High severity of abortion complications in fragile and conflict-affected settings: a cross-sectional study in two referral hospitals in sub-Saharan Africa (AMoCo study).

BACKGROUND: Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR). METHODS: We used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records' reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity. RESULTS: We analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%). CONCLUSION: Our data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings.

Review of maternal death audits in refugee camps in UNHCR East and Horn of Africa and Great Lakes Region, 2017-2019.

OBJECTIVES: To review the quality of maternal death audits and identify factors contributing to refugee maternal deaths in the East and Horn of Africa. METHODS: Maternal death audits submitted to The UN Refugee Agency (UNHCR) from 2017 to 2019 in 43 refugee camps in eight countries were analyzed for completeness, obstetric history, cause of death, and contributing factors. RESULTS: A total of 191 refugee maternal death audits were retrieved. The mean age of the deceased was 28 years (range, 15-45 years), and 13% were adolescents and 17% were of advanced maternal age. Most patients (55%) were grand multigravida (≥5 pregnancies). The majority (86%) attended antenatal care visits, with 51% attending four or more visits. Among women who delivered (n = 140), 91% were facility-based deliveries. Most (68%) deaths occurred postpartum. Obstetric hemorrhage (49%) was the leading direct cause of death (with 77 cases of postpartum hemorrhage), followed by hypertensive disorder (19%) and infection (15%). Delays in care were identified in 185 (97%) cases. Delays in receiving care were more prevalent (81%) than in seeking (61%) and reaching (26%) care. CONCLUSION: Factors contributing to delays in receiving care highlight the capacity gaps in provision of emergency obstetric care, including management of postpartum hemorrhage, requiring urgent additional investments. Audit findings also show the need for attention and action towards family planning, contraception, and adolescent sexual and reproductive health services.

Catalyst for change: Lessons learned from overcoming barriers to providing safe abortion care in Médecins Sans Frontières projects.

CONTEXT: Despite instituting a policy in 2004, Médecins Sans Frontières (MSF) continuously struggled to routinely provide safe abortion care (SAC). In 2016, the organization launched an initiative aimed at increasing availability of SAC in MSF projects and increasing understanding of abortion-related dynamics in humanitarian settings. METHODOLOGY: From March 2017 to April 2018, MSF staff conducted support visits to 10 projects in a country in sub-Saharan Africa. Each visit followed a systematic approach with six key components and related tools that were later shared with teams worldwide. Data regarding women seeking abortion services and related outcomes were collected and analyzed retrospectively. RESULTS: From Q1 2017 through Q4 2019, SAC provision increased significantly in all 10 projects, rising from three to 759 safe abortions per quarter. Teams received 3831 patients seeking SAC and provided 3640 first and second trimester abortions, over 99% via medication methods. The overall complication rate was 4.29% and 0.3% for severe, life-threatening complications. No major security incidents were reported. MSF provision of SAC worldwide increased from 781 in 2016 (the year before this initiative began) to 21,546 in 2019. CONCLUSION: Implementation of SAC in humanitarian settings-even those with significant legal restrictions-is possible and necessary. Both first and second trimester medication abortion can be safely and effectively provided through both home- and facility-based models of care. Programmatic data provide valuable insights into abortion-related dynamics which must shape operational decision-making. Addressing internal barriers and providing direct field support were key to stimulating organizational cultural change.

Tranexamic Acid for Postpartum Hemorrhage Treatment in Low-Resource Settings: A Rapid Scoping Review.

Tranexamic acid (TXA) effectively reduces bleeding in women with postpartum hemorrhage (PPH) in hospital settings. To guide policies and practices, this rapid scoping review undertaken by two reviewers aimed to examine how TXA is utilized in lower-level maternity care settings in low-resource settings. Articles were searched in EMBASE, MEDLINE, Emcare, the Maternity and Infant Care Database, the Joanna Briggs Institute Evidence-Based Practice Database, and the Cochrane Library from January 2011 to September 2021. We included non-randomized and randomized research looking at the feasibility, acceptability, and health system implications in low- and lower-middle-income countries. Relevant information was retrieved using pre-tested forms. Findings were descriptively synthesized. Out of 129 identified citations, 23 records were eligible for inclusion, including 20 TXA effectiveness studies, two economic evaluations, and one mortality modeling. Except for the latter, all the studies were conducted in lower-middle-income countries and most occurred in tertiary referral hospitals. When compared to placebo or other medications, TXA was found effective in both treating and preventing PPH during vaginal and cesarean delivery. If made available in home and clinic settings, it can reduce PPH-related mortality. TXA could be cost-effective when used with non-surgical interventions to treat refractory PPH. Capacity building of service providers appears to need time-intensive training and supportive monitoring. No studies were exploring TXA acceptability from the standpoint of providers, as well as the implications for health governance and information systems. There is a scarcity of information on how to prepare the health system and services to incorporate TXA in lower-level maternity care facilities in low-resource settings. Implementation research is critically needed to assist practitioners and decision-makers in establishing a TXA-inclusive PPH treatment package to reduce PPH-related death and disability.

Implementing Heat-Stable Carbetocin for Postpartum Haemorrhage Prevention in Low-Resource Settings: A Rapid Scoping Review.

Heat-stable carbetocin (HSC), a long-acting oxytocin analogue that does not require cold-chain transportation and storage, is effective in preventing postpartum haemorrhage (PPH) in vaginal and caesarean deliveries in tertiary-care settings. We aimed to identify literature documenting how it is implemented in resource-limited and lower-level maternity care settings to inform policies and practices that enable its introduction in these contexts. A rapid scoping review was conducted with an 8-week timeframe by two reviewers. MEDLINE, EMBASE, Emcare, the Joanna Briggs Institute Evidence-Based Practice Database, the Maternity and Infant Care Database, and the Cochrane Library were searched for publications in English, French, and Spanish from January 2011 to September 2021. Randomized and non-randomized studies examining the feasibility, acceptability, and health system considerations in low-income and lower-middle-income countries were included. Relevant data were extracted using pretested forms, and results were synthesized descriptively. The search identified 62 citations, of which 12 met the eligibility criteria. The review did not retrieve studies focusing on acceptability and health system considerations to inform HSC implementation in low-resource settings. There were no studies located in rural or lower-level maternity settings. Two economic evaluations concluded that HSC is not feasible in terms of cost-effectiveness in lower-middle-income economies with private sector pricing, and a third one found superior care costs in births with PPH than without. The other nine studies focused on demonstrating HSC effectiveness for PPH prevention in tertiary hospital settings. There is a lack of evidence on the feasibility (beyond cost-effectiveness), acceptability, and health system considerations related to implementing HSC in resource-constrained and lower-level maternity facilities. Further implementation research is needed to help decision-makers and practitioners offer an HSC-inclusive intervention package to prevent excessive bleeding among pregnant women living in settings where oxytocin is not available or of dubious quality.

A call to safeguard sexual and reproductive health information and services during Ebola outbreaks.

The recent Ebola virus disease (EVD) outbreaks in 2021 exemplify how sexual and reproductive health services are too often considered unessential during health emergencies. Bleeding for reasons other than EVD, such as pregnancy complications or rape, can be construed as EVD symptoms, reinforcing fear and stigmatisation, and delaying timely access to adequate care. In this commentary, we urgently call on all humanitarian actors to integrate the Minimum Initial Services Package for Sexual and Reproductive Health in Crisis Situations into current and future EVD preparedness and response efforts.

Neonatal mortality burden and trends in UNHCR refugee camps, 2006-2017: a retrospective analysis.

BACKGROUND: More than 100 million people were forcibly displaced over the last decade, including millions of refugees displaced across international borders. Although refugee health and well-being has gained increasing attention from researchers in recent years, few studies have examined refugee birth outcomes or newborn health on a regional or global scale. This study uses routine health information system data to examine neonatal mortality burden and trends in refugee camps between 2006 and 2017. METHODS: Refugee population and mortality data were exported from the United Nations High Commissioner for Refugees (UNHCR) Health Information System (HIS) database. Tableau was used to export the data. Stata was used for data cleaning and statistical analysis. Neonatal mortality burdens and trends in refugee camps were analyzed and compared to national and subnational neonatal mortality rates captured by household surveys. FINDINGS: One hundred fifty refugee camps in 21 countries were included in this study, with an average population of 1,725,433 between 2006 and 2017. A total of 663,892 live births and 3382 neonatal deaths were captured during this period. Annual country-level refugee camp neonatal mortality rates (NMR) ranged from 12 to 56 neonatal deaths per 1000 live births. In most countries and years where national population-based surveys are available, refugee camp NMR as reported in the UNHCR HIS was lower than that of the immediate host community. CONCLUSION: The UNHCR HIS provides insights into the neonatal mortality burden among refugees in camp settings and issues to consider in design and use of routine health information systems to monitor neonatal health in sub-national populations. Increased visibility of neonatal deaths and stillbirths among displaced populations can drive advocacy and inform decisions needed to strengthen health systems. Efforts to count every stillbirth and neonatal death are critical, as well as improvements to reporting systems and mechanisms for data review within broader efforts to improve the quality of neonatal care practices within and outside of health facilities.

"Better dead than being mocked": an anthropological study on perceptions and attitudes towards unwanted pregnancy and abortion in the Democratic Republic of Congo.

Unwanted pregnancy and unsafe abortion contribute significantly to the burden of maternal suffering, ill health and death in the Democratic Republic of Congo (DRC). This qualitative study examines the vulnerabilities of women and girls regarding unwanted pregnancy and abortion, to better understand their health-seeking behaviour and to identify barriers that hinder them from accessing care. Data were collected in three different areas in eastern DRC, using in-depth individual interviews, group interviews and focus group discussions. Respondents were purposively sampled. All interviews were audio recorded and transcribed verbatim. Transcriptions were screened for relevant information, manually coded and analysed using qualitative content analysis. Perceptions and attitudes towards unwanted pregnancy and abortion varied across the three study areas. In North Kivu, interviews predominantly reflected the view that abortions are morally reprehensible, which contrasts the widespread practice of abortion. In Ituri many perceive abortions as an appropriate solution for reducing maternal mortality. Legal constraints were cited as a barrier for health professionals to providing adequate medical care. In South Kivu, the general view was one of opposition to abortion, with some tolerance towards breastfeeding women. The main reasons women have abortions are related to stigma and shame, socio-demographics and finances, transactional sex and rape. Contrary to the prevailing critical narrative on abortion, this study highlights a significant need for safe abortion care services. The proverb "Better dead than being mocked" shows that women and girls prefer to risk dying through unsafe abortion, rather than staying pregnant and facing stigma for an unwanted pregnancy.

Lessons Learned From Helping Babies Survive in Humanitarian Settings.

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.

Wishful thinking versus operational commitment: is the international guidance on priority sexual and reproductive health interventions in humanitarian settings becoming unrealistic?

Twenty-one years ago, a global consortium of like-minded institutions designed the landmark Minimum Initial Service Package (MISP) for sexual and reproductive health (SRH) to guide national and international humanitarian first responders in preventing morbidity and mortality at the onset of chaos, destruction, and high insecurity caused by disasters or conflicts. Since then, the MISP has undergone limited change and has become an international reference in humanitarian response. This article discusses our perspectives regarding the 2018 changes to the MISP that have created division among humanitarian field practitioners, academics, advocates, and development agencies. With more than 50 pages, the new MISP chapter dilutes key guidance and messages on the most life-saving activities, leaving actors with excessive room for interpretation as to which priority activities need to be first implemented. Consequently, non-life-saving interventions may take precedence over essential ones. Insecurity, scarce human and financial resources, logistics constrains, and other limitations imposed by field reality at the onset of a crisis must be considered. We strongly recommend that an institution with the mandate, legitimacy, and technical expertise in the review of guidelines reexamines the 2018 edition of the MISP. We urge experienced first-line responders, national actors, and relevant agencies to join efforts to ensure that the MISP remains focused on a very limited set of essential activities and supplies that are pragmatic, field-oriented, and, most importantly, immediately life-saving for people in need.

Why Médecins Sans Frontières (MSF) provides safe abortion care and what that involves.

MSF responds to needs for the termination of pregnancy, including on request (TPR); it is part of the organization's work aimed at reducing maternal mortality and suffering; and preventing unsafe abortions in the countries where we work. Following the publication of "Why don't humanitarian organizations provide safe abortion care?" we offer an insight into MSF's experience over the past few years. The article looks at the legal concerns and proposes that the importance of addressing maternal mortality should replace them and the operational set-up and action organized in a way that mitigates risks. MSF took a policy decision on safe abortion care in 2004; the fact that care did not expand rapidly to relevant MSF projects came as a surprise, reflecting the important weight social norms around abortion have everywhere. The need to engage in an open dialogue with staff, relevant medical actors and at community level became more obvious. Finally the article looks some key lessons that have emerged for the organization as part of the effort to prevent ill health, maternal death and suffering caused by unwanted pregnancy and unsafe abortion.