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Abstract Background Neonatal deaths account for over 40% of all deaths in children younger than five years of age and neonatal mortality rates are highest in areas affected by humanitarian emergencies. Of the ten countries with the highest neonatal mortality rates globally, six are currently or recently affected by a humanitarian emergency. Yet, little is known about newborn care in crisis settings. Understanding current policies and practices for the care of newborns used by humanitarian aid organizations will inform efforts to improve care in these challenging settings. Methods Between August 18 and September 25, 2009, 56 respondents that work in humanitarian emergencies completed a web-based survey either in English or French. A snow ball sampling technique was used to identify organizations that provide health services during humanitarian emergencies to gather information on current practices for maternal and newborn care in these settings. Information was collected about continuum-of-care services for maternal, newborn and child health, referral services, training and capacity development, health information systems, policies and guidelines, and organizational priorities. Data were entered into MS Excel and frequencies and percentages were calculated. Results The majority of responding organizations reported implementing components of neonatal and maternal health interventions. However, multiple barriers exist in providing comprehensive care, including: funding shortages (63.3%), gaps in training (51.0%) and staff shortages and turnover (44.9%). Conclusions Neonatal care is provided by most of the responding humanitarian organizations; however, the quality, breadth and consistency of this care are limited.

Abstract Background Despite the serious consequences of conflict for reproductive health, populations affected by conflict and its aftermath face tremendous barriers to accessing reproductive health services, due to insecurity, inadequate numbers of trained personnel and lack of supplies. Family planning is often particularly neglected. Methods In six conflict-affected areas in Sudan, northern Uganda and the Democratic Republic of Congo, household surveys of married or in-union women of reproductive age were conducted to determine baseline measures of family planning knowledge, attitudes and behaviors regarding contraception. Health facility assessments were carried out to assess baseline measures of family planning services availability. Data were double-entered into CSPro 3.2 and exported to SAS 9.2, which was used to calculate descriptive statistics. The studies' purposes were to guide program activities and to serve as a baseline against which program accomplishments could be measured. Results Knowledge of modern contraceptive methods was low relative to other sub-Saharan African countries, and use of modern methods was under 4% in four sites; in two sites with prior family planning services it was 12% and 16.2%. From 30% to 40% of women reported they did not want a child within two years, however, and an additional 12% to 35% wanted no additional children, suggesting a clear need for family planning services. The health facilities assessment showed that at most only one-third of the facilities mandated to provide family planning had the necessary staff, equipment and supplies to do so adequately; in some areas, none of the facilities were prepared to offer such services. Conclusions Family planning services are desired by women living in crisis situations when offered in a manner appropriate to their needs, yet services are rarely adequate to meet these needs. Refugee and internally displaced women must be included in national and donors' plans to improve family planning in Africa.

Abstract Background The treatment for Plasmodium falciparum malaria in Sudan has been in process of change since 2003. Preceding the change, this study aimed to determine which artemisinin-based combination therapies is more effective to treat uncomplicated malaria in Malakal, Upper Nile, Sudan. Methods Clinical trial to assess the efficacy of 2 antimalarial therapies to treat P. falciparum infections in children aged 6–59 months, in a period of 42 days after treatment. Results A total of 269 children were followed up to 42 days. Artesunate plus Sulfadoxine/Pyrimethamine (AS+SP) and Artesunate plus Amodiaquine (AS+AQ) were both found to be efficacious in curing malaria infections by rapid elimination of parasites and clearance of fever, in preventing recrudescence and suppressing gametocytaemia. The combination of AS+SP appeared slightly more efficacious than AS+AQ, with 4.4% (4/116) versus 15% (17/113) of patients returning with malaria during the 6-week period after treatment (RR = 0.9, 95% CI 0.81–0.96). PCR analysis identified only one recrudescence which, together with one other early treatment failure, gave efficacy rates of 99.0% for AS+AQ (96/97) and 99.1% for AS+SP (112/113). However, PCR results were incomplete and assuming part of the indeterminate samples were recrudescent infections leads to an estimated efficacy ranging 97–98% for AS+SP and 88–95% for AS+AQ. Conclusion These results lead to the recommendation of ACT, and specifically AS+SP, for the treatment of uncomplicated falciparum malaria in this area of Sudan. When implemented, ACT efficacy should be monitored in sentinel sites representing different areas of the country.

Introduction and Importance: Circumcision is one of the most commonly performed procedures since ancient times for different indications. Following circumcision, various complications can happen including urethro-cutaneous fistula(UCF). The urethro-cutaneous fistula usually occurs ventrally, and our case is the first from Ethiopia to report dorsal UCF. To our knowledge, there are only two case reports with dorsal UCF., Case Presentation: We report a case of a 13-year-old male child for whom UCF repair was done in June 2023, after presenting with a urine leak from the dorsal side of the penis at two sites which started after a no-health professional circumcised him. Up on evaluation, he was having dorsal UCF. He was admitted and operated on the fistula tract was excised completely, and the fistula was repaired. The patient is having a smooth post-operative course., Clinical Discussion: Male circumcision is one of the most common procedures performed since ancient. It is indicated for different reasons. The incidence of circumcision varies with geography: Ethiopia is one of the countries with above 90 % rate of male circumcision. Various complications can happen following circumcision, UCF being one of the less commonly happening complications. When it happens, it will usually be on the ventral aspect, with only two cases reported having dorsal UCF. Dorsal UCF can be repaired as other types of fistula and has a similar outcome., Conclusion: Even though it is rare to find dorsal UCF it can happen following circumcision and can be managed as other UCF., Competing Interests: Declaration of competing interest No authors have disclosed any conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Importance: Sudden infant death syndrome (SIDS) is a major cause of infant death in the US. Previous research suggests that inborn errors of metabolism may contribute to SIDS, yet the relationship between SIDS and biomarkers of metabolism remains unclear., Objective: To evaluate and model the association between routinely measured newborn metabolic markers and SIDS in combination with established risk factors for SIDS., Design, Setting, and Participants: This was a case-control study nested within a retrospective cohort using data from the California Office of Statewide Health Planning and Development and the California Department of Public Health. The study population included infants born in California between 2005 and 2011 with full metabolic data collected as part of routine newborn screening (NBS). SIDS cases were matched to controls at a ratio of 1:4 by gestational age and birth weight z score. Matched data were split into training (2/3) and testing (1/3) subsets. Data were analyzed from January 2005 to December 2011., Exposures: Metabolites measured by NBS and established risk factors for SIDS., Main Outcomes and Measures: The primary outcome was SIDS. Logistic regression was used to evaluate the association between metabolic markers combined with known risk factors and SIDS., Results: Of 2 276 578 eligible infants, 354 SIDS (0.016%) cases (mean [SD] gestational age, 38.3 [2.3] weeks; 220 male [62.1%]) and 1416 controls (mean [SD] gestational age, 38.3 [2.3] weeks; 723 male [51.1%]) were identified. In multivariable analysis, 14 NBS metabolites were significantly associated with SIDS in a univariate analysis: 17-hydroxyprogesterone, alanine, methionine, proline, tyrosine, valine, free carnitine, acetyl-L-carnitine, malonyl carnitine, glutarylcarnitine, lauroyl-L-carnitine, dodecenoylcarnitine, 3-hydroxytetradecanoylcarnitine, and linoleoylcarnitine. The area under the receiver operating characteristic curve for a 14-marker SIDS model, which included 8 metabolites, was 0.75 (95% CI, 0.72-0.79) in the training set and was 0.70 (95% CI, 0.65-0.76) in the test set. Of 32 infants in the test set with model-predicted probability greater than 0.5, a total of 20 (62.5%) had SIDS. These infants had 14.4 times the odds (95% CI, 6.0-34.5) of having SIDS compared with those with a model-predicted probability less than 0.1., Conclusions and Relevance: Results from this case-control study showed an association between aberrant metabolic analytes at birth and SIDS. These findings suggest that we may be able to identify infants at increased risk for SIDS soon after birth, which could inform further mechanistic research and clinical efforts focused on monitoring and prevention.

Importance: Preterm birth (PTB) (gestational age <37 weeks) is a major cause of infant mortality and morbidity in the US and is marked by racial and ethnic and socioeconomic inequities. Further research is needed to elucidate the association of risk and protective factors with trends in PTB rates and with related inequities., Objective: To describe the association of PTB rates with inequities as well as related risk and protective factors over the past decade in a US population-based cohort., Design, Setting, and Participants: This retrospective cohort study of singleton live births in California from January 1, 2011, to December 31, 2022, was conducted using vital statistics records and hospital records. The cohort included births with a gestational age of 22 to 44 weeks., Main Outcomes and Measures: Preterm birth rates by racial and ethnic group and by public and nonpublic insurance (considered as a proxy for socioeconomic status) were studied across years. Log-linear regression (relative risks with 95% CIs) was used to evaluate risk and protective factors within groups. Associations of PTB rates with risk and protective factors were assessed., Results: This study included 5 431 018 singleton live births to individuals who identified as American Indian or Alaska Native (0.3%), Asian (14.2%), Black (4.9%), Hispanic (47.8%), or White (27.0%). A total of 43.1% of births were to individuals with public health insurance. From 2011 to 2022, the overall PTB rate increased from 6.8% to 7.5% (change [SE], 10.6% [0.6%]; z score of 18.5; P < .001). Differences in PTB rates and associated changes were observed for racial and ethnic groups and insurance groups. For example, 2022 PTB rates ranged from 5.8% among White individuals with nonpublic insurance to 11.3% among Black individuals with public health insurance. From 2011 to 2022, PTB rates decreased from 9.1% to 8.8% (change [SE], -3.5% [4.2]; z score of -0.8; P = .42) among Black individuals with nonpublic insurance, whereas they increased from 6.4% to 9.5% (change [SE], 49.8% [16.0%]; z score of 3.1; P = .002) among American Indian or Alaska Native individuals with nonpublic insurance. Increases in some risk factors (eg, preexisting diabetes, sexually transmitted infections, mental health conditions) were observed in most groups, and decreases in some protective factors (eg, participation in the California Women, Infants, and Children program) (P for trend < .001 from 2011 to 2021) were observed mostly in low-income groups., Conclusions and Relevance: In this cohort study of singleton live births in California, PTB rates increased in many groups. Persistent racial and ethnic and socioeconomic inequities were also observed. Changes in risk and protective factors provided clues to patterns of PTB. These data point to an urgent need to address factors associated with PTB at both the individual and population levels.

Objectives: To estimate referral compliance and examine factors that influence decisions to comply with referral for newborn and maternal complications in Bosaso, Somalia., Setting: Bosaso, Somalia, is a large port city that hosts a large proportion of internally displaced persons. The study was conducted at the only four primary health centres offering 24/7 delivery services and the only public referral hospital in Bosaso., Participants: All pregnant women who sought care at four primary centres and were referred to the hospital for maternal complications or mothers whose newborns were referred for neonatal complications were approached for enrolment from September to December 2019. In-depth interviews (IDIs) of 54 women and 14 healthcare workers (HCWs) were conducted., Outcome Measures: This study examined timely referral compliance from the primary centre to the hospital. IDIs were analysed for a priori themes investigating the decision-making process and experience of care for maternal and newborn referrals., Results: Overall, 94% (n=51/54) of those who were referred, 39 maternal and 12 newborns, complied with the referral and arrived at the hospital within 24 hours. Of the three that did not comply, two delivered on the way, and one cited lack of money as the reason for noncompliance. Four themes emerged: trust in medical authority, cost of transportation and care, quality of care, and communications. The factors that facilitated compliance were the availability of transportation, family support, concern for health, and trust in medical authority. HCWs raised the importance of considering the maternal-newborn dyad throughout the referral process, and the need for official standard operating procedures for referrals including communications between the primary care and the hospital., Conclusions: High compliance for referral from primary to hospital care for maternal and newborn complications was observed in Bosaso, Somalia. Costs associated with transportation and care at the hospital need attention to motivate compliance., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aims: The American Academy of Pediatrics describes late preterm infants, born at 34 to 36 completed weeks' gestation, as at-risk for rehospitalization and severe morbidity as compared to term infants. While there are prediction models that focus on specific morbidities, there is limited research on risk prediction for early readmission in late preterm infants. The aim of this study is to derive and validate a model to predict 7-day readmission., Methods: This is a population-based retrospective cohort study of liveborn infants in California between January 2007 to December 2011. Birth certificates, maintained by California Vital Statistics, were linked to a hospital discharge, emergency department, and ambulatory surgery records maintained by the California Office of Statewide Health Planning and Development. Random forest and logistic regression were used to identify maternal and infant variables of importance, test for association, and develop and validate a predictive model. The predictive model was evaluated for discrimination and calibration., Results: We restricted the sample to healthy late preterm infants ( n  = 122,014), of which 4.1% were readmitted to hospital within 7-day after birth discharge. The random forest model with 24 variables had better predictive ability than the 8 variable logistic model with c-statistic of 0.644 (95% confidence interval 0.629, 0.659) in the validation data set and Brier score of 0.0408. The eight predictors of importance length of stay, delivery method, parity, gestational age, birthweight, race/ethnicity, phototherapy at birth hospitalization, and pre-existing or gestational diabetes were used to drive individual risk scores. The risk stratification had the ability to identify an estimated 19% of infants at greatest risk of readmission., Conclusions: Our 7-day readmission predictive model had moderate performance in differentiating at risk late preterm infants. Future studies might benefit from inclusion of more variables and focus on hospital practices that minimize risk., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Competing Interests: The authors have declared that no competing interests exist.

Objective: Late preterm infants have an increased risk of morbidity relative to term infants. We sought to determine the rate, temporal trend, risk factors, and reasons for 30-day readmission., Methods: This is a retrospective cohort study of infants born at 34 to 42 weeks' gestation in California between January 1, 2011, and December 31, 2017. Birth certificates maintained by California Vital Statistics were linked to discharge records maintained by the California Office of Statewide Health Planning and Development. Multivariable logistic regression was used to identify risk factors and derive a predictive model., Results: Late preterm infants represented 4.3% (n = 122 014) of the study cohort (n = 2 824 963), of which 5.9% (n = 7243) were readmitted within 30 days. Compared to term infants, late preterm infants had greater odds of readmission (odds ratio [OR]: 2.34 [95% confidence interval (CI): 2.28-2.40]). The temporal trend indicated increases in all-cause and jaundice-specific readmission infants (P < .001). The common diagnoses at readmission were jaundice (58.9%), infections (10.8%), and respiratory complications (3.5%). In the adjusted model, factors that were associated with greater odds of readmission included assisted vaginal birth, maternal age ≥34 years, diabetes, chorioamnionitis, and primiparity. The model had predictive ability of 60% (c-statistic 0.603 [95% CI: 0.596-0.610]) in late preterm infants who had <5 days length of stay at birth., Conclusion: The findings contribute important information on what factors increase or decrease the risk of readmission. Longitudinal studies are needed to examine promising hospital predischarge and follow-up care practices., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: Maternal and perinatal death surveillance and response (MPDSR) is a system of identifying, analysing and learning lessons from such deaths in order to respond and prevent future deaths, and has been recommended by WHO and implemented in many low-and-middle income settings in recent years. However, there is limited documentation of experience with MPDSR in humanitarian settings. A meeting on MPDSR in humanitarian settings was convened by WHO, UNICEF, CDC and Save the Children, UNFPA and UNHCR on 17th-18th October 2019, informed by semi-structured interviews with a range of professionals, including expert attendees., Consultation Findings: Interviewees revealed significant obstacles to full implementation of the MPDSR process in humanitarian settings. Many obstacles were familiar to low resource settings in general but were amplified in the context of a humanitarian crisis, such as overburdened services, disincentives to reporting, accountability gaps, a blame approach, and politicisation of mortality. Factors more unique to humanitarian contexts included concerns about health worker security and moral distress. There are varying levels of institutionalisation and implementation capacity for MPDSR within humanitarian organisations. It is suggested that if poorly implemented, particularly with a punitive or blame approach, MPDSR may be counterproductive. Nevertheless, successes in MPDSR were described whereby the process led to concrete actions to prevent deaths, and where death reviews have led to improved understanding of complex and rectifiable contextual factors leading to deaths in humanitarian settings., Conclusions: Despite the challenges, examples exist where the lessons learnt from MPDSR processes have led to improved access and quality of care in humanitarian contexts, including successful advocacy. An adapted approach is required to ensure feasibility, with varying implementation being possible in different phases of crises. There is a need for guidance on MPDSR in humanitarian contexts, and for greater documentation and learning from experiences., (© 2022. The Author(s).)

Introduction: There is limited literature on neonatal mortality in humanitarian emergencies. We estimated neonatal mortality and stillbirth rates; determined whether an association exists between proximity to a secondary health facility and neonatal mortality or stillbirth; and tested the correlation between the number of health facilities in a camp and neonatal mortality or stillbirth rates in Rohingya refugee camps in Bangladesh., Methods: We conducted a prospective community-based mortality surveillance in 29 out of 34 Rohingya refugee camps between September 2017 and December 2018, covering approximately 811 543 Rohingya refugees with 19 477 estimated live births. We linked mortality surveillance data with publicly available information on camp population, number of functional health facilities and camp and health facility geospatial coordinates. Using descriptive statistics and spatial analyses, we estimated the mortality rate and tested for correlations., Results: Overall, the estimated neonatal mortality rate was 27.0 (95% CI: 22.3 to 31.8) per 1000 live births, and the stillbirth rate was 15.2 (95% CI: 10.8 to 19.6) per 1000 total births. The majority of neonatal deaths (76.3%, n=405/531) and stillbirths (72.1%, n=202/280) occurred at home or in the community. A positive correlation existed between the camp population size and number of health facilities inside the camp (Spearman's rho=0.56, p value<0.01). No statistically significant correlation existed between the camp neonatal mortality rate or stillbirth rate and number of health facilities inside the camp. Camps that were located closer to a secondary health facility as compared with a labour room/sexual and reproductive health unit had a lower neonatal mortality rate (p value<0.01)., Conclusions: The results provide insight into the neonatal mortality and stillbirth rates in Rohingya refugees camps in Bangladesh during 2017-2018. Prospective community-based mortality surveillance may be a feasible method to evaluate the effectiveness of humanitarian responses in improving neonatal survival and preventing stillbirths., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In humanitarian settings, strengthening health systems while responding to the health needs of crisis-affected populations is challenging and marked with evidence gaps. Drawing from a decade of family planning and postabortion care programming in humanitarian settings, this paper aims to identify strategic components that contribute to health system strengthening in such contexts. Materials and Methods: A diverse range of key informants from North Kivu (Democratic Republic of Congo, DRC) and Puntland (Somalia), including female and male community members, adolescents and adults, healthcare providers, government and community leaders, participated in qualitative interviews, which applied the World Health Organization health system building blocks framework. Data were thematically analyzed according to this framework. Results: Findings from the focus group discussions (11 in DRC, 7 in Somalia) and key informant interviews (seven in DRC, four in Somalia) involving in total 54 female and 72 male participants across both countries indicate that health programs in humanitarian settings, such as Save the Children's initiative on family planning and postabortion care, could contribute to strengthening health systems by positively influencing national policies and guidance, strengthening local coordination mechanisms, capacitating the healthcare workforce with competency-based training and supportive supervision (benefiting facilities supported by the project and beyond), developing the capacity of Ministry of Health staff in the effective management of the supply chain, actively and creatively mobilizing the community to raise awareness and create demand, and providing quality and affordable services. Financial sustainability is challenged by the chronically limited healthcare expenditure experienced in both humanitarian contexts. Conclusions: In humanitarian settings, carefully designed healthcare interventions, such as those that address the family planning and postabortion care needs of crisis-affected populations, have the potential not only to increase access to essential services but also contribute to strengthening several components of the health system while increasing the government capacity, ownership, and accountability., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Tran, Meyers, Malilo, Chabo, Muselemu, Riziki, Libonga, Shire, Had, Ali, Arab, Da'ar, Kahow, Adive, Gebru, Monaghan, Morris, Gallagher, Jouanicot, Pougnier and Amsalu.)

Existing global guidance for addressing women's and children's health and nutrition in humanitarian crises is not sufficiently contextualised for conflict settings specifically, reflecting the still-limited evidence that is available from such settings. As a preliminary step towards filling this guidance gap, we propose a conflict-specific framework that aims to guide decision makers focused on the health and nutrition of women and children affected by conflict to prioritise interventions that would address the major causes of mortality and morbidity among women and children in their particular settings and that could also be feasibly delivered in those settings. Assessing local needs, identifying relevant interventions from among those already recommended for humanitarian settings or universally, and assessing the contextual feasibility of delivery for each candidate intervention are key steps in the framework. We illustratively apply the proposed decision making framework to show what a framework-guided selection of priority interventions might look like in three hypothetical conflict contexts that differ in terms of levels of insecurity and patterns of population displacement. In doing so, we aim to catalyse further iteration and eventual field-testing of such a decision making framework by local, national, and international organisations and agencies involved in the humanitarian health response for women and children affected by conflict., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

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.

Humanitarian crises, driven by disasters, conflict, and disease epidemics, have profound effects on society, including on people's health and well-being. Occurrences of conflict by state and nonstate actors have increased in the last 2 decades: by the end of 2018, an estimated 41.3 million internally displaced persons and 20.4 million refugees were reported worldwide, representing a 70% increase from 2010. Although public health response for people affected by humanitarian crisis has improved in the last 2 decades, health actors have made insufficient progress in the use of evidence-based interventions to reduce neonatal mortality. Indeed, on average, conflict-affected countries report higher neonatal mortality rates and lower coverage of key maternal and newborn health interventions compared with non-conflict-affected countries. As of 2018, 55.6% of countries with the highest neonatal mortality rate (≥30 per 1000 live births) were affected by conflict and displacement. Systematic use of new evidence-based interventions requires the availability of a skilled health workforce and resources as well as commitment of health actors to implement interventions at scale. A review of the implementation of the Helping Babies Survive training program in 3 refugee responses and protracted conflict settings identify that this training is feasible, acceptable, and effective in improving health worker knowledge and competency and in changing newborn care practices at the primary care and hospital level. Ultimately, to improve neonatal survival, in addition to a trained health workforce, reliable supply and health information system, community engagement, financial support, and leadership with effective coordination, policy, and guidance are required., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Berkelhamer is a current member of the American Academy of Pediatrics Helping Babies Survive Planning Group. The other authors have indicated that they have no potential conflicts of interest to disclose, (Copyright © 2020 by the American Academy of Pediatrics.)

Background: Increasingly, neonatal mortality is concentrated in settings of conflict and political instability. To promote evidence-based practices, an interagency collaboration developed the Newborn Health in Humanitarian Settings: Field Guide. The essential newborn care component of the Field Guide was operationalized with the use of an intervention package encompassing the training of health workers, newborn kit provisions and the installation of a newborn register., Methods: We conducted a quasi-experimental prepost study to test the effectiveness of the intervention package on the composite outcome of essential newborn care from August 2016 to December 2018 in Bossaso, Somalia. Data from the observation of essential newborn care practices, evaluation of providers' knowledge and skills, postnatal interviews, and qualitative information were analyzed. Differences in two-proportion z-tests were used to estimate change in essential newborn care practices. A generalized estimating equation was applied to account for clustering of practice at the health facility level., Results: Among the 690 pregnant women in labor who sought care at the health facilities, 89.9% (n = 620) were eligible for inclusion, 84.7% (n = 525) were enrolled, and newborn outcomes were ascertained in 79.8% (n = 419). Providers' knowledge improved from pre to posttraining, with a mean difference in score of + 11.9% (95% CI: 7.2, 16.6, p-value < 0.001) and from posttraining to 18-months after training with a mean difference of + 10.9% (95% CI: 4.7, 17.0, p-value < 0.001). The proportion of newborns who received two or more essential newborn care practices (skin-to-skin contact, early breastfeeding, and dry cord care) improved from 19.9% (95% CI: 4.9, 39.7) to 94.7% (95% CI: 87.7, 100.0). In the adjusted model that accounted for clustering at health facilities, the odds of receiving two or more essential newborn practices was 64.5 (95% CI: 15.8, 262.6, p-value < 0.001) postintervention compared to preintervention. Predischarge education offered to mothers on breastfeeding 16.5% (95% CI: 11.8, 21.1) vs 44.2% (95% CI: 38.2, 50.3) and newborn illness danger signs 9.1% (95% CI: 5.4, 12.7) vs 5.0% (95% CI: 2.4, 7.7) remained suboptimal., Conclusions: The intervention package was feasible and effective in improving essential newborn care. Knowledge and skills gained after training were mostly retained at the 18-month follow-up.

Introduction: Conflict adversely impacts health and health systems, yet its effect on health inequalities, particularly for women and children, has not been systematically studied. We examined wealth, education and urban/rural residence inequalities for child mortality and essential reproductive, maternal, newborn and child health interventions between conflict and non-conflict low-income and middle-income countries (LMICs)., Methods: We carried out a time-series multicountry ecological study using data for 137 LMICs between 1990 and 2017, as defined by the 2019 World Bank classification. The data set covers approximately 3.8 million surveyed mothers (15-49 years) and 1.1 million children under 5 years including newborns (<1 month), young children (1-59 months) and school-aged children and adolescents (5-14 years). Outcomes include annual maternal and child mortality rates and coverage (%) of family planning services, 1+antenatal care visit, skilled attendant at birth (SBA), exclusive breast feeding (0-5 months), early initiation of breast feeding (within 1 hour), neonatal protection against tetanus, newborn postnatal care within 2 days, 3 doses of diphtheria, pertussis and tetanus vaccine, measles vaccination, and careseeking for pneumonia and diarrhoea., Results: Conflict countries had consistently higher maternal and child mortality rates than non-conflict countries since 1990 and these gaps persist despite rates continually declining for both groups. Access to essential reproductive and maternal health services for poorer, less educated and rural-based families was several folds worse in conflict versus non-conflict countries., Conclusions: Inequalities in coverage of reproductive / maternal health and child vaccine interventions are significantly worse in conflict-affected countries. Efforts to protect maternal and child health interventions in conflict settings should target the most disadvantaged families including the poorest, least educated and those living in rural areas., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Unsafe abortion contributes to maternal mortality worldwide and disproportionately affects the most disadvantaged women and girls; thus, improving the treatment of complications of abortion is essential. Shifting PAC treatment from sharp dilation and curettage (D&C) to the use of aspiration techniques, notably manual vacuum aspiration (MVA), and medical treatment with misoprostol improves health outcomes. Equally critical is ensuring that women have access to voluntary contraception after an abortion to prevent future unintended pregnancies. In humanitarian settings, access to voluntary family planning to disrupt the cycle of unsafe abortion is even more critical because access to quality services cannot be guaranteed due to security risks, migration, and devastation of infrastructure. Save the Children applied a multipronged postabortion care (PAC) approach in the Democratic Republic of the Congo (DRC), Somalia, and Yemen that focused on capacity building; assurance of supplies and infrastructure; community collaboration and mobilization; and monitoring and evaluation., Methods: Program-level data were extracted for each of the 3 countries from the inception of their program through 2017. The sources of information included monthly service delivery reports that tracked key PAC indicators as well as qualitative data from evaluations of community mobilization activities., Results: The number of PAC clients increased in all countries. In the DRC in 2012, 19% of PAC clients requiring treatment received D&C; in 2017 the percentage was reduced to 3%. In 2013, 25% of all PAC clients in Yemen were treated with D&C; this percentage was reduced to 3% in 2017. The proportion of women choosing contraception after an abortion increased. In 2012, only 42% of all PAC clients in the DRC chose a contraceptive method; by 2017, the proportion had increased to 70%. Somalia had substantial increases in PAC demand, with the percentage of all PAC clients electing contraception increasing from 64% in 2012 to 82% in 2017. In Yemen, where the health system has been constrained due to severe conflict, the percentage of PAC clients choosing voluntary contraception rose from 17% in 2013 to 38% in 2017. Uptake and demand for PAC was mobilized through targeted community outreach in each context., Conclusion: These data demonstrate that providers can effectively shift away from D&C as treatment for PAC and that contraceptive uptake by PAC clients can increase substantially, even in settings where the use of contraception after abortion is often stigmatized., (© Gallagher et al.)

Background: Newborn mortality is increasingly concentrated in contexts of conflict and political instability. However, there are limited guidelines and data on the availability and quality of newborn care in conflict settings. In 2016, an interagency collaboration developed the Newborn Health in Humanitarian Settings Field Guide- Interim version (Field Guide) . In this study, we sought to understand the baseline availability and quality of essential newborn care in Bossaso, Somalia as part of an investigation to determine the feasibility and effectiveness of the Field Guide in improving newborn care in humanitarian settings., Methods: A cross-sectional study was conducted at four purposely selected health facilities serving internally displaced persons affected by conflict in Bossaso. Essential newborn care practice and patient experience with childbirth care received at the facilities were assessed via observation of clinical practice during childbirth and the immediate postnatal period, and through postnatal interviews of mothers. Descriptive statistics and logistic regression were employed to summarize and examine variation by health facility., Results: Of the 332 pregnant women approached, 253 (76.2%) consented and were enrolled. 97.2% (95% CI: 94.4, 98.9) had livebirths and 2.8% (95% CI: 1.1, 5.6) had stillbirths. The early newborn mortality was 1.7% (95% CI: 0.3, 4.8). Nearly all [95.7%, (95% CI: 92.4, 97.8)] births were attended by skilled health worker. Similarly, 98.0% (95% CI: 95.3, 99.3) of newborns received immediate drying, and 99.2% (95% CI: 97.1, 99.9) had delayed bathing. Few [8.6%, (95% CI: 5.4, 12.9)] received immediate skin-to-skin contact and the practice varied significantly by facility ( p  < 0.001). One-third of newborns [30.1%, (95% CI: 24.4, 36.2)] received early initiation of breastfeeding and there was significant variation by facility ( p  < 0.001). While almost all [99.2%, (95% CI: 97.2, 100)] service providers wore gloves while attending births, handwashing was not as common [20.2%, (95% CI: 15.4, 25.6)] and varied by facility ( p  < 0.001). Nearly all [92%, (95% CI: 86.9, 95.5)] mothers were either very happy or happy with the childbirth care received at the facility., Conclusion: Essential newborn care interventions were not universally available. Quality of care varied by health facility and type of intervention. Training and supervision using the Field Guide could improve newborn outcomes., Competing Interests: Competing interestsThe authors declare that they have no competing interests.

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.

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.

Highest rates of neonatal mortality occur in countries that have recently experienced conflict. International Medical Corps implemented a package of newborn interventions in June 2016, based on the Newborn health in humanitarian settings: field guide, targeting community- and facility-based health workers in displaced person camps in South Sudan. We describe health workers' knowledge and attitudes toward newborn health interventions, before and after receiving clinical training and supplies, and recommend dissemination strategies for improved uptake of newborn guidelines during crises. A mixed methods approach was utilised, including pre-post knowledge tests and in-depth interviews. Study participants were community- and facility-based health workers in two internally displaced person camps located in Juba and Malakal and two refugee camps in Maban from March to October 2016. Mean knowledge scores for newborn care practices and danger signs increased among 72 community health workers (pre-training: 5.8 [SD: 2.3] vs. post-training: 9.6 [SD: 2.1]) and 25 facility-based health workers (pre-training: 14.2 [SD: 2.7] vs. post-training: 17.4 [SD: 2.8]). Knowledge and attitudes toward key essential practices, such as the use of partograph to assess labour progress, early initiation of breastfeeding, skin-to-skin care and weighing the baby, improved among skilled birth attendants. Despite challenges in conflict-affected settings, conducting training has the potential to increase health workers' knowledge on neonatal health post-training. The humanitarian community should reinforce this knowledge with key actions to shift cultural norms that expand the care provided to women and their newborns in these contexts.

Context: Despite the inclusion of sexual and reproductive health (SRH) services in the minimum standards of health care in humanitarian settings, access to SRH services, and especially to contraception, is often compromised in war. Very little is known about continuation and switching of contraceptive methods in these settings. An evaluation of a contraceptive services program in North Kivu, Democratic Republic of the Congo (DRC) was conducted to measure 12-month contraceptive continuation by type of contraceptive method (short-acting or long-acting)., Methods: A stratified systematic sample of women who initiated a contraceptive method 12-18 months prior to data collection was selected retrospectively from facility registers. A total of 548 women was interviewed about their contraceptive use: 304 who began a short-acting method (pills, injectables) and 244 who began a long-acting method (intra-uterine devices, implants). Key characteristics of short-acting method versus long-acting method acceptors were compared using chi-square statistics for categorical data and t-tests for continuous data. Unadjusted and adjusted Cox proportional hazard ratios were estimated to assess factors associated with discontinuation., Results: At 12 months, 81.6% women reported using their baseline contraceptive method continuously, with more long-acting than short-acting contraceptive acceptors (86.1% versus 78.0%, p = .02) continuing contraceptive use. Use of a short-acting method (Hazard ratio (HR) 1.74 [95%CI 1.13-2.67]) and desiring a child within two years (HR 2.58 [95%CI 1.45-4.54]) were associated with discontinuation within the first 12 months of use. The vast majority (88.3%) of women reported no prior contraceptive use., Conclusion: This is the first study of contraceptive continuation in a humanitarian setting. The high percentages of women continuing contraceptive use found here demonstrates that women will choose to initiate and continue use of their desired contraceptive method, even in a difficult, unstable and low contraceptive prevalence setting like North Kivu.

Background: Over 40% of all deaths among children under 5 are neonatal deaths (0-28 days), and this proportion is increasing. In 2012, 2.9 million newborns died, with 99% occurring in low- and middle-income countries. Many of the countries with the highest neonatal mortality rates globally are currently or have recently been affected by complex humanitarian emergencies. Despite the global burden of neonatal morbidity and mortality and risks inherent in complex emergency situations, research investments are not commensurate to burden and little is known about the epidemiology or best practices for neonatal survival in these settings., Methods: We used the Child Health and Nutrition Research Initiative (CHNRI) methodology to prioritize research questions on neonatal health in complex humanitarian emergencies. Experts evaluated 35 questions using four criteria (answerability, feasibility, relevance, equity) with three subcomponents per criterion. Using SAS 9.2, a research prioritization score (RPS) and average expert agreement score (AEA) were calculated for each question., Results: Twenty-eight experts evaluated all 35 questions. RPS ranged from 0.846 to 0.679 and the AEA ranged from 0.667 to 0.411. The top ten research priorities covered a range of issues but generally fell into two categories- epidemiologic and programmatic components of neonatal health. The highest ranked question in this survey was "What strategies are effective in increasing demand for, and use of skilled attendance?", Conclusions: In this study, a diverse group of experts used the CHRNI methodology to systematically identify and determine research priorities for neonatal health and survival in complex humanitarian emergencies. The priorities included the need to better understand the magnitude of the disease burden and interventions to improve neonatal health in complex humanitarian emergencies. The findings from this study will provide guidance to researchers and program implementers in neonatal and complex humanitarian fields to engage on the research priorities needed to save lives most at risk.

Haiti's Ministry of Public Health and Population collaborated with global partners to enhance malaria surveillance in two disaster-affected areas within 3 months of the January 2010 earthquake. Data were collected between March 4 and April 9, 2010 by mobile medical teams. Malaria rapid diagnostic tests (RDTs) were used for case confirmation. A convenience sample of 1,629 consecutive suspected malaria patients was included. Of these patients, 1,564 (96%) patients had malaria RDTs performed, and 317 (20.3%) patients were positive. Of the 317 case-patients with a positive RDT, 278 (87.7%) received chloroquine, 8 (2.5%) received quinine, and 31 (9.8%) had no antimalarial treatment recorded. Our experience shows that mobile medical teams trained in the use of malaria RDTs had a high rate of testing suspected malaria cases and that the majority of patients with positive RDTs received appropriate antimalarial treatment. Malaria RDTs were useful in the post-disaster setting where logistical and technical constraints limited the use of microscopy.

Background: Despite the serious consequences of conflict for reproductive health, populations affected by conflict and its aftermath face tremendous barriers to accessing reproductive health services, due to insecurity, inadequate numbers of trained personnel and lack of supplies. Family planning is often particularly neglected., Methods: In six conflict-affected areas in Sudan, northern Uganda and the Democratic Republic of Congo, household surveys of married or in-union women of reproductive age were conducted to determine baseline measures of family planning knowledge, attitudes and behaviors regarding contraception. Health facility assessments were carried out to assess baseline measures of family planning services availability. Data were double-entered into CSPro 3.2 and exported to SAS 9.2, which was used to calculate descriptive statistics. The studies' purposes were to guide program activities and to serve as a baseline against which program accomplishments could be measured., Results: Knowledge of modern contraceptive methods was low relative to other sub-Saharan African countries, and use of modern methods was under 4% in four sites; in two sites with prior family planning services it was 12% and 16.2%. From 30% to 40% of women reported they did not want a child within two years, however, and an additional 12% to 35% wanted no additional children, suggesting a clear need for family planning services. The health facilities assessment showed that at most only one-third of the facilities mandated to provide family planning had the necessary staff, equipment and supplies to do so adequately; in some areas, none of the facilities were prepared to offer such services., Conclusions: Family planning services are desired by women living in crisis situations when offered in a manner appropriate to their needs, yet services are rarely adequate to meet these needs. Refugee and internally displaced women must be included in national and donors' plans to improve family planning in Africa.

Background: The treatment for Plasmodium falciparum malaria in Sudan has been in process of change since 2003. Preceding the change, this study aimed to determine which artemisinin-based combination therapies is more effective to treat uncomplicated malaria in Malakal, Upper Nile, Sudan., Methods: Clinical trial to assess the efficacy of 2 antimalarial therapies to treat P. falciparum infections in children aged 6-59 months, in a period of 42 days after treatment., Results: A total of 269 children were followed up to 42 days. Artesunate plus Sulfadoxine/Pyrimethamine (AS+SP) and Artesunate plus Amodiaquine (AS+AQ) were both found to be efficacious in curing malaria infections by rapid elimination of parasites and clearance of fever, in preventing recrudescence and suppressing gametocytaemia. The combination of AS+SP appeared slightly more efficacious than AS+AQ, with 4.4% (4/116) versus 15% (17/113) of patients returning with malaria during the 6-week period after treatment (RR = 0.9, 95% CI 0.81-0.96). PCR analysis identified only one recrudescence which, together with one other early treatment failure, gave efficacy rates of 99.0% for AS+AQ (96/97) and 99.1% for AS+SP (112/113). However, PCR results were incomplete and assuming part of the indeterminate samples were recrudescent infections leads to an estimated efficacy ranging 97-98% for AS+SP and 88-95% for AS+AQ., Conclusion: These results lead to the recommendation of ACT, and specifically AS+SP, for the treatment of uncomplicated falciparum malaria in this area of Sudan. When implemented, ACT efficacy should be monitored in sentinel sites representing different areas of the country.