Newborn care in humanitarian settings
A humanitarian crisis may result from a natural disaster, such as an earthquake, flood or epidemic, or from political turmoil, armed conflict, or other types of social upheaval. Such crises threaten the health, safety and wellbeing of a community or a large group of people across a region or a country. This threat is not only due to the impact of injuries and illnesses directly related to the crisis, but also because of the destruction of existing health services and systems resulting from the crisis.
In recent years, humanitarian crises worldwide have intensified in terms of complexity and scale. Regional political turmoil and armed conflicts have produced the largest global numbers of refugees and internally displaced persons seen in over 15 years. The United Nations High Commissioner for Refugees (UNHCR) estimated that in 2015, 65.3 million people were displaced from their homes by conflict or persecution 1. In parallel, natural disasters, exacerbated by climate change, regularly wreak havoc on populations in low-resource settings worldwide.
Improving survival and reducing morbidity in new-bornnewborns is dependent on strong health systems and, is therefore particularly challenging in humanitarian settings. There has been little attempt to quantify the additional burden of deaths in the first month of life in emergency contexts, but in all settings, estimates of the proportion of neonatal deaths are significant. Some of the highest estimated neonatal mortality rates (NMRs) are found in settings affected by conflict, many of which have NMRs of over 40 per 1000 live births, such as the Democratic Republic of Congo (43.5), Central African Republic (40.9), Somalia (45.7), Pakistan (42.2) and Mali (41.5) (Figure 1)4.
Causes of neonatal mortality and morbidity in humanitarian settings
The limited data that do exist on neonatal mortality in humanitarian settings suggest that the main causes of mortality are similar to other low resource settings, such as neonatal sepsis, prematurity and intrapartum-related complications. Collapse in health systems will contribute to increasing numbers of newborn deaths and morbidity from these main causes, but may also increase the burden of a number of specific causes of mortality and morbidity. For example, the burden of neonatal tetanus is found to be significantly greater in many humanitarian settings due to collapse or lack of antenatal tetanus vaccination 5. The lack of other antenatal preventative services such as STI treatment may lead to increases in congenital syphilis. Futhermore, interruption of intermittent preventive treatment of malaria in pregnancy (IPTp) may lead to reductions in birth weight 6. Additionally, in settings with high HIV prevalence, interruption of antiretroviral treatment for pregnant women and prevention of mother to child transmission (PMTCT) may cause important increases in the vertical transmission of HIV 7.
What is currently done to provide newborn care in humanitarian settings?
Newborn health in humanitarian emergencies is intimately linked to the quality of obstetric care that can be delivered. Traditionally, maternal health has been a higher priority than newborn health in humanitarian emergencies. Fortunately, however, most interventions aimed at improving maternal health improve neonatal health as well, particularly in terms of access to essential obstetric care and clean delivery.
In different humanitarian settings, there are varying levels of priority accorded to the foetus and newborn . A particularly complex dilemma in many humanitarian settings is the need for caesarean sections. In many cases caesarean sections are performed solely to protect the unborn child, placing the mother at risk for both the current and future pregnancies. However, in some humanitarian settings, a decision will be made to only perform caesarean sections for maternal complications, resulting in potential negative effects on newborn health.
Resources and guidelines
A comprehensive humanitarian response plan, in any region or nation, should incorporate newborn health services in order to ensure a safe and healthy start to life. Currently, newborn care in humanitarian settings is provided ad hoc by staff deployed for emergency response, including field-level health personnel who may originate from host governments, local and international non-governmental organizations (NGOs), e.g. Médecins Sans Frontières (MSF), United Nations agencies, donor organisations or private voluntary organisations.
Organisations, such as the WHO and MSF, have compiled their own clinical guidelines for basic care of newborns in humanitarian settings, but the level of neonatal care provided is highly context-specific, ranging from basic to intensive The Inter-Agency Working Group on Reproductive Health in Crisis (IAWG) is also working with key stakeholders to revise a Newborn Health in Humanitarian Settings Field Guide 8. It will alsointegrate essential supplies for newborn care into pre-packaged kits for reproductive, maternal, and child health.
However, given the wide range of providers and organisations with no uniform training, it remains challenging to provide universal guidelines for newborn health in humanitarian emergencies beyond a minimum range of basic interventions. This lack of agreed standards for newborn health care provision in humanitarian settings results in a large variation in quality of care. Care for sick or underweight babies is particularly problematic as they are usually dependent on facility-based care for survival, which may be interrupted or unavailable in emergency settings.
Challenges and considerations to collecting data
Obtaining accurate data in humanitarian settings is a challenge. There are competing priorities, limited funding and often insufficient security for data collection. Internal displacement of populations quickly renders data incomplete or out of date. Conducting research and/or data collection during an emergency or humanitarian crisis has also been considered a distraction, taking attention or shifting the focus away from medical and other priorities, especially in the acute phase of an emergency. Data collection relating to newborns can present specific challenges due to the sensitive nature of the information being gathered, e.g. some questions may lead to recall of past trauma such as loss of a child.
The following five considerations should be taken into account when collecting data on newborn health in humanitarian settings 3:
- A mixed methods approach is key; in particular, complementing quantitative data collection with qualitative data collection is time consuming, but important to understand the local context;
- Data collection tools and data collection should be tailored to all local languages and/or dialects, e.g. to reflect diverse populations and nationalities in a refugee camp;
- Existing tools should be continuously reviewed, validated, and modified to ensure they are robust;
- The importance of investing in building local capacity for data collection; and
- Recognising the need for both those who have experienced trauma and data collectors to debrief after documenting these experiences.
Conclusions and future work
Newborn health is a relatively new priority in global health, and has only recently been an interest in humanitarian settings. Encouragingly, and perhaps due to increasing recognition that large improvements can be made with simple interventions, it is attracting more attention and research interest 9.
The nature of humanitarian crises significantly affects the type of newborn care that mothers, families and societies of are able to provide and seek. Most humanitarian contexts are clearly not situations into which many families would choose to have a child, but with collapse in reproductive health services and access to contraception, escalation in sexual violence, and general diminution in the status of women which often ensues, few women are able to exercise this choice. Competing priorities in humanitarian settings such security, water, sanitation, food, the health of older children and family members, and displacement, often compromise the capacity of mothers and families to care for a newborn, and reduce their ability to take on the additional burden and opportunity cost associated with facility-based newborn care. Therefore, newborn care should be prioritised in the context of a comprehensive humanitarian response which is aimed at addressing all general needs of a population, in order that mothers and families are empowered with the resources required to look after their newborn.
© London School of Hygiene & Tropical Medicine 2019