The relationship between armed conflict and reproductive, maternal, newborn and child health and nutrition status and services in northeastern Nigeria: a mixed-methods case study

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.

Assessing post-abortion care using the WHO quality of care framework for maternal and newborn health: a cross-sectional study in two African hospitals in humanitarian settings

BACKGROUND

Abortion-related complications remain a main cause of maternal mortality. There is little evidence on the availability and quality of post-abortion care (PAC) in humanitarian settings. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR).

METHODS

We mapped indicators corresponding to the eleven domains of the WHO Maternal and Newborn Health quality-of-care framework to assess inputs, processes (provision and experience of care), and outcomes of PAC. We measured these indicators in four components of a cross-sectional multi-methods study: 1) an assessment of the hospitals' PAC signal functions, 2) a survey of the knowledge, attitudes, practices, and behavior of 140 Nigerian and 84 CAR clinicians providing PAC, 3) a prospective review of the medical records of 520 and 548 women presenting for abortion complications and, 4) a survey of 360 and 362 of these women who were hospitalized in the Nigerian and CAR hospitals, respectively.

RESULTS

Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26 in the CAR hospital. In both hospitals, less than 2.5% were treated with dilatation and sharp curettage. Over 80% of women received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients with no documented indication. Among discharged women in CAR, 99% received contraceptive counseling but only 39% did in Nigeria. Over 80% of women in Nigeria reported positive experiences of respect and preservation of dignity. Conversely, in CAR, 37% reported that their privacy was always respected during examination and 62% reported short or very short waiting time before seeing a health provider. In terms of communication, only 15% felt able to ask questions during treatment in both hospitals. The risk of abortion-near-miss happening ≥ 24h after presentation was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time.

CONCLUSION

Our comprehensive assessment identified that these two hospitals in humanitarian settings provided lifesaving PAC. However, hospitals need to strengthen the patient-centered approach engaging patients in their own care and ensuring privacy, short waiting times and quality provider-patient communication. Health professionals would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.

Armed conflict, insecurity, and attitudes toward women's and girls' reproductive autonomy in Nigeria

BACKGROUND

Armed conflict and insecurity have been linked to deteriorations in reproductive health and rights globally. In Nigeria, armed violence has taken a significant toll on women's and girls' health and safety. However, knowledge is limited about how conflict shapes attitudes surrounding their ability to make autonomous decisions on relationships and childbearing. Drawing on a socioecological framework and terror management theory, we aimed to investigate the association between conflict, insecurity, and attitudes toward women's and girls' reproductive autonomy in Nigeria.

METHODS

We conducted a cross-sectional study using data from two sources: the World Values Survey (WVS) and the Uppsala Conflict Data Program-Georeferenced Event Dataset (UCDP-GED). Nationally representative data on attitudes of 559 men and 534 women was collected by WVS in 2017-2018. Linear probability models estimated the association between attitudes toward five dimensions of women and girl's reproductive autonomy (contraception, safe abortion, marital decision-making, delayed childbearing, early marriage), respondents' perceptions of neighborhood insecurity using WVS data, and geospatial measures of conflict exposure drawn from UCDP-GED.

RESULTS

Exposure to armed conflict and perceived neighborhood insecurity were associated with more supportive attitudes toward access to safe abortion among both men and women. Among women, conflict exposure was associated with higher support for contraception and the perception that early marriage can provide girls with security. Conflict-affected men were more likely to support a delay in girls' childbearing.

CONCLUSION

Our findings suggest that conflict and insecurity pose a threat to, but also facilitate opportunities for, women's and girls' reproductive autonomy. Contraception, abortion, early marriage, and postponement or childbearing may be perceived as risk-aversion strategies in response to mortality threats, livelihood losses, and conflict-driven sexual violence. Our findings foreshadow changes in fertility and relationship patterns in conflict-affected Nigeria and highlight the need for health programming to ensure access to contraception and safe abortion services.

Guidance on sexual, reproductive, maternal, newborn, child and adolescent health in humanitarian and fragile settings: a scoping review

INTRODUCTION

Progress related to sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) has stalled. COVID-19, conflict and climate change threaten to reverse decades of progress and to ensure the health and well-being of vulnerable populations in humanitarian and fragile settings (HFS) going forward, there is a need for tailored guidance for women, children and adolescents (WCA). This review seeks to map and appraise current resources on SRMNCAH in HFS.

METHODS

In line with the updated Joanna Briggs Institute guidance and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews framework, a manual literature review was conducted of global and regional guidance published between January 2008 and May 2023 from members of the Global Health Cluster, the Global Nutrition Cluster and the Inter-Agency Working Group on Reproductive Health in Crises. A content analysis was conducted. Scores were then calculated according to the Appraisal of Guidelines for Research and Evaluation II scoring tool and subsequently categorised as high quality or low quality.

RESULTS

A total of 730 documents were identified. Of these, 141 met the selection criteria and were analysed. Available guidance for delivering SRMNCH services exists, which can inform policy and programming for the general population and WCA. Important gaps related to beneficiaries, health services and health system strengthening strategies were identified.

CONCLUSION

The review revealed there is evidence-based guidance available to support interventions targeting WCA in HFS, including: pregnant and lactating women, women of reproductive age, adolescents, newborns, small vulnerable newborns, stillbirths, refugees and internally displaced persons and WCA with disabilities. However, gaps related to beneficiaries, health services and health system strengthening strategies must be addressed in updated guidance that is created, disseminated and monitored in a standardised way that is mindful of the need to respond rapidly in HFS.

Health transformation toward universal healthcare coverage amidst conflict: examining the impact of international cooperation in Niger

Background

Approximately 70% of Sub-Saharan African countries have experienced armed conflicts with significant battle-related fatalities in the past two decades. Niger has witnessed a substantial rise in conflict-affected populations in recent years. In response, international cooperation has aimed to support health transformation in Niger's conflict zones and other conflict-affected areas in Sub-Saharan Africa. This study seeks to review the available evidence on health interventions facilitated by international cooperation in conflict zones, with a focus on Niger.

Methods

We conducted a systematic literature review (SLR) adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was conducted from 2000 to 4 September 2022 using MeSH terms and keywords to identify relevant studies and reports in Sub-Saharan Africa and specifically in Niger. Databases such as PubMed (Medline), Google Scholar, Google, and gray literature were utilized. The findings were presented both narratively and through tables and a conceptual framework.

Results

Overall, 24 records (10 studies and 14 reports) that highlighted the significant role of international cooperation in promoting health transformation in conflict zones across Sub-Saharan Africa, including Niger, were identified. Major multilateral donors identified were the World Health Organization (WHO), United Nations Children's Fund (UNICEF), United Nations Fund for Population Activities (UNFPA), World Bank, United States Agency for International Development (USAID), European Union, European Commission Humanitarian Aid (ECHO), Global Fund, and Global Alliance for Vaccines and Immunization (GAVI). Most supports targeted maternal, newborn, child, adolescent, and youth health, nutrition, and psycho-social services. Furthermore, interventions were in the form of public health initiatives, mobile clinic implementation, data management, human resource capacity building, health information systems, health logistics, and research funding in conflict zones.

Conclusion

This literature review underscores the significant engagement of international cooperation in strengthening and transforming health services in conflict-affected areas across Sub-Saharan Africa, with a particular focus on Niger. However, to optimize the effectiveness of healthcare activities from short- and long-term perspectives, international partners and the Ministry of Public Health need to re-evaluate and reshape their approach to health intervention in conflict zones.

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.

Determinants of child survival practice among caregivers in internally displaced persons' camps in Abuja Municipal Area Council, Nigeria

BACKGROUND

Child survival remains a major public health challenge in the sub-Saharan region of Africa, especially Nigeria. The Boko Haram crisis, which has aggravated this, has led to the displacement of many people in the north-eastern region, including children under five. This study investigated the determinants of child survival practice among caregivers in internally displaced persons' (IDP) camps in Abuja Municipal Area Council (AMAC), Nigeria.

METHODOLOGY

A cross-sectional design was used to collect data on determinants of child survival practice from 312 caregivers in five purposively selected IDP camps in AMAC using the snowball sampling technique. Data were analysed using univariate, bivariate, and multivariate statistics at 5% level of significance.

RESULTS

The mean age of respondents was 29.6 ± 6.72 years. There was a significant (p < 0.05) relationship between the predisposing, reinforcing, enabling and environmental factors studied and child survival practice. Findings also indicated that all factors were significant (p < 0.05) predictors of child survival practice with the reinforcing factor being the major predictor (ß = 0.38; t = 6.08).

CONCLUSION

Attention needs to be paid to all factors, particularly the reinforcing factor of social support in order to promote optimal child survival practice among caregivers in AMAC IDP camps. Collaboration with social work professionals would be an added benefit to enhance social support.

Noma disease among internally displaced persons in Northeast Nigeria: a retrospective descriptive study

Background

Recently recognized by the World Health Organization as a neglected tropical disease, Noma, an acute and destructive gangrenous disease affecting the gums and facial structures within the oral cavity, has a high mortality rate if untreated.

Objectives

To investigate the prevalence and impact of Noma among internally displaced populations in Northeastern Nigeria.

Design

A retrospective study.

Methods

This retrospective study investigates the prevalence and impact of Noma among internally displaced populations in Northeastern Nigeria. Noma is endemic in Northern Nigeria, Africa, and its occurrence has been linked to extreme poverty, malnutrition, poor hygiene, and inadequate healthcare - conditions exacerbated by the ongoing Boko Haram conflict.

Results

The retrospective descriptive cross-sectional analysis of 17 cases reveals a median age of 8 years, with most of the patients being children who suffer significant social stigmas, such as difficulties in speaking, eating, and social integration, including reduced school attendance and marital prospects.

Conclusion

The study highlights the urgent need for comprehensive research into the etiology of Noma and its socio-economic impact. It emphasizes the necessity for early and effective intervention strategies, particularly in conflict-stricken areas with limited healthcare access.

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.

Utilization of insecticide-treated nets and associated factors among childbearing women in Northern Nigeria

BACKGROUND

Studies have explored the correlates of insecticide-treated nets in Nigeria. The few studies that focused on Northern Nigeria mostly examined individual correlates, but largely ignored the community correlates. Also, the persistence of armed insurgencies in the region calls for more research attention. This study examines the utilization and the associated individual and community factors of insecticide-treated nets in Northern Nigeria.

METHODS

The study adopted a cross-sectional design. Data were extracted from the 2021 Nigeria Malaria Indicator Survey (NMIS). A weighted sample size of 6873 women was analysed. The outcome variable was the utilization of insecticide-treated nets. The explanatory variables selected at the individual/household level were maternal age, maternal education, parity, religion, sex of head of household, household wealth, and household size. The variables selected at the community level were the type of place of residence, geo-political zone of residence, the proportion of children under five who slept under a bed net, the proportion of women aged 15-49 who heard malaria media messages, and the community literacy level. Two variables, namely, the number of mosquito bed nets in the household, and the number of rooms used for sleeping were included for statistical control. Three multilevel mixed-effect regression models were fitted.

RESULTS

The majority of childbearing women (71.8%) utilized insecticide-treated nets. Parity and household size were the significant individual/household characteristics associated with the utilization of insecticide-treated nets. The proportion of under-five children in the community who slept under mosquito bed nets, and the geopolitical zone of residence were significant community correlates of the use of insecticide-treated nets. In addition, the number of rooms for sleeping, and the number of mosquito bed nets in the households were significantly associated with the utilization of insecticide-treated nets.

CONCLUSION

Parity, household size, number of sleeping rooms, number of treated bed nets, geo-political zone of residence, and proportion of under-five children sleeping under bed nets are important associated factors of the utilization of insecticide-treated nets in Northern Nigeria. Existing malaria preventive initiatives should be strengthened to target these characteristics.

Childhood exposure to armed conflict and nutritional health outcomes in Nigeria

BACKGROUND

Armed conflicts are associated with an increased risk of food insecurity, the leading cause of malnutrition in low-and-middle-income countries. Multiple studies have uncovered significant influences of childhood malnutrition on children's overall health and development. As a result, it is increasingly important to understand how childhood experience of armed conflict intersects with childhood malnutrition in conflict-prone countries like Nigeria. This study examined the association between different measures of childhood experiences of armed conflicts and the nutritional health outcomes of children aged 36-59 months.

METHODS

We used data from the Nigeria Demographic and Health Survey linked with Uppsala Conflict Data Program Geo-Referenced Events Dataset using geographic identifiers. Multilevel regression models were fitted on a sample of 4226 children aged 36-59 months.

RESULTS

The prevalence of stunting, underweight and wasting was 35%, 20% and 3%, respectively. Armed conflicts were mostly recorded in the North-eastern states of Borno (222 episodes) and Adamawa (24 episodes). Exposure to armed conflicts ranged from 0 (no experience of armed conflict) to 3.75 conflicts per month since the child's birth. An increase in the frequency of armed conflicts is associated with increased odds of childhood stunting [AOR = 2.52, 95%CI: 1.96-3.25] and underweight [AOR = 2.33, 95%CI: 1.19-4.59] but not wasting. The intensity of armed conflict was only marginally associated with stunting and underweight but not wasting. Longer conflicts that occurred in the last year were also associated with the odds of stunting [AOR = 1.25, 95%CI: 1.17-1.33] and underweight [AOR = 1.19, 95%CI: 1.11-1.26] but not wasting.

CONCLUSION

Childhood exposure to armed conflict is associated with long-term malnutrition in children aged 36-59 months in Nigeria. Strategies that aim to end childhood malnutrition could target children exposed to armed conflicts.

High severity of abortion complications in fragile and conflict-affected settings: a cross-sectional study in two referral hospitals in sub-Saharan Africa (AMoCo study)

BACKGROUND

Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR).

METHODS

We used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records' reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity.

RESULTS

We analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%).

CONCLUSION

Our data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings.

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.

Exploring the influence of health management processes on health outcomes among internally displaced persons (IDPs)

Background

Despite global action and policy initiatives, internally displaced persons (IDPs) experience poor living conditions and lack healthcare access compared to refugees. This study sought to understand the relationship between health management processes and health outcomes among camp-dwelling IDPs in northern Nigeria.

Method

73 individuals participated in either a focus group (n = 49) or one-to-one interview (n = 24), comprising IDPs (n = 49), camp managers (n = 9), health workers (n = 7) and government administrative authorities (n = 8). Interviews explored IDP health management processes, partners and perceptions around camp management. Data were analysed using an inductive thematic approach.

Results

Four main themes were identified: opinions about healthcare organisation and management, service availability, interventions and information management, and IDP health outcomes. Though many stakeholders, partnerships, and national and international government agencies were involved in the provision of healthcare services, respondents described efforts as disjointed. Reports suggested that the coordination and management of health services and resources were not tailored to the needs of those living in all camps. And because so many national and international agencies were involved, but under weak coordination, access to services was less than optimal and adequate management of critical public health interventions was lacking. Varied allocation of resources such as funding, medication and medically trained staff were viewed as key factors in the availability and the ability to access what was considered as essential healthcare services.

Conclusion

The health of IDPs in camp-like settings was compromised by uncoordinated management, treatment, and control of communicable and non-communicable diseases. Government authorities need to be aware and consider the complexity of the multiagency involvement in the management and provision of IDP healthcare services. Introducing systems to streamline, monitor and support IDP healthcare management could be cost-effective strategies for achieving optimal health care.

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.

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.