This Blog was published July 5, 2023 Global Health
in PLOS BLOGS Speaking of Medicine and Health
By guest contributors Dr. Elizabeth Adjoa Kumah, Dr. Charles Ameh, Emily Monaghan, Andrew Clarke, Lorna Barungi Muhirwe, and Tanjida Yesmin Basanti
Current estimates indicate that there have been limited progress towards achieving maternal and newborn health Sustainable Development Goal (SDG) targets since 2015, and the evidence shows that countries affected by humanitarian crises disproportionately contribute to global maternal and newborn mortality and morbidity. Recent estimates from Save the Children and the World Health Organisation indicate that about 61% of global maternal deaths occurred in countries affected by humanitarian crises, whilst more than 80% of countries with the highest newborn mortality have suffered from recent conflict, natural disaster or both. Stillbirths are largely absent in global data tracking, however a 2020 report by the UN Inter-agency Group for Child mortality estimates that low and lower-middle income countries account for 84% of all stillbirths. Most of these countries have been affected by humanitarian crises such as war and/or natural disaster.
Emergent humanitarian settings and situations of conflict, post-conflict, disease outbreaks and disaster significantly hinder maternal and newborn health (MNH) improvement efforts required to meet global targets. More than 235 million people (75%) in need of humanitarian assistance globally are women and children, and this has been compounded by the COVID-19 pandemic. For example, evidence shows a significant increase in clinically relevant anxiety, depression and intimate partner violence in the first 9 months of the pandemic – all of which are concerningly relevant to perinatal health. Furthermore, estimates by the United Nations suggest that the COVID-19 pandemic increased the number of people requiring humanitarian assistance by 40% from 2020.
In humanitarian crises, it is standard for health services to be provided in camp settings and guidance such as the inter-agency field manual on reproductive health and the Minimum Initial Service Package (MISP) for Sexual and Reproductive Health in crisis situations are available for programme implementers. However, this guidance is focussed on the acute phase of a response, although it does recommend transition to comprehensive service where possible. There is limited research on the effectiveness of these packages, or how they account for differing cultural needs, or respond to previous negative experiences of health services by the populations they serve. Furthermore, refugee women and girls who live outside these camps usually do not have access to either camp level health and support services, or national health systems. With estimates showing that half of refugee women and girls live in cities and not refugee camps, it is concerning that this population are potentially overlooked in humanitarian response.
A 2021 systematic review on the delivery of maternal and newborn health interventions in conflict settings included 115 publications with limited reporting of coverage or effectiveness data. Most studies reported on the antenatal period, less on postnatal care and much less on newborn care. Barriers to the implementation of MNH interventions/services in humanitarian settings included insecurity, lack of resources and lack of skilled health staff, while factors that facilitate the delivery of services included multi-stakeholder collaboration, introduction of new technology or systems innovations, and staff training.
Save the Children supports the needs of women, girls, and newborns through health programming in refugee camps in Uganda, Bangladesh, and other settings, including managing health facilities in collaboration with other MNH stakeholders using standardised humanitarian MNH packages of care. Well-established refugee camps in West Nile, Uganda, were formed in 2017 following an influx of refugees in 2016, fleeing prolonged insecurity in South Sudan. Uganda is well known for its progressive refugee policy, and has a Comprehensive Refugee Response Framework in place, which includes a pilar for emergency response and ongoing needs, integrated service delivery, support for the host community and inclusion of refugees in government planning. In comparison, Bangladesh, accommodates 1.3 million people in need of humanitarian assistance, 65% of which are Rohingya refugees, who fled from insecurity in Myanmar in 2017. Health services in Cox’s Bazar district, the main camps for the Rohingya population, are provided in coordination with 34 other sexual and reproductive health (SRH) stakeholders through 174 service delivery points.
Heath data from camps in Uganda and Bangladesh show contrasting rates for MNH service uptake. In West Nile, first antenatal care (ANC) visit (66%), facility delivery (70%), and postnatal care attendance (92%) are comparable to the local host community. However, in Cox’s Bazaar refugee camp, the data shows rates that are well below that of the general population: a) first ANC visit: 5.8% in Cox’s Bazaar refugee population vs 12.6% in host population; b) facility delivery: 48% vs 49%; and c) postnatal care attendance: 33.8% vs 52%. It is not clear why there are such remarkable differences in service uptake and further research is required to explore this. However, evidence shows that indigenous women in low- and middle-income countries including Bangladesh, experience significant inequities in accessing reproductive and maternal health services. They may find these services ‘culturally unfriendly’ and inflexible to meet their needs, which limits their demand for these services. This, together with previous negative experiences of health services, may be factors inhibiting the utilisation of maternal health services in Cox’s Bazar camps. Understanding the reasons for poor utilisation of SRH/MNH services within such populations, co-creating services and evaluating the impact of these services, will be critical to improving access to quality reproductive and maternal health services.
The Emergency Obstetric and Quality of Care unit at the Liverpool School of Tropical Medicine conducts implementation research to improve the quality of care during pregnancy, childbirth and afterwards, in resource constrained settings such as humanitarian and conflict areas. Good quality care is critical to Universal Health Coverage and effective coverage of services and is the key to sustained reduction in the number of deaths related to pregnancy and childbirth.
To achieve the SDG targets for MNH and reduce perinatal mortality in humanitarian and protracted crisis settings, accelerated action is required to overcome the impact of the COVID-19 pandemic. To do this, context-specific research to understand the factors that contribute to inefficient delivery of a comprehensive range of MNH services, including poor coverage/uptake of services is needed. This should result in context-specific, culturally acceptable services co-created with the target population.