"Implementation of intensified COVID-19 vaccination optimization (ICVOPT) campaigns strategy in complex humanitarian emergency settings and hard-to-reach areas; a case of South Sudan".

INTRODUCTION: The COVID-19 pandemic is still a public health concern in South Sudan having caused suffering since the first case of COVID-19 was introduced on 28th February 2020. COVAX vaccines have since been introduced using a number of strategies including fixed site, temporary mobile, hit and run in flooded and conflict affected areas. We aim to describe the 2 ICVOPT campaigns that were conducted to improve the uptake and document lessons learnt during the initial rollout of the COVID-19 vaccination programin South Sudan between February 2022 and June 2022 each lasting for 7-days. METHODOLOGY: We conducted an operational cross-sectional descriptive epidemiological study of a series of the intensified COVID-19 vaccination Optimization (ICVOPT) campaigns from February 2022 to June 2022. Before the campaign, a bottom up micro-planning was conducted, validated by the County Health Departments (CHDs) and national MOH team. Each of the 2 campaigns lasted for 7 days targeting 30% of the eligible unvaccinated target population who were18 years and above. Each team consisted of 2 vaccinators, 2 recorders and 1 mobilizer. The teams employed both fixed site, temporary mobile, hit and run in flooded and conflict affected areas. The number of teams were calculated based on the daily workload per day (80 persons per team/day) for the duration of the campaigns. RESULTS: A total of 444,030 individuals were vaccinated with primary series COVID-19 vaccine (J&J) out of the targeted 635,030 persons. This represented 69.9% of target population in the selected 28 counties and 10 states of South Sudan in 7 days' ICVOPT campaigns. More eligible persons were reached in 7 days campaigns than the 9 months of rollout of the COVID-19 vaccine prior to ICVOPT campaigns using the fixed site strategy at the health facility posts. CONCLUSION: Intensified COVID-19 vaccination Optimization (ICVOPT) campaigns were vital and fast in scaling up vaccination coverages as compared to the fixed site vaccination strategies (2022 progress report on the Global Action Plan for Healthy Lives and Well-being for All Stronger collaboration for an equitable and resilient recovery towards the health-related Sustainable Development Goals, incentivizing collaboration, 2022) in complex humanitarian emergency settings and hard-to-reach areas of South Sudan.

Lessons to learn from the analysis of routine health data from Moria Refugee Camp on Lesvos, Greece.

BACKGROUND: Refugees in humanitarian settings commonly experience many health needs and barriers to access healthcare; health data from these settings are infrequently reported, preventing effective healthcare provision. This report describes health needs of refugees in Moria Camp on Lesvos, Greece-Europe's largest refugee camp. METHODS: A set of routinely collected service data of 18 131 consultations of 11 938 patients, attending a primary care clinic in the camp over 6 months in 2019-20, was analysed retrospectively, focusing on chronic health conditions. RESULTS: The most frequent chronic conditions were musculoskeletal pain (25.1%), mental health (15.9%), cardiac (12.7%) and endocrine conditions (8.9%). In all, 70.4% of consultations were for acute health problems, with high rates of injuries and wounds (20.8%), respiratory infections (12.5%), gastroenteritis (10.7%) and skin problems (9.7%), particularly scabies. CONCLUSIONS: The prevalence of acute and chronic health problems is high in this setting, with some likely attributable to the deplorable living conditions in the camp. Despite its magnitude, the interpretability of routine health data is limited. A research agenda is identified, and a framework for chronic disease management in refugee camps is proposed.

Advancing the Role of Higher Education Institutions to Support Palliative Care Education in Primary Care and Humanitarian Settings within Low- and Middle-Income Countries: Online Workshop Report.

The need for palliative care is increasing, especially in low- and middle-income countries (LMICs). Higher education institutions (HEIs) have a role to play in developing a skilled palliative care workforce in LMICs. A workshop was held to discuss this issue, and it was attended by experts from around the world. The workshop highlighted the challenges and opportunities for palliative care education in HEIs for LMIC settings. The participants discussed the importance of a collaborative interprofessional approach and advocacy for the inclusion of palliative care into a wide range of curricula. They also expressed the hope to explore possibilities of networks to continue this discussion and incorporate the wider perspectives from primary care and humanitarian practitioners.

Factors influencing the effective management of diabetes during humanitarian crises in low- and middle-income countries: a systematic review.

OBJECTIVES: The management of non-communicable chronic diseases such as diabetes mellitus is often poor in humanitarian crisis settings. Poor disease management can have serious long-term consequences. This review sought to identify studies that explored the effectiveness of interventions and the determinants that may improve the management of diabetes in the humanitarian context. STUDY DESIGN: A systematic review was conducted of all types of studies that implemented diabetes programmes in humanitarian settings. METHODS: MEDLINE, Embase, CINAHL and Web of Science were searched for relevant articles using multiple search terms for relevant studies published in English between 2000 and June 2020. Quality assessments using valid tools, were conducted. A narrative synthesis of the findings was then performed. RESULTS: The search yielded 550 citations. After de-duplicating and screening, 19 studies were eligible for inclusion. Most studies were conducted in the Middle East (74%), Asia (16%) and Africa (10%). The interventions reported to improved diabetes care included the mHealth tool, intensive lifestyle intervention, task-shifting, psychosocial support, distribution of glucometers and comprehensive care. Insufficient drug supply, out-of-pocket cost, the complexity of insulin therapy and low adherence to guidelines were identified as barriers. CONCLUSION: There is a paucity of evidence on optimal diabetes care in acute crisis and natural disaster settings. The review was constrained by the low quality of the studies included. Nevertheless, it is likely that mHealth can be feasibly utilised, as educational SMS messages are cost-effective and electronic medical records can enhance disease monitoring. In addition, a multidisciplinary approach to care improves glycaemic control and is desirable due to the multifaceted nature of the disease and management required. Several key barriers have been identified that need to be tackled. Overall, the evidence base for diabetes care in humanitarian settings remains sparse, and further research is needed.

Epidemiology of surgery in a protracted humanitarian setting: a 20-year retrospective study of Nyarugusu Refugee Camp, Kigoma, Western Tanzania.

BACKGROUND: There are 80 million forcibly displaced persons worldwide, 26.3 million of whom are refugees. Many refugees live in camps and have complex health needs, including a high burden of non-communicable disease. It is estimated that 3 million procedures are needed for refugees worldwide, yet very few studies exist on surgery in refugee camps, particularly protracted refugee settings. This study utilizes a 20-year dataset, the longest dataset of surgery in a refugee setting to be published to date, to assess surgical output in a setting of protracted displacement. METHODS: A retrospective review of surgeries performed in Nyarugusu Camp was conducted using paper logbooks containing entries between November 2000 and September 2020 inclusive. Abstracted data were digitized into standard electronic form and included date, patient nationality, sex, age, indication, procedure performed, and anesthesia used. A second reviewer checked 10% of entries for accuracy. Entries illegible to both reviewers were excluded. Demographics, indication for surgery, procedures performed, and type of anesthesia were standardized for descriptive analysis, which was performed in STATA. RESULTS: There were 10,799 operations performed over the 20-year period. Tanzanians underwent a quarter of the operations while refugees underwent the remaining 75%. Ninety percent of patients were female and 88% were 18 years of age or older. Caesarean sections were the most common performed procedure followed by herniorrhaphies, tubal ligations, exploratory laparotomies, hysterectomies, appendectomies, and repairs. The most common indications for laparotomy procedures were ectopic pregnancy, uterine rupture, and acute abdomen. Spinal anesthesia was the most common anesthesia type used. Although there was a consistent increase in procedural volume over the study period, this is largely explained by an increase in overall camp population and an increase in caesarean sections rather than increases in other, specific surgical procedures. CONCLUSION: There is significant surgical volume in Nyarugusu Camp, performed by staff physicians and visiting surgeons. Both refugees and the host population utilize these surgical services. This work provides context to the surgical training these settings require, but further study is needed to assess the burden of surgical disease and the extent to which it is met in this setting and others.

Cost-effectiveness of WHO Problem Management Plus for adults with mood and anxiety disorders in a post-conflict area of Pakistan: randomised controlled trial.

BACKGROUND: With the development of evidence-based interventions for treatment of priority mental health conditions in humanitarian settings, it is important to establish the cost-effectiveness of such interventions to enable their scale-up. AIMS: To evaluate the cost-effectiveness of the Problem Management Plus (PM+) intervention compared with enhanced usual care (EUC) for common mental disorders in primary healthcare in Peshawar, Pakistan. Trial registration ACTRN12614001235695 (anzctr.org.au). METHOD: We randomly allocated 346 participants to either PM+ (n = 172) or EUC (n = 174). Effectiveness was measured using the Hospital Anxiety and Depression Scale (HADS) at 3 months post-intervention. Cost-effectiveness analysis was performed as incremental costs (measured in Pakistani rupees, PKR) per unit change in anxiety, depression and functioning scores. RESULTS: The total cost of delivering PM+ per participant was estimated at PKR 16 967 (US$163.14) using an international trainer and supervisor, and PKR 3645 (US$35.04) employing a local trainer. The mean cost per unit score improvement in anxiety and depression symptoms on the HADS was PKR 2957 (95% CI 2262-4029) (US$28) with an international trainer/supervisor and PKR 588 (95% CI 434-820) (US$6) with a local trainer/supervisor. The mean incremental cost-effectiveness ratio (ICER) to successfully treat a case of depression (PHQ-9 ≥ 10) using an international supervisor was PKR 53 770 (95% CI 39 394-77 399) (US$517), compared with PKR 10 705 (95% CI 7731-15 627) (US$102.93) using a local supervisor. CONCLUSIONS: The PM+ intervention was more effective but also more costly than EUC in reducing symptoms of anxiety, depression and improving functioning in adults impaired by psychological distress in a post-conflict setting of Pakistan.

Mediators of focused psychosocial support interventions for children in low-resource humanitarian settings: analysis from an Individual Participant Dataset with 3,143 participants.

BACKGROUND: Research on psychosocial interventions has been focused on the effectiveness of psychosocial interventions on mental health outcomes, without exploring how interventions achieve beneficial effects. Identifying the potential pathways through which interventions work would potentially allow further strengthening of interventions by emphasizing specific components connected with such pathways. METHODS: We conducted a preplanned mediation analysis using individual participant data from a dataset of 11 randomized controlled trials (RCTs) which compared focused psychosocial support interventions versus control conditions for children living in low- and middle-income countries (LMICs) affected by humanitarian crises. Based on an ecological resilience framework, we hypothesized that (a) coping, (b) hope, (c) social support, and (d) functional impairment mediate the relationship between intervention and outcome PTSD symptoms. A systematic search on the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PubMed, PyscARTICLES, Web of Science, and the main local LMICs databases was conducted up to August 2018. The hypotheses were tested by using individual participant data obtained from study authors of all the studies included in the systematic review. RESULTS: We included 3,143 children from 11 studies (100% of data from included studies), of which 1,877 from six studies contributed to the mediation analysis. Functional impairment was the strongest mediator for focused psychosocial interventions on PTSD (mediation coefficient -0.087, standard error 0.040). The estimated proportion of effect mediated by functional impairment, and adjusted for confounders, was 31%. CONCLUSIONS: Findings did not support the proposed mediation hypotheses for coping, hope, and social support. The mediation through functional impairment may represent unmeasured proxy measures or point to a broader mechanism that impacts self-efficacy and agency.

Programme potential for the prevention of and response to sexual violence among female refugees: a literature review.

Continuing international conflict has resulted in several million people seeking asylum in other countries each year, over half of whom are women. Their reception and security in overburdened camps, combined with limited information and protection, increases their risk and exposure to sexual violence (SV). This literature review explores the opportunities to address SV against female refugees, with a particular focus on low-resource settings. A systematic literature review of articles published between 2000 and 2016 was conducted following PRISMA guidelines. Databases including Medline (Ovid), PubMed, Scopus, PsychINFO, CINAHL and the Cochrane Library. Grey literature from key refugee websites were searched. Studies were reviewed for quality and analysed according to the framework outlined in the UNHCR Guidelines on Prevention and Response of Sexual Violence against Refugees. Twenty-nine studies met the inclusion criteria, of which 7 studies addressed prevention, 14 studies response and 8 addressed both. There are limited numbers of rigorously evaluated SV prevention and response interventions available, especially in the context of displacement. However, emerging evidence shows that placing a stronger emphasis on programmes in the category of engagement/participation and training/education has the potential to target underlying causes of SV. SV against female refugees is caused by factors including lack of information and gender inequality. This review suggests that SV interventions that engage community members in their design and delivery, address harmful gender norms through education and advocacy, and facilitate strong cooperation between stakeholders, could maximise the efficient use of limited resources.

What it takes to get it right: A qualitative study exploring optimal handover of health programmes in Tonkolili District, Sierra Leone.

Since 2015 Médecins Sans Frontières (MSF) has been supporting the Ministry of Health (MoH) in Tonkolili district, Sierra Leone, with an integrated health care approach at the community, primary health centre (PHC), and hospital level. This programme is planned to be handed over to MoH. To prepare for this handover, a qualitative study exploring elements of a successful handover was undertaken in 2019. Focus group discussions (FGD) with the community members (n-48) and in-depth interviews (IDI) with MSF staff, community leaders, and MoH staff in Sierra Leone (n-15) were conducted. Data were audio-recorded, transcribed verbatim from English, Creole, and Themne, coded, and thematically analysed. Participants expressed that an optimal project handover and exit strategy should be a continuous, long-term, the staggered process included from the inception of the programme design. It requires clear communication and relationship building by all relevant stakeholders and demands efficient resources and management capacity. Associated policy implications are applicable across humanitarian settings on the handover of programmes where the government is functional and willing to accept responsibilities.

Diabetes Care in Humanitarian Settings.

Despite the increasing prevalence of diabetes in populations experiencing humanitarian crisis, along with evidence that people living with diabetes are at higher risk for poor outcomes in a crisis, diabetes care is not routinely included in humanitarian health interventions. We here describe 4 factors that have contributed to the inequities and lack of diabetes inclusion in humanitarian programmes: (1) evolving paradigms in humanitarian health care, (2) complexities of diabetes service provision in humanitarian settings, (3) social and cultural challenges, and (4) lack of financing. We also outline opportunities and possible interventions to address these challenges and improve diabetes care among crisis-affected populations.

Methodological and Ethical Implications of Using Remote Data Collection Tools to Measure Sexual and Reproductive Health and Gender-Based Violence Outcomes among Women and Girls in Humanitarian and Fragile Settings: A Mixed Methods Systematic Review of Peer-Reviewed Research.

Purpose: This systematic review investigates the methodological and ethical implications of using remote data collection tools to measure sexual/reproductive health (SRH) and gender-based violence (GBV) outcomes among women and girls in humanitarian and fragile settings. Methods: We included empirical studies of all design types that collected any self-reported primary data related to SRH/GBV using information and communication technology, in the absence of in-person interactions, from women and girls in humanitarian and fragile settings. The search was run in March 2021 without filters or limits in Ovid Medline, Embase, Web of Science, Clinicaltrials.gov, and Scopus. Quality was assessed using an adapted version of the MMAT tool. Two reviewers independently determined whether each full text source met the eligibility criteria, and conflicts were resolved through consensus. A-priori extraction fields concerned methodological rigor and ethical considerations. Results: 21 total studies were included. The majority of studies were quantitative descriptive, aiming to ascertain prevalence. Telephone interviews, online surveys, and mobile applications, SMS surveys, and online discussion forums were used as remote data collection tools. Key methodological considerations included the overuse of non-probability samples, lack of a defined sampling frame, the introduction of bias by making eligibility contingent on owning/accessing technology, and the lack of qualitative probing. Ethical consideration pertained to including persons with low literacy, participant safety, use of referral services, and the gender digital divide. Conclusion: Findings are intended to guide SRH/GBV researchers and academics in critically assessing methodological and ethical implications of using remote data collection tools to measure SRH and GBV in humanitarian and fragile settings.

Effects of Nutrition Counselling and Unconditional Cash Transfer on Child Growth and Family Food Security in Internally Displaced Person Camps in Somalia-A Quasi-Experimental Study.

The effects of nutrition counselling (NC) and unconditional cash transfer (UCT) in improving growth in children under five and household food security are poorly understood in humanitarian settings. Therefore, this study aimed to evaluate the effects of NC and NC combined with unconditional cash transfer (NC + UCT) on children's growth and food security in Somalia. The study was performed with a quasi-experimental design in two districts in the Banadir region of Somalia. Caregivers (n = 255) with mildly to moderately malnourished children aged 6 to 59 months old (n = 184) were randomized to the NC, NC + UCT and control groups. The interventions consisted of weekly NC for three months alone or in combination with UCT. The outcome variables were wasting, underweight, stunting, and food security. Difference-indifferences analysis was used to estimate the effect of the interventions. Our study did not find any significant impacts of NC or NC + UCT on child wasting, underweight, stunting, food security or household expenses. In conclusion, NC, alone or in combination with UCT, did not impact children's growth or household food security. Thus, a culturally tailored NC programme over a longer period, supplemented with cash transfer, could be beneficial to consider when designing interventions to reduce malnutrition and food insecurity.

The role of integrated programs in the prevention of COVID-19 in a humanitarian setting.

The COVID-19 pandemic has caused a severe depletion to health systems worldwide. In the South Kordofan state, a war-torn humanitarian region in Sudan, the United Nations High Commissioner for Refugees and the WHO Emergencies Programme have led the development of integrated programs for health, peace and rehabilitation by training rapid response teams to strengthen both surveillance system and response capacities, engaging the communities at risk with health education and promotion activities, as well as following proper infection, prevention and control measures during case investigation. Also, Early Help Assessment coordinators met with health services managers and recruited 14 teams who were trained to ensure a rapid response to COVID-19. Also, the implementation of water, sanitation and hygiene services was upscaled. Although the local community of South Kordofan is fragile and at high risk of infectious diseases, the limited numbers of detected cases of COVID-19 and COVID-19 deaths could be attributed to the early preparation and integration of programs that helped to prevent the local spread of COVID-19. This lesson needs to be thoroughly investigated to estimate whether it is cost-effective and to determine the feasibility of it being successfully implemented in other humanitarian settings.

Measuring the dosage of brief and skill-targeted social-emotional learning (SEL) activities in humanitarian settings.

Introduction: In humanitarian settings, social-emotional learning (SEL) programs for children are often delivered using a field-feasible approach where the programs are more easily deployable and adaptable in the field, require minimal training, and depend less on the strict sequence and structure of the program components to elicit the intended treatment effect. However, evidence is lacking on what aspects of this implementation approach enable the SEL programming to be more beneficial to children's SEL development. Method: In this study, we propose and evaluate measures for three dimensions of dosage (quantity, duration, and temporal pattern) of two sets of brief and skill-targeted SEL activities (Mindfulness and Brain Games) implemented in 20 primary schools in two low-income chiefdoms of Sierra Leone. Results: We find preliminary evidence of predictive validity that these dosage measures could predict children's attendance and classroom adaptive behavior. Discussion: This study is the first to develop procedures to measure the dimensions of dosage of brief SEL activities in humanitarian settings. Our findings illuminate the need for future research on optimizing the dosage and implementation design of SEL programming using brief SEL activities.

Investigating Incidence, Correlates, and Consequences of Child Marriage Among Syrian Refugees Residing in the South of Lebanon: A Cross-Sectional Study.

PURPOSE: Research on child marriage has increased in volume but remains scarce in humanitarian settings. This study aimed to investigate rates, correlates, and consequences of child marriage among Syrian refugees in South Lebanon. METHODS: A sample of 1,593 female adolescents and 893 adults was selected using a multistage stratified cluster survey design. We quantified the cumulative incidence of child marriage among age cohorts of female refugees and identified risk factors associated with child marriage using survival methods. We also presented sexual and reproductive health measures among child brides. RESULTS: We found evidence that child marriage was widely practiced among adolescent girls, with Kaplan-Meier curves showing that 32.56% of girls aged 10-19 transitioned to marriage by age 17. Although high, this was lower than rates among women aged 25-29 (p < .005), indicating that child marriage was already widely practiced in prewar Syria. Our Cox models indicated that several factors, which mirror drivers of child marriage in stable settings, are associated with hazard of child marriage in this context. We additionally found important sexual and reproductive health gaps among child brides, such as low levels of knowledge of the dangers of early childbearing and closely spaced births as well as high rates of early and multiple births. CONCLUSIONS: Child marriage is a pervasive practice among Syrian refugees residing in this setting. Our results suggest that a confluence of factors at different levels of the social ecology increase refugee girls' vulnerability to child marriage. They also demonstrate the pressing need for interventions that target refugee child brides.

Understanding and Responding to Substance Use and Abuse in the Palestinian Refugee Camps in Lebanon Prior to and During COVID-19 Times.

Due to its geographical proximity to the Syrian conflict and the occupied territories, Lebanon has experienced an influx of refugees in recent times. Palestinian refugees are an identified key vulnerable population, with displaced communities increasingly experiencing camp insecurity, vulnerability to drug use and related health harms. A qualitative study consisting of in-depth interviews and focus group discussions (FGDs) was undertaken as part of a regional exercise investigating Palestinian community experiences of substance and drug use in refugee camps. Thematic analysis triangulated the perspectives of 11 professional stakeholders representing United Nations, human rights and non-governmental organizations (NGOs), and eight Palestinian community members. Emerging themes centered on the interplay between socio-economic instability, lack of law enforcement and camp governance contributing to concerning levels of familial, drug and camp violence, trafficking and availability of drugs. Transactional sex and the exploitation of women and children in drug dealing, diversification toward drug manufacture and dealing of drugs with the outside community were described. There is a lack of harm reduction and rehabilitation supports for those in need. This study highlights the complexities in tackling drug dealing and related criminal activity within refugee camps and humanitarian settings, and the vulnerabilities of those living within to harmful drug use.

Using a community-based system dynamics approach for understanding inclusion and wellbeing: a case study of special needs education in an eastern African refugee camp.

BACKGROUND: Children with disabilities face unique challenges in humanitarian aid settings and education may provide protective measures against abuse and exploitation. There are growing calls for inclusive education of children with disabilities in formal education, but little guidance exists on how to enhance inclusion in complex and resource-constrained contexts of humanitarian settings. CASE PRESENTATION: This study used a community-based system dynamics approach to understand key stakeholders' perspectives of the drivers and effects of inclusion and wellbeing for children with disabilities, and to elicit recommendations to enhance educational inclusion in a refugee camp in Eastern Africa. Community-based system dynamics sessions, designed based on group model building scripts and facilitated by a team of four people, took place with organization staff, community leaders, and parents and caregivers of children with disabilities. The process produced a causal loop diagram depicting the stakeholders' perspectives of how multiple components interact in a system to drive inclusion and wellbeing of children with disabilities over time. CONCLUSIONS: Findings indicate participants have a broad conceptualization of inclusion, highlighting the value of community interaction and importance of meeting basic needs, and also demonstrate that including children in mainstream educational settings in a complex humanitarian context requires a more nuanced approach given the lack of existing resources to support Western models of educational inclusion fully.

Tutor of Resilience: A Model for Psychosocial Care Following Experiences of Adversity.

This article describes a model for training service providers to provide interventions that build resilience among individuals who have experienced adversity. The Tutor of Resilience model emphasizes two distinct dimensions to training: (1) transforming service providers' perceptions of intervention beneficiaries by highlighting their strengths and capacity for healing; and (2) flexibly building contextually and culturally specific interventions through a five-phase model of program development and implementation. Tutor of Resilience has been employed successfully with child and youth populations under stress in humanitarian settings where mental health and psychosocial support professionals are required to design and deliver interventions that enhance resilience among vulnerable children.

A qualitative study on health care providers' experiences of providing comprehensive abortion care in Cox's Bazar, Bangladesh.

BACKGROUND: Humanitarian settings are characterised by limited access to comprehensive abortion care. At the same time, humanitarian settings can increase the vulnerability of women and girls to unintended pregnancies and unsafe abortions. Humanitarian actors and health care providers can play important roles in ensuring the availability and accessibility of abortion-related care. This study explores health care providers' perceptions and experiences of providing comprehensive abortion care in a humanitarian setting in Cox's Bazar, Bangladesh and identifies barriers and facilitators in service provision. METHOD: In-depth interviews (n = 24) were conducted with health care providers (n = 19) providing comprehensive abortion care to Rohingya refugee women and with key informants (n = 5), who were employed by an organisation involved in the humanitarian response. Data were analysed using an inductive content analysis approach. RESULTS: The national menstrual regulation policy provided a favourable legal environment and facilitated the provision of comprehensive abortion care, while the Mexico City policy created organisational barriers since it made organisations unable or unwilling to provide the full comprehensive abortion care package. Supplies were available, but a lack of space created a barrier to service provision. Although training from organisations had made the health care providers confident and competent and had facilitated the provision of services, their knowledge of the national abortion law and menstrual regulation policy was limited and created a barrier to comprehensive abortion services. Even though the health care providers were willing to provide comprehensive abortion care and had acquired skills and applied strategies to communicate with and provide care to Rohingya women, their personal beliefs and their perceptions of Rohingya women influenced their provision of care. CONCLUSION: The availability and accessibility of comprehensive abortion care was limited by unfavourable abortion policies, a lack of privacy, a lack of knowledge of abortion laws and policies, health care providers' personal beliefs and a lack of cultural safety. To ensure the accessibility and availability of quality services, a comprehensive approach to sexual and reproductive health and rights is needed. Organisations must ensure that health care providers have knowledge of abortion policies and the ability to provide quality care that is woman-centred and non-judgmental.

A review of methodology and tools for measuring maternal mortality in humanitarian settings.

Estimation of maternal mortality ratio (MMR) in humanitarian settings ('settings of conflict, displacement and natural disaster') is challenging, particularly where communities have dissolved and geographical areas are inaccessible. During humanitarian events, the reproduction of maternal mortality figures by the media is common, and are often based on inaccurate reports. In light of such uncertainties and challenges, the aim of this article was to review and appraise the methodology and data collection tools used to measure MMR in humanitarian settings. A critical review of both grey and peer-review publications was conducted, focussing on articles published from January 1995 until December 2016. In the final review, articles that provided an estimate of MMR from a humanitarian setting were included. The assessment of study quality was based on an adapted framework for the quality of mortality studies in humanitarian settings. Overall, 13 peer-review publications and one grey publication were included in the final review. These were grouped according to settings: camp, clinic, household and census. Studies varied in their definition of MMR, and few studies objectively defined the humanitarian setting. Household-based studies were based on retrospective designs and on the recall of surviving family members. Although many studies attempted to purposively sample the populations afflicted, there was substantial evidence of selection bias; few studies were able to confirm the maternal deaths through medical certificates, or attempted to visit homes to re-inquire about deaths using verbal autopsy. The variation in methods and tools applied suggest that maternal mortality estimates are more likely to be markedly different from the true unknown level. The implications are that a standardized methodology and tools are necessary: that are consistent in definition, use a representative sample where possible, attempt to triangulate and validate data sources, and reconfirm deaths through household visits with informant interviews.