1 Improving maternal, newborn and women’s reproductive health in crisis settings: Findings from a Cochrane systematic review Primus Che Chi Centre for Research on Health Care in Disasters, PHS, KI and PRIO 10th GLOBVAC conference, Trondheim
2 Outline Background and aim Intervention areas and study outcomesResults: Flowchart; Included studies & Effects of interventions; Near-miss excluded studies Discussion Summary of main results Near-miss excluded studies & Key lessons learnt Conclusions Implications for practice Implications for research 10th GLOBVAC conference
3 Background and aim Poor maternal, newborn and reproductive health in crisis settings Increasing number of people affected by crises globally (frequent disaster events, deepening conflicts etc) Challenges of health systems in crises; need to adapt to patient-centred service delivery Aim: To identify, synthesise and evaluate the effects of health system and other interventions aimed at improving maternal, newborn and women’s reproductive health in crisis settings 10th GLOBVAC conference
4 How the interventions might work Improving the demand for basic health services Increasing the supply and quality of basic health services Ensuring the security of health personnel and protection of health facilities Reducing the risk for sexual violence and providing adequate support for survivors Reducing the risk of transmission of HIV and other STIs Ensuring mothers and newborns have access to life-saving health services. 10th GLOBVAC conference
5 Types of outcome measures Primary outcomes Coverage of or access to health services (e.g. ANC coverage and access to skilled birth attendance) Utilisation of health services (e.g. attendance at ANC clinics) Adverse effects (e.g. health worker attrition and unanticipated increased workload) Secondary outcomes Patient outcomes (e.g. maternal and newborn mortality and morbidity) Quality of care (e.g. adherence to recommended practice or guidelines) Resource use 10th GLOBVAC conference
6 Results 10th GLOBVAC conference
7 Flowchart 10th GLOBVAC conference
8 Included studies Bass 2013: RCT on the impact of cognitive processing therapy (a mental health intervention) on female sexual-violence survivors with high levels of PTSD symptoms and combined depression and anxiety symptoms compared to individual support in Eastern DRC Bass 2016: RCT on impact of Village Savings and Loans Associations (VSLA) on economic, social, and psychological outcomes among female sexual violence survivors with elevated mental health symptoms and impaired functioning in DRC 10th GLOBVAC conference
9 Excluded near-miss studiesImprove the demand for and supply of basic health services (these were merged as most study interventions implemented both) – 8 Improve security for health personnel and infrastructure: 1 Prevent sexual violence and provide appropriate assistance to survivors: 1 Reduce the transmission of HIV and Other STIs: 4 Prevent excess maternal and newborn death and disability: 5 10th GLOBVAC conference
10 Improve the demand for and supply of basic health services - 8Fofana 1997: Community loan funds to promote EmOC uptake Kandeh 1997: Community motivators to promote EmOC uptake Samai 1997: Transportation and communication supplies (1 4WD & 8 motor bikes) to promote EmOC uptake Leigh 1997: Health facility upgrade and staff recruitment to promote EmOC uptake Krause 2006: Infrastructural upgrade, supply of EmOC commodities and services to improve availability of EmOC Mullany 2010: Provision of mobile maternal health services, including EmOC through a three-tiered collaborative network of community-based maternal health workers. Huber 2010: Community engagement and the provision of culturally acceptable FP services Casey 2013: Upgrading of local health facilities with FP services especially LAPM and provision of mobile FP services to improve the availability of LAPM 10th GLOBVAC conference
11 Improve security for health personnel and infrastructure: 1 Chu 2011: Evacuation of expatriate surgical staff, followed by remote support of local surgical staff from abroad. Prevent sexual violence and provide appropriate assistance to survivors: 1 Post-rape mental health (psychological support) by a clinical psychologist. 10th GLOBVAC conference
12 Reduce the transmission of HIV and Other STIs: 4Rutta 2008: Implementation of a comprehensive PMTCT programme in a refugee camp. Kiboneka 2009: Implementation of a combination ART programme within a conflict-affected population through a NGO clinic, mobile outreaches and home visits. Bannink-Mbazzi 2013:Implementation of a PMTCT programme in a conflict-affected population, involving facility upgrade and supplies, community sensitization, economic empowerment and male involvement O’brien 2010: Integration of HIV care, including ART within 24 existing programme across conflict-affected settings 10th GLOBVAC conference
13 Prevent excess maternal and newborn death and disability: 5Ayoya 2013: Establishment of baby tents in earthquake affected area to promote safe places for breastfeeding and infant formula feeding. Chu 2011: Establishment of a remote model of surgical care in conflict-affected Somalia where trained local Somali doctors and nurses for a surgical programme are remotely supported by expatriates in Nairobi, Kenya. Cowan 2013: Distribution of portable sleeping spaces for babies during an earthquake to reduce the risk of sudden unexpected death in infancy. Purdin 2009: Establishment of a refugee EmOC centre for Afghan refugees in Pakistan. Schaider 1999: Training of TBAs and provision of delivery supplies to undertake deliveries in an area with health facilities in conflict-affected Angola 10th GLOBVAC conference
14 Summary of main results: Discussion Summary of main results: Two studies addressed only 1 of 6 intervention areas; ‘preventing sexual violence and providing appropriate assistance to survivors’ Group psychotherapy → improved mental health outcomes VSLA groups → no effect on mental health outcomes but improved economic and social functioning outcomes Primary and secondary outcomes: Largely unreported 10th GLOBVAC conference
15 Excluded near-miss studiesAssessed both the primay and secondary study outcomes. The predominant study area was conflict-affected settings. Most studies were aimed at improving the supply and demand for basic health services. No study specifically focused on improving the security of health personnel and infrastructure Most of the studies were from sub-Saharan Africa. 10th GLOBVAC conference
16 Key lessons learnt - 1 An intervention consisting of a package/group of intervention activities are more common and appear to be more effective compared to an intervention with just a single intervention activity. Interventions implemented through public-private partnerships tend to be more comprehensive and effective, maximizes limited resources and potentially more sustainable. 10th GLOBVAC conference
17 Key lessons learnt - 2 Integration of an intervention into an existing programme tend to be more comprehensive, effective and sustainable. To maximize the potential effect and impact of an intervention it should include a strong component of community engagement and sensitization. 10th GLOBVAC conference
18 Key lessons learnt - 3 The private sector (especially international NGOs) constitute the main coordinating and implementing bodies for most interventions in crisis settings, occasionally in collaboration with the public sector. Weak study designs remains the major challenge to implementing interventions in crisis settings, substantially affecting the quality of the evidence generated. 10th GLOBVAC conference
19 Generalisability cautioned; role of context Conclusions Group psychotherapy may improve mental health outcomes in female survivors of sexual violence but not VSLA groups Implementation of group psychotherapy and VSLA may concurrently improve economic, social and mental health functioning among such populations Generalisability cautioned; role of context Potentially useful interventions for improving MNWRH exist; need for further testing with rigorous study designs Interventions to protect healthcare; need ideas and studies needed 10th GLOBVAC conference
20 References Bass J, Murray s, Cole G et al. Economic, social and mental health impacts of an economic intervention for female sexual violence survivors in Eastern Democratic Republic of Congo. Global Mental Health 2016, 3, e19, page 1 of 12. doi: /gmh Bass JK, Annan J, McIvor Murray S et al. Controlled trial of psychotherapy for Congolese survivors of sexual violence. N Engl J Med Jun 6;368(23): doi: /NEJMoa Ayoya MA, Golden K, Ngnie-Teta I, Moreaux MD, Mamadoultaibou A, Koo L, Boyd E, Beauliere JM, Lesavre C, Marhone JP. Protecting and improving breastfeeding practices during a major emergency: lessons learnt from the baby tents in Haiti. Bulletin of the World Health Organization 2013;91(8):612-7. Bannink-Mbazzi F, Lowicki-Zucca M, Ojom L, Kabasomi SV, Esiru G, Homsy J. High PMTCT program uptake and coverage of mothers, their partners and babies in Northern Uganda: Achievements and lessons learned over 10 years of implementation ( ). Journal of Acquired Immune Deficiency Syndromes 2003;62(5):e138–e145. Casey SE, McNab SE, Tanton C, Odong J, Testa AC, Lee-Jones L. Availability of long-acting and permanent family-planning methods leads to increase in use in conflict-affected northern Uganda: evidence from cross-sectional baseline and endline cluster surveys. Global Public Health 2013;8(3): Chu KM, Ford NP, Trelles M. Providing surgical care in Somalia: A model of task shifting. Conflict and Health 2011;15(5):12. Cowan S, Bennett S, Clarke J, Pease A. An evaluation of portable sleeping spaces for babies following the Christchurch earthquake of February Journal of paediatrics and child health 2013;49(5):364-8. Fofana P, Samai O, Kebbie A, Sengeh P. Promoting the use of obstetric services through community loan funds, Bo, Sierra Leone. The Bo PMM Team.. International journal of gynaecology and obstetrics 1997;59(Suppl 2):S Huber D, Saeedi N, Samadi AK. Achieving success with family planning in rural Afghanistan. Bulletin of the World Health Organization 2009;88(3): Hustache S, Moro MR, Roptin J, Souza R, Gansou GM, Mbemba A, Roederer T, Grais RF, Gaboulaud V, Baubet T. Evaluation of psychological support for victims of sexual violence in a conflict setting: results from Brazzaville, Congo. International journal of mental health systems 2009;1(3):7. Kandeh HB, Leigh B, Kanu MS, Kuteh M, Bangura J, Seisay AL.. Community motivators promote use of emergency obstetric services in rural Sierra Leone. The Freetown/Makeni PMM Team. International journal of gynaecology and obstetrics 1997;59(Suppl 2):s Kiboneka A, Nyatia RJ, Nabiryo C, Anema A, Cooper CL, Fernandes KA, Montaner JS, Mills EJ. Combination antiretroviral therapy in population affected by conflict: outcomes from large cohort in northern Uganda. British Medical Journal 2009;17(338):b201. Krause SK, Meyers JL, Friedlander E. Improving the availability of emergency obstetric care in conflict-affected settings. Global Public Health 2006;1(3): Leigh B, Kandeh HB, Kanu MS, Kuteh M, Palmer IS, Daoh KS, Moseray F. Improving emergency obstetric care at a district hospital, Makeni, Sierra Leone. The Freetown/Makeni PMM Team. International journal of gynaecology and obstetrics 1997;59(Suppl 2):s55-65. Mullany LC, Lee TJ, Yone L, Lee CI, Teela KC, Paw P, Shwe Oo EK, Maung C, Kuiper H, Masenior NF, Beyrer C. Impact of community-based maternal health workers on coverage of essential maternal health interventions among internally displaced communities in eastern Burma: the MOM project. PLoS medicine 2010;7(8):e O'Brien DP, Venis S, Greig J, Shanks L, Ellman T, Sabapathy K, Frigati L, Mills C. Provision of antiretroviral treatment in conflict settings: the experience of Médecins Sans Frontières. Conflict and Health 2010;4(12). Purdin S, Khan T, Saucier R. Reducing maternal mortality among Afghan refugees in Pakistan. International journal of gynaecology and obstetrics 2009;105(1):82-5. Rutta E, Gongo R, Mwansasu A, Mutasingwa D, Rwegasira V, Kishumbu S, Tabayi J, Masini T, Ramadhani H.. Prevention of mother-to-child transmission of HIV in a refugee camp setting in Tanzania. Global Public Health 2008;3(1):62-76. Samai O, Sengeh P. Facilitating emergency obstetric care through transportation and communication, Bo, Sierra Leone. The Bo PMM Team. International journal of gynaecology and obstetrics 1997;59(S157-64). Schaider J, Ngonyani S, Tomlin S, Rydman R, Roberts R. International maternal mortality reduction: outcome of traditional birth attendant education and intervention in Angola. Journal of Medical Systems 1999;23(2): 10th GLOBVAC conference