Measuring supply-side service disruption: a systematic review of the methods for measuring disruption in the context of maternal and newborn health services in low and middle-income settings.

OBJECTIVES: During the COVID-19 pandemic, most essential services experienced some level of disruption. Disruption in LMICs was more severe than in HICs. Early reports suggested that services for maternal and newborn health were disproportionately affected, raising concerns about health equity. Most disruption indicators measure demand-side disruption, or they conflate demand-side and supply-side disruption. There is currently no published guidance on measuring supply-side disruption. The primary objective of this review was to identify methods and approaches used to measure supply-side service disruptions to maternal and newborn health services in the context of COVID-19. DESIGN: We carried out a systematic review and have created a typology of measurement methods and approaches using narrative synthesis. DATA SOURCES: We searched MEDLINE, EMBASE and Global Health in January 2023. We also searched the grey literature. ELIGIBILITY CRITERIA: We included empirical studies describing the measurement of supply-side service disruption of maternal and newborn health services in LMICs in the context of COVID-19. DATA EXTRACTION AND SYNTHESIS: We extracted the aim, method(s), setting, and study outcome(s) from included studies. We synthesised findings by type of measure (ie, provision or quality of services) and methodological approach (ie, qualitative or quantitative). RESULTS: We identified 28 studies describing 5 approaches to measuring supply-side disruption: (1) cross-sectional surveys of the nature and experience of supply-side disruption, (2) surveys to measure temporal changes in service provision or quality, (3) surveys to create composite disruption scores, (4) surveys of service users to measure receipt of services, and (5) clinical observation of the provision and quality of services. CONCLUSION: Our review identified methods and approaches for measuring supply-side service disruption of maternal and newborn health services. These indicators provide important information about the causes and extent of supply-side disruption and provide a useful starting point for developing specific guidance on the measurement of service disruption in LMICs.

Strengthening Health Systems in Humanitarian Settings: Multi-Stakeholder Insights on Contraception and Postabortion Care Programs in the Democratic Republic of Congo and Somalia.

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.

Breastfeeding knowledge of mothers in protracted crises: the Gaza Strip example.

The protection and support of breastfeeding is the most effective intervention to prevent child morbidity and mortality especially in humanitarian crisis.During the Palestine-Israel conflict healthcare services are understaffed and lack basic resources, with frequent power cuts and stock-outs of essential drugs and equipment. This case study seeks to answer the questions: (1) How does the protracted crisis in Gaza affect the breastfeeding practices of the most vulnerable population; and (2) What is the role that midwives can play in improving breastfeeding practices?The study was conducted using a mixed method approach with quantitative and qualitative methods. Purposeful selection of women and children was conducted utilising eligibility criteria, women with children less than 2 years of age were included. All the respondents were asked if they agreed to participate in the survey.A total of 63% practice early initiation of breastfeeding and 42% confirmed that their new-borns were given liquids other than breast milk during the first 3 days of life. Fifty percent of mothers addressed breast milk insufficiency by drinking additional fluids and 40% by using infant formula. Only 18% of women said that they received breastfeeding information during contact with health professionals throughout labour, delivery, and subsequent post-natal care visits. Many mothers during the focus group discussions (FGDs) confirm using milk to top up or replace breast milk.Myths and misconceptions around breastfeeding remain, while women do access antenatal care services and deliver in the health facilities. There is a need to a) adapt the recommendations of the operational guidance for infant and young child feeding in emergencies (IYCF-E) in the Gaza strip, to protect, promote and support breastfeeding and b) include skilled breastfeeding counselling in the pre-service and in-service training for midwives.Lessons learned included the importance of a) allocating additional research time, to account for interruption b) daily coordination with security officers to ensure safe access to localities c) identification of extra sites, in case of conflict escalation d) training of additional enumerators in case conflict escalation e) negotiation with authorities to ensure compliance with requirements.

Postabortion Care in Humanitarian Emergencies: Improving Treatment and Reducing Recurrence.

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.

Counting the cost of over-the-counter codeine containing analgesic misuse: A retrospective review of hospital admissions over a 5 year period.

INTRODUCTION AND AIMS: Combination analgesics containing codeine (CACC) are currently available over-the-counter (OTC) in many countries following a pharmacist's advice. Published case reports detail life-threatening morbidities associated with OTC-CACC misuse, although the cost of treating such patients has not been quantified. This study aims to: (i) identify and detail patients admitted to an Australian tertiary teaching hospital over a 5 year period with sequelae of OTC-CACC misuse; and (ii) estimate the costs of identified hospital admissions. DESIGN AND METHODS: Using International Classification of Diseases (10th revision) diagnostic codes, a structured search was performed to identify admissions to a tertiary teaching hospital, relating to CACC misuse, over the defined period. A retrospective case note review provided data detailing patient characteristics, presenting morbidities and resultant interventions, and an approximate cost was calculated for identified admissions. RESULTS: Ninety-nine OTC-CACC-related admissions (for 30 individual patients) were identified. Most related to gastrointestinal morbidities secondary to ibuprofen/codeine misuse. Mean length of stay per admission was 5.9 days, with 10.1% of admissions requiring intensive care. Patients consumed a daily mean of 28 OTC-CACC tablets for a mean of 606 days prior to admission. These 99 admissions were estimated to cost the health system AU$1 008 082 with a mean cost per admission of AU$10 183. DISCUSSION AND CONCLUSIONS: The outcomes of OTC-CACC misuse are serious and come at a significant cost to patient health and the Australian health-care system. Identification and management of this cohort appears sub-optimal with delays in diagnosis and high readmission rates.