Understanding health systems to improve community and facility level newborn care among displaced populations in South Sudan: a mixed methods case study

Abstract

BackgroundTargeted clinical interventions have been associated with a decreased risk of neonatal morbidity and mortality. In conflict-affected countries such as South Sudan, however, implementation of lifesaving interventions face barriers and facilitators that are not well understood. We aimed to describe the factors that influence implementation of a package of facility- and community-based neonatal interventions in four displaced person camps in South Sudan using a health systems framework.MethodsWe used a mixed method case study design to document the implementation of neonatal interventions from June to November 2016 in one hospital, four primary health facilities, and four community health programs operated by International Medical Corps. We collected primary data using focus group discussions among health workers, in-depth interviews among program managers, and observations of health facility readiness. Secondary data were gathered from documents that were associated with the implementation of the intervention during our study period.ResultsKey bottlenecks for implementing interventions in our study sites were leadership and governance for comprehensive neonatal services, health workforce for skilled care, and service delivery for small and sick newborns. Program managers felt national policies failed to promote integration of key newborn interventions in donor funding and clinical training institutions, resulting in deprioritizing newborn health during humanitarian response. Participants confirmed that severe shortage of skilled care at birth was the main bottleneck for implementing quality newborn care. Solutions to this included authorizing the task-shifting of emergency newborn care to mid-level cadre, transitioning facility-based traditional birth attendants to community health workers, and scaling up institutions to upgrade community midwives into professional midwives. Additionally, ongoing supportive supervision, educational materials, and community acceptance of practices enabled community health workers to identify and refer small and sick newborns.ConclusionsImproving integration of newborn interventions into national policies, training institutions, health referral systems, and humanitarian supply chain can expand emergency care provided to women and their newborns in these contexts.Electronic supplementary materialThe online version of this article (10.1186/s12884-018-1953-4) contains supplementary material, which is available to authorized users.

Health policy mapping and system gaps impeding the implementation of reproductive, maternal, neonatal, child, and adolescent health programs in South Sudan: a scoping review

“…The low use of family planning services was found to be influenced by social and cultural norms [28,29,38]. A study conducted in Renk County based on a participatory ethnographic approach indicated that the participants experienced pressure to increase the size of their families.…”

“…Low motivation Only two studies reported data on healthcare providers' motivation [38,53]. A qualitative study conducted in Juba with 18 healthcare providers reported poor supervision, a lack of training opportunities, and low salary to be the determinants influencing the motivation of healthcare providers and thus affecting their performance [53].…”

An analytic perspective of a mixed methods study during humanitarian crises in South Sudan: translating facility- and community-based newborn guidelines into practice

“…At the global level, learnings were used beyond humanitarian settings to inform methodologies for measuring newborn care signal functions in other low resource settings and a newborn medical supply kit for community-and facility-based care. (18,19) The ndings of this research have been shared through the Newborn Health in Emergencies webpage hosted by Save the Children, (20) blogs disseminated through the Healthy Newborn Network, (20-22) a correspondence published in The Lancet,(23) a public webinar as part of Save the Children's Health and Nutrition Series, (24) poster and oral presentations at several international conferences, and research articles in peer-reviewed journals (9)(10)(11). Several policy and programmatic changes were also made at the global level such as development of a global roadmap to accelerate newborn health program scale-up in humanitarian settings and the Newborn Health Humanitarian Settings Field Guide that included an implementation toolkit.…”

“…Improvements in knowledge, however, did not lead to adoption of interventions at the community level. Postnatal home visits in the rst week of life, while new and acceptable to community health workers, were not sustained during periods of mass displacement because of the inability to locate households and limited staff available to manage competing priorities (11). In facilities, 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.…”

An analytic perspective of a mixed methods study during humanitarian crises in South Sudan: translating facility- and community-based newborn guidelines into practice

“…(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).…”