Humanitarian Context
After gaining independence in 2011, South Sudan enjoyed relative peace and progress until December 2013 when internal conflict arose between the government and the opposition. This worsened in 2016 leading to massive displacement of the population in Juba and rapidly spread to other regions of the country particularly the Upper Nile and areas with relative peace and stability.(1) Fragmentation of political groups and longstanding intercommunal cattle raiding further intensified and increased the number of internally displaced persons (IDP) seeking refuge in United Nations (UN) protection of civilian (POC) camps.(2) By the end of 2017, an unprecedented number of 1.9 million people were estimated to be internally displaced in a country of about 10.8 million people.(3, 4) In Juba and Malakal, the UN POC camps predominately housed displaced women and children who are from the Nuer and Shilluk tribes(1). In addition, there were over 260,000 refugees from Sudan primarily residing in Upper Nile.(5) Decades of conflict, widespread insecurity, mass migration, and lack of public funding disrupted the fragile health system in South Sudan, leaving behind long-term impacts on public health. The country continues to face a neonatal morality rate (NMR) one of the highest in Africa of 39 per 1000 live births and stillbirth rate of 30 per 1000 total births.(6–8)
Research Study
A study from 2016 to 2017 was undertaken in four displaced person camps located in Upper Nile State (Maban and Malakal Counties) and Juba Central Equatoria State to assess the implementation of a newly developed package of evidence-based newborn health interventions for humanitarian settings at the community and facility levels during a protracted humanitarian crisis.(9–11) We aimed to address outcomes of implementation research, specifically to (1) examine change in knowledge and attitudes among community- and facility-based health workers toward uptake of newborn health interventions (i.e. acceptability), (2) describe change in correct and timely newborn care practices during childbirth and the immediate postnatal period (i.e. adoption), and (3) explore health system-related factors that influence implementation. To address the first two aims, we employed a quasi-experimental pre-post design using clinical observations of delivery and postnatal care practices, structured exit interviews with recently delivered women, and semi-structured interviews with health workers (see Table 1). To explore factors influencing implementation, we employed a mixed methods case study design using in-depth interviews, focus group discussions, health facility checklists, and health worker time-use observations at multiple time points during implementation.
Table 1
Study data collection methods and sample size, April 2016—January 2017
Data collection phase | Methods | Sample Size |
Phase 1: Baseline April – June 2016 | Health facility assessment | 5 health facilities |
Time use observation | 1163 observations |
Clinical observation and exit interview | Hospital: 159 mother-newborn pairs PHCC: 201 mother-newborn pairs |
In-depth interview | 17 health workers |
Self-administered knowledge questionnaire | 127 health workers |
Phase 2: Midline July – November 2016 | Health facility assessment | 5 health facilities |
In-depth interview | 16 health workers 7 program managers |
Focus group discussion | 12 facility health worker groups 8 community health worker groups |
Supply consumption | 5 health facilities 3 community health program sites |
Phase 3: Endline November 2016 – January 2017 | Health facility assessment | 5 health facilities |
Time use observation | 565 observations |
Clinical observation and exit interview | Hospital: 106 mother-newborn pairs PHCC: 127 mother-newborn pairs |
In-depth interview | 10 health workers 4 program managers |
Focus group discussion | 3 facility health worker groups 2 community health worker groups |
Of the four displaced person camps, two were refugee camps in Maban County (Gendrassa and Kaya) and two were internally displaced persons (IDP) camps in Malakal County (Malakal POC) and Juba County (Juba POC), with populations ranging from 17,000 to 40,000 displaced persons.(3, 5) In June 2016, International Medical Corps (IMC), an international humanitarian organization, implemented the study intervention in the camps, including: clinical training and ongoing supportive supervision for community and facility-based health workers; distribution of newborn medical commodities at the community, primary care, and hospital levels; and a strategic planning workshop for senior managers to prioritize programmatic considerations. Facility-based newborn interventions were implemented in maternity wards of primary care facilities in each of the four camps and one hospital in Juba POC, and community-based interventions were integrated within community health programs in all participating camps.
The study sites were prone to sudden conflict and attack because of the political and socioeconomic circumstances in and around the camps. A month prior to the baseline study, a violent attack on Malakal POC led to the death of civilians and health workers and the burning down of a study health facility.(12) During study implementation, a maternity ward in the Juba POC was shelled during the July 2016 crisis, and tensions between refugee and host populations in Maban led to fighting and displacement during the study endline period.(13) Humanitarian agencies, including IMC, were forced to frequently suspend operations and evacuate non-local staff. The ongoing crisis introduced unanticipated events that co-occurred with the study intervention; thus, the quasi-experimental study design became susceptible to threats to internal validity. We shifted the design to a descriptive study to understand the frequency and determinants of knowledge, attitudes, and practices for newborn care; outcomes consistent with implementation science.(14)
We found that acceptability and adoption of newborn health interventions was high following a two-day simulation training and distribution of supplies among community- and facility-based health workers. Knowledge of newborn danger signs and the benefits of practices such as skin-to-skin contact and early breastfeeding initiation improved among health workers.(10) Improvements in knowledge, however, did not lead to adoption of interventions at the community level. Postnatal home visits in the first week of life, while new and acceptable to community health workers (CHWs), were not sustained during periods of mass displacement because of the inability to locate households and limited staff available to manage competing priorities.(11) At the facility level, partograph use for fetal monitoring, skin-to-skin contact, and postnatal monitoring of danger signs were the least commonly used practices at baseline, highlighting gaps in care for small and sick newborns.(9) Despite this, essential newborn practices such as thermal care (immediate drying and wrapping), infection prevention, and feeding support were high following the intervention (ranging from 79.7% to 83.2%). Addressing certain health system bottlenecks influenced implementation, particularly: (1) leadership and governance to support comprehensive services, (2) health workforce for skilled care at birth, and (3) service delivery for small and sick newborns.(11)