© The World/Alisa Reznic
Essential Newborn Care (ENC) defines minimum standards for the care of infants that must be applied immediately after birth and in the first weeks of life. ENC can be applied in any situation, as it significantly prevents neonatal deaths. However, the adaption to humanitarian disaster settings remains a challenge. Wars, refugee crises, and natural disaster affect millions of people around the world and do not spare infants born into these adverse environments. A literature review of 21 crisis settings worldwide reveals major challenges for ENC. These include the lack of trained staff, missing equipment for neonatal care, misconceptions among mothers, lack of safe spaces for breastfeeding and maternal and newborn care, and the lack of culturally adapted care standards to address the vulnerability of neonates. All these challenges must be overcome in the future to increase neonatal survival in disaster and conflict settings and to save the lives of the most vulnerable and innocent.
While climate change increases the number of natural disasters, wars and protracted conflicts dominate the daily lives of many people worldwide. Every day, children are born into these fragile and violent environments. Neonatal mortality accounts for 47% of all deaths in children under five with preterm births being the leading cause. The neonatal period of the first 28 days of life is therefore extremely vulnerable. 13 of the 15 countries with the highest neonatal mortality rate suffer from conflict, violence, and fragility, exacerbating the vulnerability and risk to newborns. In these regions, the provision of ENC is both particularly important and challenging. Proper adaption of ENC has the potential to prevent two-thirds of neonatal deaths.
ENC is the basic required care for a newborn in any situation. ENC measures include thermal care, infection prevention, initiation of breathing, feeding support, delayed cord clamping, monitoring, and postnatal care.
To promote neonatal care in humanitarian emergencies, a systematic literature review on ENC was conducted, including reports of 21 natural disasters (in Haiti, China, Japan, Nepal, the Philippines, and the USA), wars (in Iraq, Afghanistan, South Sudan, and the Democratic Republic of Congo), and refugee settings (in Thailand and Jordan).
ENC deficits in natural disaster
Some types of natural disaster are predictable, such as some weather-related catastrophes. This leads to a planned increase in the number of caesarean deliveries before the disaster from 62% to 87% to reduce uncertainty in the timing of birth. One consequence of increase of planned c-sections was the delayed initiation of breastfeeding, which can raise health concerns as human milk is important for the newborn’s immune system and basic nutrition.
Another challenge was the provision of a safe space for women to breastfeed during the crisis, and the promotion of accurate breastfeeding information to reduce misconceptions and unregulated formula feeding. One misconception was the inability to produce milk due to stress. The establishment of baby tents helped to create a safe environment and to register and assess the mother-infant pairs in a culturally appropriate manner. A sense of community was created among the pregnant women and new mothers, which contributed to psychosocial support.
The evacuation of neonatal intensive care units (NICU) presented a further challenge. Compared to other patients, hospitalised neonates require a more challenging evacuation as their risk of hypothermia and their overall vulnerability is much higher. Supply shortages, breakdown of communication technology with other hospitals, the lack of staff training and the absence of a response plan were identified as the main challenges.
ENC quality in refugee settings
Refugees are usually accommodated in various types of facilities in the host country. The quality of care for newborns was highly dependent on the refugee camp setting. ENC quality was significantly higher in the Jordanian refugee camps than in the country’s national health system, resulting in a higher neonatal mortality rate outside the camp than in the camp. This emphasises the need for partnerships and integration into local systems of the host country in order to enable access for all women and children in need of medical care and support.
ENC challenges in conflict settings
In conflict environments, cultural challenges became increasingly apparent. For example, mothers in South Sudan and Pakistan refused to provide Kangaroo Mother Care (KMC) due to religious traditions and specific cultural practices, marking the need for culturally adapted ENC guidelines. In addition, the provision of ENC relied heavily on community health workers, and subsequently in the Democratic Republic of Congo, the training of healthcare workers proved to be the most effective intervention. This highlights the urgent need to make the training of community health workers a priority.
Other recommendations from the review suggest the establishment of separate neonatal areas in health facilities with a specialised staffing team. There is a need for locally and culturally appropriate, standardised neonatal guidelines, which have proved to have the potential to reduce neonatal mortality rates by over 50% within five years. Finally, the provision of adequate equipment was one of the main challenges identified in every setting.
Paper available at: https://jhumanitarianaction.springeropen.com/articles/10.1186/s41018-022-00121-2
Ful list of authors: Sally McBride and Alison Morgan
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