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Abstract Background In South Sudan, the civil war in 2016 led to mass displacement in Juba that rapidly spread to other regions of the country. Access to health care was limited because of attacks against health facilities and workers and pregnant women and newborns were among the most vulnerable. Translation of newborn guidelines into public health practice, particularly during periods of on-going violence, are not well studied during humanitarian emergencies. During 2016 to 2017, we assessed the delivery of a package of community- and facility-based newborn health interventions in displaced person camps to understand implementation outcomes. This case analysis describes the challenges encountered and mitigating strategies employed during the conduct of an original research study. Discussion Challenges unique to conducting research in South Sudan included violent attacks against humanitarian aid workers that required research partners to modify study plans on an ongoing basis to ensure staff and patient safety. South Sudan faced devastating cholera and measles outbreaks that shifted programmatic priorities. Costs associated with traveling study staff and transporting equipment kept rising due to hyperinflation and, after the July 2016 violence, the study team was unable to convene in Juba for some months to conduct refresher trainings or monitor data collection. Strategies used to address these challenges were: collaborating with non-research partners to identify operational solutions; maintaining a locally-based study team; maintaining flexible budgets and timelines; using mobile data collection to conduct timely data entry and remote quality checks; and utilizing a cascade approach for training field staff. Conclusions The case analysis provides lessons that are applicable to other humanitarian settings including the need for flexible research methods, budgets and timelines; innovative training and supervision; and a local research team with careful consideration of sociopolitical factors that impact their access and safety. Engagement of national and local stakeholders can ensure health services and data collection continue and findings translate to public health action, even in contexts facing severe and unpredictable insecurity.

Abstract Background Decades of war left the Republic of South Sudan with a fragile health system that has remained deprived of resources since the country’s independence. We describe the coverage of interventions for women’s and children’s health in Upper Nile and Unity states, and explore factors that affected service provision during a protracted conflict. Methods We conducted a case study using a desk review of publicly available literature since 2013 and a secondary analysis of intervention coverage and conflict-related events from 2010 to 2017. During June through September 2018, we conducted 26 qualitative interviews with technical leads and 9 focus groups among health workers working in women and children’s health in Juba, Malakal, and Bentiu. Results Coverage for antenatal care, institutional delivery, and childhood vaccines were low prior to the escalation of conflict in 2013, and the limited data indicate that coverage remained low through 2017. Key factors that determined the delivery of services for women and children in our study sites were government leadership, coordination of development and humanitarian efforts, and human resource capacity. Participants felt that national and local health officials had a limited role in the delivery of services, and financial tracking data showed that funding stagnated or declined for humanitarian health and development programming during 2013–2014. Although health services were concentrated in camp settings, the availability of healthcare providers was negatively impacted by the protracted nature of the conflict and insecurity in the region. Conclusions Health care for women and children should be prioritized during acute and protracted periods of conflict by strengthening surveillance systems, coordinating short and long term activities among humanitarian and development organizations, and building the capacity of national and local government officials to ensure sustainability.

Abstract Globally, the number of people affected by conflict is the highest in history, and continues to steadily increase. There is currently a pressing need to better understand how to deliver critical health interventions to women and children affected by conflict. The compendium of articles presented in this Conflict and Health Collection brings together a range of case studies recently undertaken by the BRANCH Consortium (Bridging Research & Action in Conflict Settings for the Health of Women and Children). These case studies describe how humanitarian actors navigate and negotiate the multiple obstacles and forces that challenge the delivery of health and nutrition interventions for women, children and adolescents in conflict-affected settings, and to ultimately provide some insight into how service delivery can be improved.

Abstract Background Targeted clinical interventions have been associated with a decreased risk of neonatal morbidity and mortality. In conflict-affected countries such as South Sudan, however, implementation of lifesaving interventions face barriers and facilitators that are not well understood. We aimed to describe the factors that influence implementation of a package of facility- and community-based neonatal interventions in four displaced person camps in South Sudan using a health systems framework. Methods We used a mixed method case study design to document the implementation of neonatal interventions from June to November 2016 in one hospital, four primary health facilities, and four community health programs operated by International Medical Corps. We collected primary data using focus group discussions among health workers, in-depth interviews among program managers, and observations of health facility readiness. Secondary data were gathered from documents that were associated with the implementation of the intervention during our study period. Results Key bottlenecks for implementing interventions in our study sites were leadership and governance for comprehensive neonatal services, health workforce for skilled care, and service delivery for small and sick newborns. Program managers felt national policies failed to promote integration of key newborn interventions in donor funding and clinical training institutions, resulting in deprioritizing newborn health during humanitarian response. Participants confirmed that severe shortage of skilled care at birth was the main bottleneck for implementing quality newborn care. Solutions to this included authorizing the task-shifting of emergency newborn care to mid-level cadre, transitioning facility-based traditional birth attendants to community health workers, and scaling up institutions to upgrade community midwives into professional midwives. Additionally, ongoing supportive supervision, educational materials, and community acceptance of practices enabled community health workers to identify and refer small and sick newborns. Conclusions Improving integration of newborn interventions into national policies, training institutions, health referral systems, and humanitarian supply chain can expand emergency care provided to women and their newborns in these contexts.

Abstract Background Following the Nepal earthquake in April 2015, UNFPA estimated that 1.4 million women of reproductive age were affected, with approximately 93,000 pregnant and 28,000 at risk of sexual violence. A set of priority reproductive health (RH) actions, the Minimum Initial Services Package (MISP), was initiated by government, international and local actors. The purpose of this study was to identify the facilitators and barriers affecting the implementation of priority RH services in two districts. Methods In September 2015, a mixed methods study design was used in Kathmandu and Sindhupalchowk districts to assess the implementation of the priority RH services five months post-earthquake. Data collection activities included 32 focus group discussions with male and female participants aged 18–49; 26 key informant interviews with RH, gender-based violence (GBV), and human immunodeficiency virus (HIV) experts; and 17 health facility assessments. Results The implementation of priority RH services was achieved in both districts. In Kathmandu implementation of emergency RH services started within days of the earthquake. Facilitating factors for successful implementation included disaster preparedness; leadership and commitment among national, international, and district level actors; resource mobilization; strong national level coordination; existing reproductive and child health services and community outreach programs; and supply chain management. Barriers included inadequate MISP training for RH coordinators and managers; weak communication between national and district level stakeholders; inadequate staffing; under-resourced and fewer facilities in rural areas; limited attention given to local GBV and HIV organizations; low availability of clinical management of rape services; and low awareness of GBV services and benefits of timely care. Conclusion Ensuring RH is included in emergency preparedness and immediate response efforts and is continued through the transition to comprehensive care is critical for national governments and humanitarian response agencies. The MISP for RH remains a critical component of response efforts, and the humanitarian community should consider these learnings in future emergency response.

Abstract Background The very young adolescent (VYA) population age 10–14 years is often neglected in the field of sexual and reproductive health (SRH) research due to the combined sensitivity of the topic and the young age group, resulting in little data about the SRH needs and concerns of VYA. In 2013, the Women’s Refugee Commission (WRC), Johns Hopkins University (JHU), Adolescent and Reproductive Health Network (ARHN) and Karen Youth Organization (KYO) implemented qualitative participatory research to explore the SRH needs and risks of VYA. The study was conducted in Mae Sot town and Mae La refugee camp, both in Thailand, with migrant populations and refugees, respectively. Methods A total of 22 focus group discussions (FGD) were conducted with 176 participants. FGD were implemented with girls and boys aged 10–16, and adults in both settings. The FGD with 10–14 year olds included community mapping and photo elicitation interviews. These activities gathered information about their own perspectives, experiences and values regarding SRH, as well as SRH risks. The FGD with 15–16 year olds and adults focused on their perspectives regarding the SRH needs and risks of VYA. Results Fourteen (64%) of FGD were conducted in Mae Sot town, and 8 (36%) were conducted in Mae La refugee camp. Schools, youth centers and religious institutions were identified as key locations for obtaining SRH information. Schools are most promising, but access to schools is unequal between boys and girls. Parents can provide support and education to adolescents if they are supported to do so and if trust and comfort can be built between adolescents and parents around SRH. Conclusions To a large degree, the same themes emerged from both locations, in terms of the awareness of body changes and puberty, the centrality of peer influences, and the value of education. These findings call for rigorous study of youth-directed programs and policies that meaningfully involve key influential adults identified by vulnerable young adolescents and utilize the specific places young adolescents, themselves, voice as being critical settings for obtaining information on SRH issues.

Abstract Background Approximately 2.7 million neonatal deaths occur annually, with highest rates of neonatal mortality in countries that have recently experienced conflict. Constant instability in South Sudan further strains a weakened health system and poses public health challenges during the neonatal period. We aimed to describe the state of newborn facility-level care in displaced person camps across Juba, Malakal, and Maban. Methods We conducted clinical observations of the labor and delivery period, exit interviews with recently delivered mothers, health facility assessments, and direct observations of midwife time-use. Study participants were mother-newborn pairs who sought services and birth attendants who provided delivery services between April and June 2016 in five health facilities. Results Facilities were found to be lacking the recommended medical supplies for essential newborn care. Two of the five facilities had skilled midwives working during all operating hours, with 6.2% of their time spent on postnatal care. Selected components of thermal care (62.5%), infection prevention (74.8%), and feeding support (63.6%) were commonly practiced, but postnatal monitoring (27.7%) was less consistently observed. Differences were found when comparing the primary care level to the hospital (thermal: relative risk [RR] 0.48 [95% CI] 0.40–0.58; infection: RR 1.28 [1.11–1.47]; feeding: RR 0.49 [0.40–0.58]; postnatal: RR 3.17 [2.01–5.00]). In the primary care level, relative to newborns delivered by traditional birth attendants, those delivered by skilled attendants were more likely to receive postnatal monitoring (RR 1.59 [1.09-2.32]), but other practices were not statistically different. Mothers’ knowledge of danger signs was poor, with fever as the highest reported (44.8%) followed by not feeding well (41.0%), difficulty breathing (28.9%), reduced activity (27.7%), feeling cold (18.0%) and convulsions (11.2%). Conclusions Addressing health service delivery in contexts affected by conflict is vital to reducing the global newborn mortality rate and reaching the Sustainable Development Goals. Gaps in intrapartum and postnatal care, particularly skilled care at birth, suggest a critical need to build the capacity of the existing health workforce while increasing access to skilled deliveries.