Use in humanitarian settings

The provision of lifesaving EmONC services can be affected by humanitarian emergencies in numerous ways. The health system itself is often not resilient enough or prepared to maintain essential lifesaving services, which can have a domino or trickle-down effect.

• Critical health infrastructure, including facilities, storage warehouses, and referral transport, may be damaged or looted.
• When available, supplies may also be insufficient to meet the needs of the population in crisis, and the closing of borders and shipping routes can inhibit access.
• Mass population movements may overwhelm functioning health facilities, challenge clients’ knowledge of the closest facility at which they can receive care and how to reach it, impede existing community outreach and health promotion activities such as community health worker (CHW) health campaigns or town halls, and competing needs, such as trauma care, may draw human and financial resources away from EmONC.
• An emergency, including disease outbreaks, can severely reduce the numbers of skilled health care providers, limiting the ability to provide EmONC services.
• In addition, health providers and staff, often already overworked and under-resourced, may have been affected by the crisis themselves in myriad ways (damage to their villages/home, loss of friends or family members, loss of employment, fleeing violence), and therefore face mental health and personal crisis matters.
• Health providers’ job satisfaction and motivation can also be immensely impacted, with providers forced to deliver less-than-ideal care in situations that may be highly unstable or insecure, dangerous, lack electricity or water, or lack lifesaving drugs. The risk of provider blame for poor care can also be high if fueled by ethnic or racial tensions, or if mortality is linked to food or shelter rations.
• High staff turnover is common, both as local providers adapt to daily realities and as responders from elsewhere in the country or from international humanitarian organizations cycle through deployments. Furthermore, responders may position themselves in less "risky" locations, oversaturating services in certain areas and leaving others with few or no providers.
• Referral pathways, including related communication and transportation networks, are often disrupted, creating additional life-threatening delays due to security concerns, curfews, lack of transport, or poor travel (road or waterway) conditions.
• In humanitarian settings, the Three Delays⁵ in accessing EmONC are a major concern, with settings where 80+% of births still occur at home or in the community, and where distance to a local facility can easily be 50+ kilometers away.⁶

While some crises result in the establishment of field hospitals or even parallel health facilities, led primarily by UN and large humanitarian agencies, these are not sustainable options and may even lead to further distrust in the public system and therefore less utilization. And unfortunately, a large number of acute crises these days become protracted, with the barriers outlined above persisting for years or decades, and hampering the ability to fully meet the EmONC needs of the population in the long-term.

The Minimum Initial Service Package (MISP) for SRH in Emergencies

Several global resources and frameworks exist to deliver SRH services in a response, including the Minimum Initial Service Package for SRH in Emergencies (MISP),⁷ which is a package of priority lifesaving services and activities to be implemented in every humanitarian emergency - ideally within 48 hours from the onset of the emergency - to prevent excess SRH-related morbidity and mortality. Developed by the Inter-Agency Working Group on Reproductive Health in Crises (IAWG) and articulated in both the Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings (IAFM)⁸ and the Newborn Health in Humanitarian Settings: Field Guide (NBFG),⁹ the MISP is a critical core package to be delivered in a response through coordinated actions with all relevant partners.

In humanitarian emergencies, EmONC services should be prioritized for implementation as dictated by the MISP; establishing or re-establishing EmONC services will be one of the most critical, lifesaving actions of the humanitarian health response. Less lifesaving services such as routine antenatal and postnatal care may need to be deprioritized – perhaps provided by locally trained CHWs, through other community-level platforms, or otherwise even suspended – in order to focus limited health system resources on the provision of clean and safe delivery and EmONC care. Unfortunately, in a setting with high home births and limited access to facilities, task-shifting for ANC and PNC may lead to lower identification of high-risk pregnancies or danger signs, and higher incidences of the three delays, rendering EmONC services that much more critical.

Establishing a SRH working group

In humanitarian settings where the ‘cluster system’ is activated, which means the UN’s humanitarian response mechanisms are in place, a SRH working group should be established as part of the health cluster. This working group will include the Ministry of Health, service delivery providers such as local and international NGOs, and relevant UN agencies. Local and national partners are a critical component of this structure, as a priority is placed on not duplicating or replacing the national health system but rather strengthening or supplementing it as much as possible. Given the frequency of new and expanded service providers coming in and out of the response, such as pre-existing public and private health services, Emergency Medical Teams, and national or international NGOs, each with varying capacities for EmONC implementation, the working group should lead EmONC service planning and monitoring under the umbrella of the MISP, and will need to regularly review progress and plans for providing and expanding services.

Planning for immediate EmONC needs

During the initial response to an acute crisis, planning for immediate EmONC needs requires urgent consideration as pre-existing population numbers and service delivery points may change drastically. Essential information required includes:

• Target population size and location (which may include mapping displaced populations, including internally displaced and migrants that cross borders, and considering both those residing in camp settings and hosted by communities)
• Mapping of available health facilities and their level of functionality (as well as the partner agencies supporting them)
• Availability and skillset of health workers, and supplies and equipment.

Estimating the number of people affected and their specific demographic characteristics, such as the proportion of women of reproductive age in the affected population and the crude birth rate of the population pre-crisis, can inform initial estimates of the numbers of currently pregnant women, expected deliveries, and obstetrical and neonatal complications in the next 1-3 months. These figures, and tools such as the MISP calculator (version 2019),¹⁰ can then aid in planning for the initial (re)establishment of EmONC service delivery.

Understanding the population’s interaction with the health system pre-crisis (such as institutional delivery rates), existing health policies related to health provider scope of practice and service delivery, and which key EmONC medicines and supplies are on national essential medicine lists can further aid in planning. Social accountability mechanisms and women’s protection and empowerment programs can help to ensure that the health response is designed so that services are delivered in an acceptable and respectful way. That includes making sure that the community is aware of where and how they can access clean and safe delivery and EmONC services.

Organizing levels of EmONC

Levels of EmONC as they relate to signal functions may need to be modified to reflect local realities and meet immediate needs. In humanitarian settings, referral to higher levels of care may not be feasible or may be greatly delayed. In this case, Basic EmONC facilities may need to increase their service provision level to include certain functions currently placed at the Comprehensive EmONC level (such as blood transfusion, and ongoing care for small or sick neonates), and Comprehensive EmONC facilities may need to reflect the unavailability of Intensive EmONC facilities. Particularly in settings where facilities may be more static and access is not as restricted by curfews and instability, it may be appropriate to see more task sharing of interventions across levels of care and cadres. Flexibility in this area is recommended in terms of associated health policy and regulations and should be taken into consideration for planning and monitoring purposes as well.

Capacity building and task sharing

National preparedness plans could consider adding trigger options that allow for more enabling policies or task sharing in times of crisis, and for the deployment or redirection of trained and specialized providers to the affected areas. In addition, health systems in countries that are considered more fragile or conflict-prone may consider revising competency standards or training curricula so as to employ available cadres to their full scope of practice, e.g., empowering and enabling midwives to provide Basic EmONC services. The role of midwives and their scope of practice varies greatly between countries and while global guidance encourages midwives to be trained and supported to manage most emergencies, the reality is less certain. If accompanied with on-the-job supportive supervision and capacity strengthening, as well as the protection of the staff against repercussions regarding the scope of practice, these cadres could fill a crucial gap in delivering EmONC services.

In crises, higher level medical staff (doctors and specialists) tend to be understaffed, and many international health responders are generalist providers, able to adapt to a multitude of health needs depending on the crisis. Therefore, capacity to deliver the specialized and highly technical care required for EmONC services is often limited amongst humanitarian agencies and in humanitarian settings. Among respondents to a 2018-2019 survey of international and national Global Health Cluster partner agencies, less than half (47%) self-reported having the technical capacity to provide essential newborn care during a response, and only 29% of international partners and 33% of national partners reported offering Comprehensive EmONC services, with the Health Cluster staff noting this required immediate attention as providing these interventions is essential to reducing maternal and neonatal deaths.¹¹ Even when humanitarian health programs are funded and resourced to support maintenance and provision of EmONC services, there may be a need for capacity assessments and support to ensure EmONC readiness within national health systems, given a response strategy is often built around existing infrastructure and health workforce.

Equipment, drugs and supplies

Addressing the urgent need for supplies and equipment related to EmONC service provision during an acute crisis may be supported by the use of Interagency reproductive health kits (IARH kits)¹² and newborn care kits.¹³ These kits include standard medical material and medicines to enable EmONC care at Basic and Comprehensive levels. Though national policy environments, local population demographics, and health needs should be taken into consideration when procuring kits, medicines and medical material contained in the IARH and newborn kits may vary from those habitually used in the context and health care providers may need guidance on the new medicines and material they will be using. This may be particularly true for large equipment, such as incubators and phototherapy lamps, and newer or more advanced devices.

During an acute crisis, routine monitoring systems may be disrupted and data used for planning, if existing, may no longer be valid as populations move and/or health facilities are destroyed. The reach and oversight of the ministry of health to implement, plan and monitor EmONC services in such settings may be temporarily disrupted. Due to this dynamic and challenging context, monitoring plans may prioritize a subset of the standard indicators and these indicators may need to be monitored more frequently than recommended in How to use the EmONC Framework: Step-by-step implementation until the situation stabilizes. For example, a recently endorsed global SRMNCAH Monitoring and Evaluation Framework in Humanitarian Settings identifies a core set of SRMNCAH indicators, and notes that periodic health facility assessments should be conducted to measure availability of skilled personnel for MNH, availability of Basic EmONC, and availability of Comprehensive EmONC, including availability of post-abortion care, but it does not provide guidance on frequency or measurement methods.¹⁴ Where access is difficult due to security or other concerns, remote monitoring of key aspects of EmONC service provision may be required.¹⁵

As the number of humanitarian emergencies continue to grow globally, there is a critical need for evidence from these settings on effective methods to collect, analyze, and act on maternal and perinatal mortality data.¹⁶ Maternal and perinatal death surveillance and response (MPDSR) and related death review interventions may be considered for guiding and informing humanitarian responses to ensure investments are directed towards lifesaving services. WHO’s implementation guidance for MPDSR identifies several considerations for when and how to appropriately integrate MPDSR systems or leverage existing ones within various stages of a response.¹⁷ However, it is worth noting that available literature suggests that underutilization of surveillance systems in these settings may be partially due to challenges in identifying deaths, as most occur outside of the formal health system.¹⁸

Vulnerable populations

EmONC planning and monitoring will ideally capture utilization and effectiveness of services for key vulnerable groups. In humanitarian settings, these may include adolescents, refugees and/or internally displaced populations, and people from ethnic minority groups, amongst others. Systematic collection and reporting of disaggregated data related to EmONC indicators for these key populations can help to identify issues of availability, access or quality of care for these groups. However, this requires additional data protection and use considerations,¹⁹ which can be quite challenging, especially when there are myriad actors with disparate interests in having access to such data.²⁰ The use of electronic medical records and other digital health systems open up valuable opportunities for improving and tailoring health services within complex responses and affected settings, but stakeholders should be cautious to ensure protection of vulnerable populations.

As soon as possible following the acute crisis period, and in protracted humanitarian settings (for example in long-standing refugee camps), up until the time of the full recovery of services, EmONC planning and monitoring should be re-integrated into national or sub-national planning processes under the ministry of health, to help ensure the equitable distribution of resources for both host and refugee, internally displaced or other crisis-affected populations.