sponsors and donors.