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Lessons Learned from Helping Babies Survive in Humanitarian

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Lessons Learned from Helping Babies Survive in Humanitarian Lessons Learned From Helping Babies Survive in Humanitarian Settings Ribka Amsalu, MD,a,b Catrin Schulte-Hillen, MPH,c Daniel Martinez Garcia, MD, MPH,d Nadia Lafferty, MBChB, MRCPCH,e Catherine N. Morris, MPH,a Stephanie Gee, MPH,c Nadia Akseer, PhD,g Elaine Scudder, MA,a Samira Sami, DrPH,f Sammy O. Barasa, BScN,h Hussein Had, MSc,i Maimun Farah Maalim, MD,j Seidou Moluh, MD,c Sara Berkelhamer, MDk abstract 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. aDepartment of Global Health, Save the Children, Washington, District of Columbia; bUniversity of California San Francisco, San Francisco, California; cPublic Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland; dMedical Department, Médecins Sans Frontières, Geneva, Switzerland; eMedical Department, Médecins Sans Frontières, Barcelona, Spain; fDepartment of International Health and Center for Humanitarian Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; gCentre for Global Child Health, Hospital for Sick Children, Toronto, Canada; hDepartment of Nursing, Kenya Medical Training College, Machakos, Kenya; iSave the Children, Garowe, Puntland, Somalia; jGardo General Hospital, Puntland, Somalia; and kDepartment of Pediatrics, University of Washington, Seattle, Washington Dr Amsalu conceptualized the study and drafted the initial manuscript; Ms Schulte-Hillen, Ms Gee, Mr Moluh, Mr Barasa, Ms Morris, Mr Had, and Dr Maalim contributed to the design of the study, collected data, conducted the data analysis, and drafted the case examples; Dr Akseer conducted the data analysis; Drs Sami, Garcia, Lafferty, and Ms Scudder contributed to the design of the study; Dr Berkelhamer conceptualized the study; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2020-016915L Accepted for publication Aug 4, 2020 Address correspondence to Ribka Amsalu, MD, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA 94143. E-mail: [email protected] Downloaded from www.aappublications.org/news by guest on September 27, 2021 SUPPLEMENT ARTICLE PEDIATRICS Volume 146, number s2, October 2020:e2020016915L INTRODUCTION ($30 per 1000 live births) can be global capacities to respond to needs, fi Globally, major advances for classi ed as experiencing political and challenges in mitigating the fl fl improving newborn health have been instability or con ict in the last consequences of con ict on health achieved, including generating the decade (Table 1) on the basis of the systems. In addition, although the fl 9 evidence base, developing national Uppsala Con ict Data Program. An evidence base for newborn health has ecological analysis using national expanded since the Lancet series in strategies and action plans, and 10,11 reducing neonatal mortality.1,2 survey data from low- and middle- 2005 and there are several However, in countries affected by income countries, with methodology guidelines for humanitarian settings fi 12,13 humanitarian crises and political and de nition presented by Akseer that promote newborn health, 7 fl fi instability, newborn outcomes et al, found that con ict-affected there is insuf cient capacity in the continue to lag behind.2 countries on average have worse use of evidence-based interventions – fl Humanitarian crises, driven by NMRs compared with non con ict- to reduce neonatal mortality in the fi disasters, conflict, and disease affected countries (Fig 1). Indeed, humanitarian eld, and most epidemics, have profound effects on there continues to be a gap in organizations self-report as not ’ coverage of interventions during providing essential newborn care society, including on people s health 14 and well-being. The magnitude and pregnancy, childbirth, and postnatal services. fl severity of humanitarian crises have period between con ict-affected and – fl Authors of a 2014 evaluation of increased in the last decade. By the non con ict-affected countries 7 reproductive health services for end of 2018, an estimated 41.3 (Fig 1). refugees and IDPs in South Sudan, the million internally displaced persons Several factors have contributed to Democratic Republic of the Congo (IDPs) and 20.4 million refugees were this divergence, including an increase (DRC), and Burkina Faso found that 3 reported worldwide, which is nearly in severity and scale of conflict and out of 5 hospitals and only 5 out of 58 a 70% increase from 2010.3,4 Conflict, humanitarian crises in the last health centers were providing by its very nature, diminishes decade, overstretched national and essential newborn care services.15 Of national accountability, governance, economic growth, and resources available for social services.2,5 In TABLE 1 Occurrence of Conflict and Internal Displacement due to Conflict in 18 Counties With the addition, the impact of a crisis on Highest NMR health systems can be severe because of the destruction of health facilities, Country Neonatal Mortality UCDP: Episodes and Intensity of IDPs in This per 1000 Live Armed Conflict,b 2010–2017 Country,c 2018 shortage of skilled health workers, Births,a 2018 disruption of supply chain systems, Pakistan 42 High-intensity conflict, war 119 000 and restrictive working and Central African 41 Minor-intensity conflict 641 000 5,6 operational environments. Republic South Sudan 40 High-intensity conflict, war 1 869 000 Although occurrences of extreme Somalia 38 High-intensity conflict, war 2 648 000 weather events, earthquakes, and Afghanistan 37 High-intensity conflict, war 2 598 000 disease epidemics have also increased Guinea Bissau 37 dd in the last decade, for the purposes of Nigeria 36 High-intensity conflict, war 2 216 000 Lesotho 35 dd this Pediatrics article, we have Chad 34 Minor-intensity conflict 90 000 focused on the lessons learned in the Côte d’Ivoire 34 Minor-intensity conflict 302 000 implementation of the Helping Babies Sierra Leone 33 d 3000 Survive (HBS) training in contexts of Mali 33 Minor-intensity conflict 120 000 d conflict and displacement. Mauritania 33 Minor-intensity conflict Djibouti 32 dd Comoros 32 dd Guinea 31 dd NEONATAL SURVIVAL IN SETTINGS OF Benin 31 d 3500 CONFLICT AND DISPLACEMENT Equatorial Guinea 30 dd Neonatal mortality, defined as death UCDP, Uppsala Conflict Data Program. 8 in the first 28 days of life, has a NMR: deaths ,1 mo per 1000 live births. 2018 estimates by UN Inter-Agency Group for Child Mortality Estimation. fl b UCDP: unit of analysis events: an instance of fatal organized violence using armed force by organized actor. Minor- declined in both con ict-affected and intensity conflict: between 25 and 999 battle-related deaths in a given year. High-intensity conflict, war: at least non–conflict-affected countries from 1000 battle-related deaths in a given year. 2000 to 2018.7,8 However, 55.6% of c Internal Displacement Monitoring Center: Global report on internal displacement in 2019. Number of displaced persons due to conflict up to December 2018. the countries with the highest d No conflict documented by UCDP in the reporting period of 2010–2017.9 No data of displacement due to conflict reported neonatal mortality rates (NMRs) in the report.3 Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 146, number s2, October 2020 S209 in humanitarian settings share within the Somali state of Puntland in lessons learned from their use of one 2016, Save the Children, in such training: the American Academy coordination with the Puntland of Pediatrics HBS program. Ministry of Health (MoH), conducted a feasibility and effectiveness study of The HBS training program comprises the Newborn Health in Humanitarian 3 components: Helping Babies Settings Field Guide13 that included Breathe (HBB),19 Essential Care for providing an 8-day HBS training to Every Baby (ECEB),20 and Essential providers.24 Supplemental modules Care for Small Babies (ECSB).21 HBB on maternal health, intrapartum care, FIGURE 1 provides a simplified neonatal , fl fl supportive supervision, and health NMR ( 1 month), con ict versus noncon ict, resuscitation algorithm and skills- 1990–2017. Pooled mortality trends compare information systems were included to based training on the initial steps of conflict-affected (red line) and non–conflict- address reported gaps in participants’ affected (blue line) low- and middle-income newborn resuscitation. ECEB covers experiences.
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