Table 2

Reported barriers and facilitators in the implementation of MNH interventions

Barriers
SecurityBeing in an insecure environment was often mentioned as a hindrance to the delivery of interventions. Health facilities are destroyed, patients were also unable to access clinics due to security issues. This was especially relevant for services such as emergency obstetric care when women may need to be referred to hospitals.
Lack of resourcesShortages of supplies/resources (medicine, diagnostic tests) during a period of conflict were also noted as barriers and hampered both maternal and newborn care. Materials such as gloves for delivery, obstetric equipment or beds for premature babies were some of the ones noted as missing.43 111
Population movementThe continuous population movement limits both delivery and access to health services.
Lack of skilled health workersThe limited training of health workers was a major barrier in the delivery of interventions such as obstetric and newborn care. A few studies mentioned the lack of obstetric specialists as a barrier.43 104 A short training although helping to increase knowledge was also noted as not being enough.
Social norms/stigmaThis was noted as a barrier for both patients as well as healthcare workers. Refugees may also be stigmatised by their hosts.63
Lack of fundingLimited funding was also noted as a barrier as it limited to range of services and materials available.
Limited movement for the women/cost barriersConflict reduces means of generating income, especially during displacement. Therefore, the cost of getting health services or of transport might be weighed against other priorities. In some instances where healthcare is not subsidised, cost of care also influenced where women delivered.49
Staff affected by conflictHealth services were also limited as staff are also affected by displacement and security concerns. Shortage of staff was a big concern and in some areas was caused by the warring party. In one study, the Taliban were preventing female health providers from working.106 Some areas also experienced a high staff turnover, especially in a prolonged conflict.134
Limited servicesConflict reduces the range of available services. For maternal health, this was especially dangerous in cases where there is limited EmOC services as needed surgical facilities were not available or there was no training in the management of postpartum complications,33 64 emergency referral services were also not always available.
Quality of careThere were some differences noted between the quality of care delivered at hospitals, compared with clinics; hospitals having a higher quality.111 ANC and postnatal care were also not always delivered to their full extent.
Lack of guidelinesA few studies mentioned lack of guidelines for STI prevention or lack of newborn-specific clinical and referral protocols as barriers to implementation.112
Facilitators
CollaborationMultisectoral collaboration between international NGOs, the Ministry of Health and existing district health offices/public sector was noted as facilitators. Working with local NGOs was also a facilitator as they are already connected to the community.
Staff trainingTraining improved the skills of health workers and increased motivation. Continuous supervision/refresher training was encouraged, especially if provided by trained paediatricians or obstetricians.122 S-CORT modules are an innovative approach that focuses on training on the clinical services included in the MISP.122 One NGO developed a simple and low-cost 38-hour training course to upgrade the skills of TBAs.113
Availability of funding/resourcesHaving adequate funding allowed for more resources.
CHW involvement/outreach workersHaving maternal CHWs from the same community or refugee population was noted as a facilitator in educating women about maternal health.
Use of existing infrastructureUsing the existing infrastructure facilitated the delivery of interventions.71 110
Technological/systems innovationsImproving systems such as introducing an ultrasound in outreach settings was noted as a facilitator,23 or introducing ANC into family medicine clinics as shown by Homan et al.57 Using GIS technology with a mobile clinic was shown as being effective in delivering SRH services to IDPs.114 Having a free ambulance along with good infrastructure (roads, telephone network) was a facilitator.91
Refugee participationRefugee participation was noted as a facilitator as it provided manpower and community leadership.90 Refugee services run by refugees were shown to be feasible if there is sustained funding and technical assistance.130
Dedicated staffHaving dedicated healthcare workers was noted multiple times as being a facilitator.86 106 121
  • ANC, antenatal care; CHWs, community health workers; EmOC, emergency obstetric care; GIS, geographic information system; IDPs, internally displaced persons; MISP, Minimum Initial Service Package; MNH, maternal and neonatal health; NGOs, non-governmental organisations; SRH, sexual and reproductive health; STI, sexually transmitted infection; TBAs, traditional birth attendants.