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Table 2 Summary of articles included in the analysis and quality grade

From: Context matters: a systematic review of neonatal care in humanitarian emergencies

Author and year

Setting and emergency

Level of care

Study type

Intervention summary

Key findings

ENC

Quality grade

Ahamadani et al. (2014)

Iraq; Protracted Conflict

Hospital

Mixed methods

Qualitative: Interviews Focus groups

Observations

Quantitative: Secondary data analysis of newborn outcomes

Field based needs assessment of 300 bed Bint Al-Huda Maternity ward and teaching hospital

Challenges

- Limited supply of ENC equipment (newborn resuscitation masks, infection prevention), staffing and documentation of labour and newborns

- Thermal care

- Infection prevention

- Resuscitation

- Breastfeeding

- Postnatal checks

Moderate

- Limited to hospital settings and staff

- Higher mortality may be seen as a result of serving higher risk referral patients

Akseer et al. (2016)

Afghanistan; Protracted Conflict

Hospital

Secondary data analysis of 11 nationally representative surveys from 2003 to 2013

Implementation of Basic Package of Health Services in 2003 addressing quality, cost effectiveness, equity, and community involvement with one in several components in Maternal and Newborn Health

Strengths

- Large financing of $226 million in health with 28.5% to maternal and neonatal health

- Increased phone towers increased SBA and facility births

Challenges

- Only postnatal marker is ‘early breast feeding’

- Variations in coverage of SBAs and antenatal care over wealth quintiles

N/A

Moderate

- Data limited in the amount of reliable information available at provincial and population level

- Multivariate analysis could be subject to ecological fallacy and over interpretation

Amibor (2013)

Haiti; Earthquake

Hospital

Secondary data analysis

Assessment of child and maternal health situation prior to earthquake and effects after the disaster

Strengths

- Government led initiatives for free obstetric care prior to earthquake

Challenges

- Prior to earthquake 50% of women had access to services and 77% of population lived under the poverty line

- Delay of 4 months in MISP establishment at subnational level

- Insufficient and strained resources with multiple international organisations working in disunity

MISP (EmONC)

Moderate

-Data collection and analysis methodology not appropriately described

Ayota et al. (2013)

Haiti; Earthquake

Community

Qualitative

Assessment of impact of baby tents programme implemented by UNICEF and Haiti health ministry to promote and sustain optimal feeding and provide counselling

Established 193 baby tents in 5 cities with 180,499 infant-mother pairs and 53,503 pregnant women over—29-month timeline

Strengths

- Ability to register and assess mother/infant pairs and pregnant mothers and refer sick infants

- Ability to give culturally appropriate health promotional messages and information specifically about infant formula, Psychosocial support

Challenges

- Limited trained workforce

- High displacement with lack of social cohesion made it difficult to ensure community participation

- Difficult integration with health centres

- Breastfeeding

- Postnatal checks

Strong

Bengin et al. (2010)

China; Earthquake

Hospital

Letter to the Editor

Description of Infant Feeding patterns in Emergency

Challenges

- Delayed feeding due to increased caesarean deliveries to 87% (from 80%) to reduce uncertainty around time of birth. Of 31 post-partum mothers, 14.8% initiated breastfeeding in 1h.

- Reduced feeding education and policy resultant unregulated distribution of formula free in hospital for newborns

- Mothers felt they were unable to produce milk because they could not feed themselves

Breastfeeding

Weak

- Subject to high publication bias

Bouchghoul et al. (2015)

Jordan; Refugee Camp

Community

Prospective observational study over 6 months

Experience of NGO Gynécologie Sans Frontières obstetric care unit in Syrian Refugee Camp from Sept 2012 to Feb 2013. 3255 Antenatal consultations made

Strengths

- Partnerships with other NGOs and integration into local health system

- Separate tent for immediate care for women and newborns with postnatal checks arranged after 3 days

Challenges

- Monitoring SGA babies using Caucasian growth charts (produced an overestimate)

- High-risk pregnancies being referred to hospital outside the camp with no communication between camp and hospital (language and availability) resulting in loss in follow up

- Thermal care

- Resuscitation

- Breastfeeding

- Monitoring

- Postnatal checks

Strong

Bernard and Mathews (2008)

America; Hurricane

Hospital

Descriptive account

Evacuation of NICU following Hurricane Katrina

Strengths

- Use of instant warming pads for thermoregulation

- Early relocation of NICU to an area with emergency power

- Sending babies with full paper medical records

Challenges

- Decision to shelter family and pets of employees increased hospital capacity and strained resources

- Difficulty identifying receiving hospitals for NICU babies

- Transport of babies for evacuation to the roof (no elevators), ventilator transport units did not fit in transport trucks

- Loss of communication, water, food, and sewer services and threat of looters

- Unable to follow up babies once evacuated

- Thermal care

- Resuscitation

Weak

- Subject to recall bias and sensationalised events

Casey et al. (2015)

Multiple Regions; Refugee Camps

Hospital

Community

Cross-sectional mixed methods

63 purposively sampled HF; 28 in Burkina Faso, 25 in DRC, 9 in South Sudan

Study explored the availability and quality of, and access barriers to RH services in three humanitarian settings in Burkina Faso, Democratic Republic of the Congo (DRC), and South Sudan. These settings represented a mix of camp and non-camp settings for HF

Strengths

- Community engagement linked to increased health seeking behaviour

- Community leaders reported positive experiences with RH services, many were aware it was free and the advantage of delivering in a facility

Challenges

- Inconsistency with self-reported provision of RH and availability of supplies and trained staff to deliver them

- All facilities lacked training in newborn infection management and lack of supplies for resuscitation; 66.7% did not have resuscitation masks in DRC and 80% lacked corticosteroids in Burkina Faso

- Non-camp facilities did not have a functioning referral system.

- Poor commodity security and supply chain management

MISP (EmONC)

Strong

- Potential impact on data quality due to multiple translations from local language to English

Casey (2015)

Multiple Regions; Multiple Types

Hospital

Community

Systematic review

Evaluation of RH programmes. 7/36 papers included evaluated maternal and newborn health programmes

Strengths

- CHW and TBA training in ENC strengthened connection to formal services; training of traditional birth attendants in ENC in Liberia showed improved knowledge from pre-post training

- Opportunity to train refugees and Internally displaced person health workers to increase coverage and continuity of care

Challenges

- Similar challenges across all settings including need for highly trained health workers for RH services, need for updated competency-based training particularly for EmONC

MISP (EmONC)

Strong

-Restriction to quantitative methods and papers published in English

Casillo et al. (2016)

Philippines; Typhoon

Hospital

Community

Cohort study

56 HF underwent baseline assessments 16–22weeks of typhoon landfall with training conducted at 1 and 3 months

Quality improvement training for staff in Essential Intrapartum and Newborn Care with pre-/post- assessments.

Strengths

- Increase in KMC to 94% post training, increase in newborn bags and masks for resuscitation from 9 to 88%, and skills in breastfeeding initiation from 50 to 86%

- Overall significant increase in service provider skills and facility equipment

- Thermal care

- Breastfeeding

- Resuscitation

Moderate

-Limited discussion of analysis methods

DeYoung et al. (2018)

Nepal; Earthquake

Community

Prospective cross-sectional mixed methods design

Identified perceptions of Nepalese women and barriers/ facilitators to breastfeeding

Strengths

- Government-led health messaging 5 days after earthquake about formula distribution (ended up banned) and debunked myths about breastfeeding

- Mother-infant tents, also generated a sense of community amongst women (from the same caste)

Involving grandmothers and other members in post-disaster feeding practices

Challenges

- 6months post-earthquake baby tents were gone due to humanitarian groups leaving

- Senses of abandonment and worry for safety once NGOs left

- Perceptions varying across ethnic groups and perceived low milk supply

Breastfeeding

Strong

- Potential impact on data quality due to multiple translations from local language to English

Espiritu et al. (2014)

America; Hurricane

Hospital

Descriptive account

Evacuation of 21 infants from NICU following Hurricane Sandy

Strengths

- Use of warming pads and swaddling for thermoregulation

- Discharging of stable infants early and high-risk patients were relocated to other hospitals

- Development of a central command with a stepped-up response approach with large staffing capacity

- Prioritising neonates for evacuation by acuity, degree of respiratory support and equipment

Challenges

- Finding alternate hospitals for relocation (differing protocols, acceptance procedures, and capacity data)

- Communication and transport coordination

- Unable to follow up babies once evacuated

Thermal care

Weak

- Subject to high publication bias

Gopalan et al. (2017)

Multiple Regions;

Protracted Conflict

Hospital

Community

Systematic review

Review of Maternal and Newborn health service usage and determinants in Fragile/conflict affected states in Asia and Middle East: Afghanistan, Myanmar, Nepal, The Palestinian Territories, Syria, Timor-Leste, Yemen

Strengths

- Implementing targeted policy approaches to improve coordination of aid and planning to target vulnerable populations

- Presence of female CHW increased possibility of receiving SBA

- Addressing demand (lack of awareness, money, transport) and supply side (delivery of RH services)

Challenges

- Inequities across wealth quintiles with access and usage of services

- Thermal care

- Breastfeeding

- MISP (EmONC)

Strong

-Limited study availability with good methodological design

-Findings are primarily ungeneralisable

Hynes et al. (2017)

The Democratic Republic of Congo; Protracted Conflict

Community

Quasi-experimental design

12 HF split into two groups. Both received standard training intervention and one group received an enhanced quality improvement methodology

Participatory quality improvement intervention (12 days training in ENC run by NGO) for Facility-based maternal and newborn care with baseline/end line data of 9 months

Strengths

- Enhanced intervention group showed a greater rate of change than the control group for ENC (OR: 49.62, 95% CI: 2.79–888.28), and achieved 100% ENC completion at end line.

- End vs Baseline OR=2.44 (1.28-4.66) both groups showed increase coverage of ENC

- Success in QI methodology is ownership process by those who know health system best

- Improve care through improved logistics of work (e.g. pairing matrons with low literacy with partners who could assist filling out forms)

- Reinforcing clinical training through visual posters, notice boards, and continued practical training

- Post training HF staff felt empowered to identify problems and develop solutions

Challenges

- Scheduling of regular supervisory sessions due to access and security

- High staff turnover places stress on need to build existing supervisory systems

- Clean cord care

- Infection prevention

- Monitoring

Moderate

- Only HF receiving programme support by NGO were included in the study

-Selection bias in interviews

-Because the enhanced intervention group 100% ENC delivery at end line, simplified GEE model without controlling for socio-demographic variables resulted in very wide confidence intervals

Iwata et al. (2017)

Japan; Earthquake

Hospital

Descriptive account

Evacuation of 38 newborns from NICU

Strengths

- Development of NICU online directory allowed for inter-hospital communication (developed after 2001 earthquake)

- Prioritisation of newborns for evacuation time and location by immaturity, respiratory support and vascular routes

Challenges

- No cooperation with national disaster medical assistance team

- Difficulty keeping infants warm due to outside temperature

- Limited supply of ENC equipment

- Thermal care

- Resuscitation

Weak

Subject to high publication bias

Khan et al. (2012)

Pakistan; Protracted Conflict

Community

Evaluation, Secondary data from national reports, assessments, programme reviews and peer-reviewed literature

Examination of changes in newborn survival between 2000 and 2013; mortality, coverage and health system factors

Strengths

- Development of newborn resuscitation protocols in labour rooms and hospital centres

- Home visits conducted by CHW, coupled with intervention packages and health promotion materials significantly reduced NMR

- Utilisation of IMNCI with emphasis on recognition and referral over curative care

- General socio-economic changes over time including increased female literacy and decreased fertility rates coupled with policy changes and CHW programme (Lady Health Workers) and increased funding

Challenges

- Uptake of KMC poses significant challenges in cultural traditions and family practices

- Refusal to refer from financial/religious/cultural difficulties

- Large coverage disparities between wealth quintiles and urban/rural

- Low medical human resources

- Thermal care

- Resuscitation

- Breastfeeding

- Monitoring

- Postnatal checks

Strong

- no discussion of limitations in paper

Krause et al. (2015)

Jordan; Refugee Camp

Hospital

Formative evaluation using mixed methods (key informant interviews, HF assessments, Focus groups)

Evaluation on the status of MISP implementation in refugee camps in Jordan: Zaatri Camp (refugee camp; 15 RH services) and Irbid City (non-camp refugee site; 6 RH services)

Strengths

- Reporting from key informants that ministry of health and WHO protocols, and funds were available for MISP response

- 75% reported RH medical kits were available and adequate for response

Challenges

- Interviews with staff, all were but one was aware of MISP and nearly half new all five MISP principles

- RH response in urban areas was lagging behind camp co-ordination

- All groups reported clean delivery kits were not delivered to women as it was thought it would encourage home deliveries

MISP (EmONC)

Strong

Lam et al. (2012)

Multiple Regions; Protracted Conflict

Community

Web-based survey

Survey of 56 humanitarian workers from 27 organisations (NGO/United Nations /Government) and newborn care practices

Strengths

- 62.5% reported having policies and guidelines (66.7%) on maternal health and very few on neonatal health

- 72.9% reported routinely collecting data

- Task shifting, home-to-hospital linkages and NGO partnerships ensured continuity and access to care for women

- 80.4% immediate drying and wrapping of newborn

- 73.3% maternal skin-skin contact 1–2h after birth.

- 62.5% newborn resuscitation with bag and mask

- 87.5% promoted breastfeeding within an hour. 83.3% provided postnatal care including home visits (65.2%).

- 73.2% promoted KMC

Challenges

- Greater emphasis on maternal interventions

- 36.7% reported training on newborn care

- Referral systems limited, newborns <1.5kg are not eligible for referral too high risk.

- 53.6% promoted 6–24-h delay of bathing newborn for hypothermia prevention. 46.4% promotion of newborn care kits with 39.3% providing the kits. Only 55% promoted nothing harmful applied to cord with 48.2% promoting the use of disinfectant on cord

- Most common barriers to care included insufficient funds (63.3%), staffing (51%), and medical supplies (44.9%)

All components

Moderate

- Respondents indicated that type and breadth of care changed dependant on the setting

- Limited by respondent driven sampling

-Overall small sample size and potential for bias that could have overestimated newborn care services in emergency settings

Orlando et al. (2008)

America; Hurricane

Hospital

Descriptive account

Evacuation of 121 neonates in NICU following Hurricane Katrina

Strengths

- Attention to basic needs: thermoregulation, fluids, and hydration

- Knowledge of equipment, supplies, and emergency procedures

- Keeping weekly summaries of infants allowed for a swifter relocation and triage of infants

- Shorter staffing shifts and assigned roles/duties

Challenges

- Transport out of affected region was not a part of disaster plan—need for regional-level plan with communication systems

- Size/weight of incubators permitted aircraft use

- Emergency shelters did not accept pregnant women >34 weeks and so an influx to hospital of pregnant women before the storm

N/A

Weak

-Subject to recall bias and sensationalised events

Sami et al. (2017)

South Sudan; Protracted Conflict

Hospital

Community

Mixed methods

Pre/post knowledge tests and interviews

Description of health workers knowledge and attitudes (pre and post 2 day training session) towards newborn health interventions based off the newborn health field guide

Strengths

- Short practical based training period with supervised follow ups after training increased confidence

- Awareness of benefits of early breastfeeding increased

- Weighing newborn, providing a birth notification and delaying first bath gained importance amongst providers after receiving training

- Integrating counselling mothers on newborn danger signs into existing CHW work

Challenges

- Mothers resistance to exclusive breastfeeding, breast milk expression and prolonged skin contact (KMC) lowered health workers intention to promote these practices

- Hesitation in delayed cord clamping because “blood is still moving in the cord so there maybe risk of MTCT of infection”

- Obstacles for ENC: (1) perceived difficulty of neonatal care and additional time (taken away from mothers) and (2) organisational barriers; lack of newborn-specific referral protocols, resources, supervision and ongoing training, lack of hospital space

All components

Strong

Turner et al. (2013)

Thailand; Refugee Camp

Hospital

Retrospective descriptive study

Interviews and secondary data analysis

Development of a Special Care Baby Unit, January 2008 to December 2013, 952 infants were admitted into the unit

Strengths

- NMR decreased in this period from 21.8 to 10.7 per 1000 live births (51% decline)

- Development of a mnemonic MACHO (milk, antibiotics, cord care, heat and oxygen) to remember ENC components

- Reorganisation of staff with the development of a specific team and hospital area for newborn care

- Annual re-trainings conducted with the creation of locally appropriate standardised charts for admissions and care recordings

Challenges

- Before guidelines were developed, care depended on parental willingness to help newborn survive

All components

Strong