Abstract
Introduction:
Conflicts frequently occur in countries with high maternal and neonatal mortality and can aggravate difficulties accessing emergency care. No literature is available on whether the presence of conflict influences the outcomes of mothers and neonates during Caesarean sections (C-sections) in high-mortality settings.
Objective:
To determine whether the presence of conflict was associated with changes in maternal and neonatal mortality during C-sections.
Methods:
We analysed routinely collected data on C-sections from 17 Médecins Sans Frontières (MSF) health facilities in 12 countries. Exposure variables included presence and intensity of conflict, type of health facility and other types of access to emergency care.
Results:
During 2008–2015, 30,921 C-sections were performed in MSF facilities; of which 55.4% were in areas of conflict. No differences were observed in maternal mortality in conflict settings (0.1%) vs. non-conflict settings (0.1%) (P = 0.08), nor in neonatal mortality between conflict (12.2%) and non-conflict settings (11.5%) (P = 0.1). Among the C-sections carried out in conflict settings, neonatal mortality was slightly higher in war zones compared to areas of minor conflict (P = 0.02); there was no difference in maternal mortality (P = 0.38).
Conclusions:
Maternal and neonatal mortality did not appear to be affected by the presence of conflict in a large number of MSF facilities. This finding should encourage humanitarian organisations to support C-sections in conflict settings to ensure access to quality maternity care.
Keywords: armed conflicts, survival, maternal health, emergency medicine
Abstract
Cadre:
Des conflits surviennent souvent dans les pays où sévissent une mortalité maternelle et néonatale élevées et peuvent aggraver les difficultés d'accès aux soins d'urgence. Aucune littérature n'est disponible sur l'impact de la présence d'un conflit sur les résultats des césariennes pour les mères et les nouveaux-nés dans des contextes de mortalité élevée.
Objectif:
Evaluer si la présence d'un conflit est associée à des modifications de la mortalité maternelle et néonatale pendant les césariennes.
Méthode:
Nous avons utilisé des données recueillies en routine sur les césariennes effectuées dans 17 centres de santé de Médecins Sans Frontières (MSF) dans 12 pays. Les variables d'exposition ont inclus la présence et l'intensité du conflit, le type de structure de santé et les autres accès aux soins d'urgence.
Résultats:
Entre 2008 et 2015, 30 921 césariennes ont été réalisées dans les structures de MSF ; 55,4% l'ont été dans un contexte de conflit. Aucune différence n'a été observée en termes de mortalité maternelle en situation de conflit (0,1%) ou sans conflit (0,1%) (P = 0,08) ni en termes de mortalité néonatale en période de conflit (12,2%) et hors conflit (11,5%) (P = 0,1). Parmi les césariennes réalisées dans un contexte de conflit, la mortalité néonatale a été légèrement plus élevée dans les zones de guerre comparées aux zones de conflits mineurs (P = 0,02) ; il n'y a pas eu de différence en termes de mortalité maternelle (P = 0,38).
Conclusion:
La mortalité maternelle et néonatale n'a pas semblé affectée par la présence de conflits dans un grand nombre de structures de MSF. Ces résultats devraient encourager les organisations humanitaires à soutenir les césariennes dans les contextes de conflit afin d'assurer l'accès à des soins de santé de qualité en maternité.
Abstract
Marco de Referencia:
Los conflictos armados son frecuentes en países con elevada mortalidad materna y neonatal los cuales pueden agravar la dificultad de acceso a la salud maternal de urgencia. No existe evidencia científica que analice en conflictos, la asociación de los conflictos con el desenlace clínico de las madres y los recién nacidos tras cesáreas.
Objetivo:
Evaluar si la presencia de conflicto se asocia con modificaciones de la mortalidad materna o neonatal tras partos por cesárea.
Métodos:
Se utilizaron los datos recogidos durante las cesáreas en 17 establecimientos dirigidos por Médicos Sin Fronteras (MSF) en 12 países. Las variables de exposición incluyeron la presencia y la intensidad del conflicto, el tipo de establecimiento de salud y el acceso a otros tipos de atención de urgencia.
Resultados:
En el período 2008–2015 se practicaron 30 921 cesáreas en los establecimientos de MSF; 55,4% tuvieron lugar en situaciones de conflicto. No se observaron diferencias en la mortalidad materna durante los períodos con o sin conflicto (0,1% en ambos casos; P = 0,08) ni en la mortalidad neonatal (12,2% en períodos de conflicto y 11,5% sin conflicto; P = 0,1). En las cesáreas realizadas en entornos en conflicto, la mortalidad neonatal fue levemente superior en las zonas de guerra, en comparación con las zonas de conflicto menor (P = 0,02); no se observó diferencia en la mortalidad materna (P = 0,38).
Conclusión:
La presencia de conflicto no afecta la mortalidad materna ni neonatal en establecimientos de MSF. Nuestros resultados deberían estimular a las organizaciones humanitarias a fomentar la práctica de cesáreas en las zonas de conflicto, con el fin de garantizar el acceso a una atención de calidad.
War-affected populations can suffer from an increase in mortality rates.1,2 During active stages of conflict the outcomes are poorer and there are significant challenges to provide health care.3,4 Conflict frequently affects countries that already account for the world's greatest burden of maternal and neonatal mortality.5
Caesarean section (C-section) rates are below the recommended level in some countries with high neonatal mortality; C-section rates of up to 10% are associated with decreases in maternal and neonatal mortality rate at population level.6 This suggests that some women who need emergency C-sections do not receive them.7,8
While conflict has been shown to increase neonatal and maternal mortality rates overall,1,9 there have been no studies of whether it impacts the rate of neonate and maternal mortalities following C-sections.
Médecins Sans Frontières (MSF) is a humanitarian medical organisation that supports C-sections in emergency settings, including areas of conflicts, performing over 1.3 million deliveries worldwide from 2008 to 2015.10–14 The MSF facilities therefore present a unique opportunity to examine whether the presence of conflict affects maternal and neonatal outcomes following C-sections.
METHODS
Aim
We sought to assess whether the presence of conflict is associated with a difference in the rate of maternal and neonatal mortality during C-section interventions in 17 MSF-supported health facilities in 12 countries during 2008–2015.
Design
This was an analysis of routinely collected maternal programme data.
Setting
We included 12 countries, whose maternal and neonatal mortality rates are shown in Table 1.
TABLE 1.
Neonatal and maternal mortality rates reported by country
| Country | Neonatal mortality rate* | Maternal mortality rate† | Caesarean section rate‡ % (year) |
|---|---|---|---|
| Afghanistan§ | 35.5 | 396 | 3.7 (2010) |
| Burundi | 28.6 | 712 | 4.3 (2010) |
| Central African Republic§ | 42.6 | 882 | 4.5 (2010) |
| Democratic Republic of Congo§ | 30.1 | 693 | 5.5 (2010) |
| Haiti | 24.9 | 359 | 5.8 (2010) |
| Ivory Coast | 37.9 | 645 | 3.1 (2010) |
| Mauritania | 35.7 | 602 | 9.6 (2010) |
| Niger | 26.8 | 553 | 1.6 (2010) |
| Pakistan§ | 45.5 | 178 | 15.9 (2010) |
| Sierra Leone | 34.5 | 1360 | 3.6 (2010) |
| Syria | 7.0 | 68 | 15.0 (2002) 35 (refugees in Lebanon, 2012) |
| Somalia | 39.7 | 732 | NA |
* Defined as number of deaths per 1 000 live births. (Source: United Nations Interagency Group for Child Mortality Estimation, 2014).
† Defined as number of maternal deaths per 100 000 live births. (Source: World Health Organization, United Nations Childrens' Fund, United Nations Population Fund, World Bank Group and United Nations Development Programme (UN Maternal Mortality Estimation Inter-agency Group, 2015).
‡ Defined as the percentage of births achieved by caesarean among all live births in the period before the survey (referring to births in the 3 years before Demographic and Health Surveys and 2 years before Multiple Indicator Cluster Surveys).
§Countries with ⩾2 facilities.
NA = not available.
Each of the facilities was operational for different time periods between 2008 and 2015. Facilities were classified into general hospitals or maternities, defined as comprehensive emergency obstetric and newborn care centres (CEmONC), and according to whether they were the only CEmONC in the city, or whether there were other facilities also performing C-sections free of charge.
Emergency C-sections were carried out according to the MSF protocol,15 in which the following absolute indications are defined as life-threatening to the mother: 1) severe, uncontrolled ante-partum bleeding; 2) malpresentation that cannot be turned; 3) absolute feto-pelvic disproportion and no possibility of instrumental extraction; 4) uterine rupture; and 5) a history of ⩾3 C-sections.
The relative indications to perform a C-section is based on a consideration of the short and medium or long-term risk/benefit for the mother on a case-by-case basis. MSF C-sections were performed by local or international surgeons, by obstetricians or by general doctors with surgical skills.
The standard prerequisites for performing C-sections are the availability of skilled human resources for assessing whether a C-section is indicated; administering anaesthesia and performing surgery; and appropriate facilities, equipment, intrapartum/postpartum care and monitoring. For neonates, standard routine care was offered in the first hours of life, including resuscitation (if needed), clearing the airway, cord clamping and cord care, assessing Apgar score, clinical examination, thermoregulation, feeding, preventive treatments, vaccinations and daily monitoring.15
Study population and sampling strategy
The study population was defined as the women who underwent an emergency C-section conducted by MSF Operational Center Brussels and the neonates of these women, from January 2008 to December 2015, in selected facilities under the Emergency Obstetric Care programme. We excluded hospitals that performed <10 C-sections in a given month. There were 198 cases identified with intrauterine foetal deaths during the C-sections, which were not included in the analysis. We also excluded C-sections for which outcomes were not recorded.
Study variables and definitions
Conflicts were classified according to the Uppsala Conflict Data/Peace Research Institute Oslo (UCDP/PRIO) Armed Conflict Database classification as follows:16,17 1) the presence or absence of conflict by country and time period (semester);17 2) conflict intensity: ‘minor’ if between 25 and 999 battle-related deaths were reported and ‘war-intensity’ if there were ⩾1000 battle-related deaths by country in a given year.17
Maternal mortality was defined as the total number of maternal deaths that occurred during the time in the theatre or in the recovery room, divided by the total number of C-sections conducted. Neonatal mortality was defined as the number of neonatal deaths occurring during the C-section or the resuscitation period, divided by the total number of C-sections conducted.
The average C-section rate was the percentage of C-sections performed of the total deliveries for each year in which the facility was active from 2011 onward.
Data collection and quality assurance
MSF local staff routinely collected and entered the data into an Excel dataset (Microsoft Corp, Redmond, WA USA) in each facility for programme monitoring and evaluation. The data were reviewed at facility level and reported to the MSF Brussels headquarters, where they were revised, cleaned and validated.
Data analysis
We used a univariate analysis to describe the number of C-sections, the year, the type of facility and the presence and intensity of conflict.
We used a bivariate analysis to describe the association between the maternal and neonatal mortality outcome variables and the exposure variables described above, with significance determined as P < 0.05. The data were analysed using Stata v14 (StataCorp LLC, College Station, TX, USA).
Ethics approval
Confidentiality of information was ensured during all processing of data entry and analysis. The data were de-identified, therefore individual consent was not required. This research fulfilled the exemption criteria set by the MSF Ethics Review Board (ERB) for a posteriori analyses of routinely collected clinical data and thus did not require MSF ERB review. The study was conducted with permission from the Medical Director of MSF (Brussels, Belgium).
RESULTS
Health facility characteristics
The study included 30,921 C-sections from 2008 to 2015. There were 17 health facilities in 12 countries (three in Afghanistan, two each in Central African Republic, Democratic Republic of Congo and Pakistan and one each in Burundi, Haiti, Ivory Coast, Mauritania, Niger, Sierra Leone, Syria and Somalia).
Of the 17 health facilities, 13 were general hospitals and four were CEmONC, accounting for respectively 64.6% and 35.4% of the C-sections (Table 2).
TABLE 2.
Neonatal and maternal mortality rates by country and type of facility in C-sections, 2008–2015
| Facility by country | Neonatal mortality n (%) | Maternal mortality n (%) | Type of facility | Access Other CEmONC facility* | Mean deliveries per year n | Mean C-sections per year n | Average C-section rate† % |
|---|---|---|---|---|---|---|---|
| Afghanistan I | 74 (4.5) | 1 (0.1) | General | Yes | 11564 | 1622 | 2.8 |
| Afghanistan II | 214 (15.2) | 0 | Maternity | Yes | 14939 | 1400 | 2.3 |
| Afghanistan III | 234 (31.1) | 6 (0.8) | General | No | 2172 | 1062 | 48.9 |
| Burundi | 277 (6.2) | 3 (0.1) | Maternity | No | 1912 | 1581 | 41.4 |
| Central African Republic I | 34 (13.3) | 0 | General | No | 1658 | 253 | 7.6 |
| Central African Republic II | 97 (9.34) | 2 (0.2) | Maternity | No | 7424 | 813 | 11.0 |
| Ivory Coast | 56 (13.1) | 5 (1.2) | General | Yes | |||
| Democratic Republic of Congo I | 100 (10.4) | 1 (0.1) | General | No | 4101 | 1241 | 30.3 |
| Democratic Republic of Congo II | 490 (6.7) | 11 (0.2) | General | No | 4125 | 4650 | 28.2 |
| Haiti | 98 (8.2) | 0 | General | Yes | 1645 | ||
| Mauritania | 19 (6.7) | 0 | General | No | 1843 | 1306 | 23.6 |
| Niger | 289 (21.4) | 2 (0.2) | General | No | 2774 | 535 | 9.6 |
| Pakistan I | 45 (7.4) | 0 | General | No | |||
| Pakistan II | 773 (17.6) | 7 (0.2) | General | No | 6159 | 3426 | 13.9 |
| Sierra Leone | 753 (18.8) | 5 (0.1) | Maternity | No | 1670 | ||
| Syria | 6 (4.0) | 0 | General | No | 0 | ||
| Somalia | 70 (11.1) | 3 (0.5) | General | No | 2213 | 484 | 10.9 |
* Facilities were classified as ‘Yes’ if there were other facilities in the town providing free of charge CEmONC and ‘No’ if MSF was the only facility to provide this service.
† Percentage of C-sections performed out of the total deliveries for the years in which the facility was active; data were available between 2011 and 2015.
C-section = Caesarean section; CEmONC = comprehensive emergency obstetric and newborn care centres.
All the facilities provided free care, with 14 of 17 offering the only CEmONC care available in their respective towns and accounting for the majority of the C-sections (84.9%, n = 26,267).
Conflict characteristics
We categorised each of the C-sections according to whether they occurred within a country and during a period of conflict. Forty-four per cent of the C-sections took place in settings that were not in a defined conflict; the remaining 56% were in conflict settings.
Of the C-sections performed in conflict settings, the majority (12,240, 71.6%) were in minor-intensity country conflicts, with 4858 (28.4%) in war-intensity zones. Most minor-intensity country conflicts were internal conflicts, whereas the war-intensity conflicts tended to be across borders.
Maternal mortality
The overall maternal mortality (MM) was 0.15% (46 maternal deaths) related to C-sections. It ranged from 0% in Syria, Haiti and one of the Pakistani facilities to 0.80% (six maternal deaths) in one of the Afghan facilities (P < 0.001).
The MM decreased from 0.25% (four maternal deaths) in 2008 to 0.07% (three maternal deaths) in 2015 (P < 0.02).
C-sections performed in non-conflict countries showed a MM of 0.11%, which was not statistically different from that in conflict settings (0.18%). In conflict settings, the MM was not statistically different (0.1% vs. 0.2%) between minor and war-intensity conflicts.
C-sections in general hospitals reported a higher MM (0.18%) compared to maternities (0.09%), with a borderline statistically significant difference (P = 0.05). MM was not different in towns where no other facilities were offering free-of-charge C-sections compared to those where care was available at other facilities.
Neonatal mortality
The overall neonatal mortality (NM) was 11.7% (n = 3629) of neonates born through C-section. It ranged from 3.9% in the Syrian facility to 31.1% in one of the Afghan facilities (P < 0.001) (Table 2). The NM decreased from 15.9% (n = 252) in 2008 to 10.0% (n = 429) in 2015 (P < 0.001).
The NM in non-conflict settings was 11.8%, which was not statistically different from that of neonates born in conflict settings (11.7%) (Table 3). Table 3 shows the NM for each facility during periods of conflict compared to non-conflict. In conflict zones, the NM was 11.2% in areas of minor conflicts compared to 13.0% in war settings, showing a small difference.
TABLE 3.
Neonatal and maternal mortality distribution by conflict setting and access to C-sections, 2008–2015
| Neonate deaths | Maternal deaths | |||||
|---|---|---|---|---|---|---|
| n | % | P value | n | % | P value | |
| Presence of conflict | ||||||
| Absence of conflict | 1632 | 11.8 | 0.7 | 15 | 0.1 | 0.09 |
| Conflict (internal and international) | 1997 | 11.7 | 33 | 0.2 | ||
| Intensity of the conflict | ||||||
| Minor | 631 | 11.2 | 0.001 | 20 | 0.2 | 0.38 |
| War | 658 | 13.0 | 11 | 0.2 | ||
| Type of facility | ||||||
| General hospital | 2288 | 11.4 | 0.03 | 36 | 0.2 | 0.05 |
| Maternity | 1341 | 12.3 | 10 | 0.1 | ||
| Access to other CEmONC | ||||||
| No (MSF only free care) | 3187 | 12.1 | 0.001 | 40 | 0.2 | 0.7 |
| Yes | 442 | 9.5 | 6 | 0.1 | ||
C-section = Caesarean section; CEmONC = comprehensive emergency obstetric and newborn care centres; MSF = Médecins Sans Frontières.
General hospitals showed no statistically significant difference in NM compared with maternity facilities.
Neonates born in towns where no other facilities were offering free-of-charge C-sections showed a significantly higher NM (12.1%) than those where care was available at other facilities (9.5%).
DISCUSSION
Our study assessed whether conflict settings were associated with differences in maternal and neonatal mortality during MSF-supported emergency C-sections in a number of high mortality countries. To our knowledge, this is the largest published study of this question. Surprisingly, there were no increases in maternal or neonatal mortality in conflict settings. We present the implications and potential reasons for these findings.
From 2008 to 2015, 17 MSF-supported facilities performed the majority of C-sections in conflict settings and in towns where the facility was the only one to offer free emergency care. This demonstrates the feasibility of providing quality emergency C-sections in conflict settings, despite the perceived threats. The literature on the provision of C-sections during conflicts varies according to the conflict. During the Balkans War, C-section rates decreased, while the rate remained high in northern Sri Lanka and among Syrian women living in Lebanon during those conflicts.18
Our study found no differences in maternal or neonatal mortality in emergency C-sections between conflict and non-conflict periods. This is in contrast to a previous MSF study by Chu et al. of 19,643 surgical procedures (including obstetrics, trauma, abdominal conditions, infections, neoplasms, accidental and violent injury) from 2001 to 2008, which showed a rate of operative general mortality 4.6 times higher in conflict settings than in non-conflict settings.19
There were two main differences between the studies, which may explain this discrepancy. First, we only included C-sections in our study, whereas Chu et al. incorporated all surgical procedures and reported differences in mortality according to whether the procedures were abdominal, gynaecological or under emergency circumstances, and according to the American Society of Anesthesiologists (ASA) physical status. Second, we used a more specific definition of conflict for each facility by time period.
Since we found no differences in mortality according to conflict, type of conflict or type of facility, we suggest that other factors could influence mortality. These could be related to the accessibility of healthcare, clinical presentation or type of procedure. Our study included only those women who had reached health facilities and had one specific operation. Further studies that includes other forms of delivery, number of stillborn, more complex pathology or patients with delayed access to care during conflict would be required to assess other reasons.
Access to health care during conflict is a key dimension and further evidence is needed to understand how access influences patient outcomes.20 Higher maternal mortality, for example, has been reported in countries with recent conflicts compared to countries without conflict (respectively 1000 per 100,000 births vs. 690 per 100,000 births), but confounders were missing and the possible reasons not clarified.21
There is also a complex relationship between exposure to conflict and the utilisation of maternal health services.22 Previous studies have shown that conflict is associated with worse indicators of maternal health service utilisation such as contraceptive use and institutional deliveries, whereas, ironically, skilled birth assistance was better in conflict areas.22 Conversely, other sources have shown limited associations between conflict and maternal health indicators, such as antenatal care and institutional deliveries.23,24 Further research is needed to document the mechanisms through which conflict influences mortality in C-sections.25
A previous study reported that the barriers to accessing health care in Afghanistan were associated with a higher number of maternal deaths compared with women who died from non-maternal causes.26 In one maternity clinic in a small provincial town in Afghanistan in our study, maternal mortality was >30% when more complicated C-sections were attended compared to <5% in a Kabul facility where women usually presented with fewer obstetrical complications. In Afghanistan, accessibility to C-sections is a problem, and timely referral has been identified as a priority to decrease the proportion of emergency C-sections.27 This hypothesis is supported by our findings of a higher mortality in settings located in towns with less access to CEmONC.
Ideally, studies that explore the relation between conflict and health care should include information about women who do not reach the health facilities, through aspects such as availability of services, geographical accessibility, acceptability and contact with the service.28 In our study, this would have allowed a better understanding of the relations between conflict, accessibility and mortality outcome. Unfortunately, in practice, this information is rarely available in conflict settings, due to limited feasibility of conducting household and community surveys during war.
Regarding the clinical presentation of the patients, a study conducted in three MSF facilities in Burundi, the Democratic Republic of the Congo and Sierra Leone showed that type of facility was not a factor associated with maternal or neonatal mortality.29 However, in the same analysis, parity, certain C-section indications and age (for neonatal mortality) were associated with increased mortality. This suggests that the outcomes of C-sections may be influenced more by individual factors than by facility- or setting-related factors.
We also suggest that the lack of a difference in mortality rates with or without conflict could be related to the MSF's use of standardised procedures, adequate equipment and proper staff in all their supported surgical facilities. Donabedian's framework defines quality of care as: structure (i.e., equipment, human resources); process (i.e., implementation of standardised protocols, diagnostic resources); and outcome, where each component is influenced by the previous one, making the components interdependent.30,31 For the MSF C-sections, standards for provision of surgical care were maintained for these three domains in both conflict and non-conflict settings, leading to similar outcomes.32 To continue health-care provision during conflict and non-conflict, homogenous minimal quality standards should therefore continue to be implemented and monitored.
There were a number of strengths to this study. The large number of C-sections over a sustained period of time in different settings permitted the observation of meaningful maternal mortality, with a unique comparability between MSF-supported facilities due to similar standardised clinical protocols, team structures, medical devices, drugs, patient files, data collection and supplies in all countries and facilities.
A major limitation of our study was the use of conflict definitions per UCDP/PRIO, which reflects active conflict only at country level. This categorisation may not correspond to the local situation at facility level. To minimise this, we validated the conflict category with the staff at each of the facilities. Another limitation was that data on neonatal mortality were only collected intraoperatively and the outcomes at the time of discharge were not assessed. This may have led to an underestimation of the number of neonatal deaths, although this may not have had a different impact between the conflict and non-conflict settings.
CONCLUSION
Despite the presence of conflict, a large number of C-sections were performed in MSF-supported facilities over the 8 years of the study period across multiple settings, with no differences in neonatal or maternal mortality compared with non-conflict settings. This is encouraging evidence, supporting the continuation of emergency C-section provision as part of maternity care in conflict settings.
Acknowledgments
We would like to thank the mothers and children for being part of the study, the Médecins Sans Frontières (MSF) field teams for their collaboration and T Reid and I Zuniga for their critical review of the manuscript. MSF provided the Open Access publishing fee.
Availability of data and materials
The data that support the findings of this study are available from MSF. Restrictions apply to the availability of these data, which were utilised under license for the current study and are not publicly available. These data are, however, available from the authors upon reasonable request and with permission of MSF.
Footnotes
Conflicts of interest: none declared.
References
- 1.O'Hare B A, Southall D P. First do no harm: the impact of recent armed conflict on maternal and child health in Sub-Saharan Africa. J R Soc Med. 2007;100(12):564–570. doi: 10.1258/jrsm.100.12.564. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Verwimp P, Van Bavel J. Child survival and fertility of refugees in Rwanda. Eur J Population. 2005;21:271. [Google Scholar]
- 3.Sidel V W, Levy B S. The health impact of war. Int J Inj Contr Saf Promot. 2008;15(4):189–195. doi: 10.1080/17457300802404935. [DOI] [PubMed] [Google Scholar]
- 4.Tam C C, Lopman B A, Bornemisza O, Sondorp E. Epidemiology in conflict: a call to arms. Emerg Themes Epidemiol. 2004;3:3–5. doi: 10.1186/1742-7622-1-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Joshi M. Comprehensive peace agreement implementation and reduction in neonatal, infant and under-5 mortality rates in post-armed conflict states, 1989–2012. BMC Int Health Hum Rights. 2015;15(27):1–10. doi: 10.1186/s12914-015-0066-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.World Health Organization WHO Statement on Caesarean section rates. Executive summary. Geneva, Switzerland: WHO; 2014. [Google Scholar]
- 7.Betrán A P, Merialdi M, Lauer J A et al. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol. 2007;21(2):98–113. doi: 10.1111/j.1365-3016.2007.00786.x. [DOI] [PubMed] [Google Scholar]
- 8.Cavallaro F L, Cresswell J A, França G V, Victora C G, Barros A J, Ronsmans C. Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa. Bull World Health Organ. 2013;91(12):914–922. doi: 10.2471/BLT.13.117598. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Lindskog EE. The effect of war on infant mortality in the Democratic Republic of Congo. BMC Public Health. 2016;16(1):1059. doi: 10.1186/s12889-016-3685-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Médecins Sans Frontières MSF activity report 2008. Geneva, Switzerland: MSF; 2009. http://www.msf.org/sites/msf.org/files/msf-activity-report-2008.pdf Accessed August 2019. [Google Scholar]
- 11.Médecins Sans Frontières MSF activity report 2009. Geneva, Switzerland: MSF; 2010. http://www.msf.org/sites/msf.org/files/msf-activity-report-2009.pdf Accessed August 2019. [Google Scholar]
- 12.Médecins Sans Frontières MSF activity report 2010. Geneva, Switzerland: MSF; 2011. http://www.msf.org/sites/msf.org/files/msf-activity-report-2010.pdf Accessed August 2019. [Google Scholar]
- 13.Médecins Sans Frontières International activity report 2015. Geneva, Switzerland: MSF; 2016. http://www.msf.org/sites/msf.org/files/international_activity_report_2015_en_2nd_ed_0.pdf Accessed August 2019. [Google Scholar]
- 14.Médecins Sans Frontières International activity report 2014. Geneva, Switzerland: MSF; 2015. http://cdn.msf.org/sites/msf.org/files/msf_international_activity_report_2014_en.pdf Accessed August 2019. [Google Scholar]
- 15.Médecins Sans Frontières Essential obstetric and newborn care. 2015 ed. Geneva, Switzerland: MSF; 2015. http://refbooks.msf.org/msf_docs/en/obstetrics/obstetrics_en.pdf Accessed August 2019. [Google Scholar]
- 16.Pettersson T, Wallensteen P. Armed conflicts, 1946–2014. J Peace Res. 2015;52(4):536–550. [Google Scholar]
- 17.Gleditsch N P, Wallensteen P, Eriksson M, Sollenberg M, Strand H. Armed conflict 1946–2001: a new dataset. J Peace Res. 2002;39(5):615–637. [Google Scholar]
- 18.Huster K M J, Patterson N, Schilperoord M, Spiegel P. Cesarean sections among Syrian refugees in Lebanon from December 2012/January 2013 to June 2013: probable causes and recommendations. Yale J Biol Med. 2014;87(3):269–288. [PMC free article] [PubMed] [Google Scholar]
- 19.Chu K M, Ford N, Trelles M. Operative mortality in resource-limited settings: the experience of Medecins Sans Frontieres in 13 countries. Arch Surg. 2010 Aug;145(8):721–725. doi: 10.1001/archsurg.2010.137. [DOI] [PubMed] [Google Scholar]
- 20.Blanchet K, Sistenich V, Ramesh A An evidence review of research on health interventions in humanitarian crises. Cardiff, UK: Enhancing Learning and Research in Humanitarian Assitance; 2005. [Google Scholar]
- 21.O'Hare B A M, Southall D P. First do no harm: the impact of recent armed conflict on maternal and child health in Sub-Saharan Africa. R Soc Med. 2007;100:564–570. doi: 10.1258/jrsm.100.12.564. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Chi P M, Bulage P, Urdal H, Sundby J. A qualitative study exploring the determinants of maternal health service uptake in post-conflict Burundi and Northern Uganda. BMC Pregnancy and Childbirth. 2015;15:18. doi: 10.1186/s12884-015-0449-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Namasivayam A, Arcos González P, Castro Delgado R, Chi P C. The effect of armed conflict on the utilization of maternal health services in Uganda: a population-based study. PLoS Curr. 2017;9 doi: 10.1371/currents.dis.557b987d6519d8c7c96f2006ed3c271a. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Gopalan S S, Silverwood R J, Salman O, Howard N. associations between acute conflict and maternal care usage in Egypt: An uncontrolled before-and-after study using demographic and health survey data. Int J Health Policy Manag. 2019;8(3):158–167. doi: 10.15171/ijhpm.2018.107. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Lindskog E E. The effect of war on infant mortality in the Democratic Republic of Congo. BMC Public Health. 2016;16(1):1059. doi: 10.1186/s12889-016-3685-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Bartlett L A, Jamieson D J, Kahn T, Sultana M, Wilson H G, Duerr A. Maternal mortality among Afghan refugees in Pakistan, 1999–2000. Lancet. 2002;359:643–649. doi: 10.1016/S0140-6736(02)07808-X. [DOI] [PubMed] [Google Scholar]
- 27.Chu K, Cortier H, Maldonado F, Mashant T, Ford N, Trelles M. Cesarean section rates and indications in sub-Saharan Africa : a multi-country study from Medecins Sans Frontières. PLoS One. 2012;7(9) doi: 10.1371/journal.pone.0044484. e44484. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Tanahashi T. Health service coverage and its evaluation. Bull World Health Organ. 1978;56(2):295–303. [PMC free article] [PubMed] [Google Scholar]
- 29.Kim Y M, Tappis H, Zainullah P et al. Quality of Caesarean delivery services and documentation in first-line referral facilities in Afghanistan: a chart review. BMC Pregnancy Childbirth. 2012;12(1):14. doi: 10.1186/1471-2393-12-14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260:1743–1748. doi: 10.1001/jama.260.12.1743. [DOI] [PubMed] [Google Scholar]
- 31.Smitz Naranjo L L, Viswanatha Kaimal P. Applying Donabedian's theory as a framework for bariatric surgery accreditation. Bariatric Nursing and Surgical Patient Care. 2011;6(1):33–37. [Google Scholar]
- 32.Alvarado O, Trelles M, Tayler-smith K et al. Orthopaedic surgery in natural disaster and conflict settings : how can quality care be ensured ? Int Orthop. 2015;39(10):1901–1908. doi: 10.1007/s00264-015-2781-z. [DOI] [PubMed] [Google Scholar]