Table 3

Characteristics of included publications

StudyCountryCrisis typePopulationStudy designInterventionKey findingsQuality
Peer-reviewed literature
Amsalu et al36SomaliaProtracted conflictGeneral and internally displaced people (IDP)Cross-sectionalEssential newborn care (ENC) at four primary healthcare (PHC) centres. Thermal care, feeding support, hygiene, newborn resuscitation.Significant variation between health facilities (p<0.001) in the practice of skin-to-skin, support in breastfeeding initiation, early breastfeeding initiation and dry cord care.High
Amsalu et al55SomaliaProtracted conflictGeneral and IDPPre-post studyEight-day training of healthcare workers (HCWs) at four PHC centres in ENC, including care of small babies; provision of supplies and medications and creation of a newborn health record system (following Field Guide recommendations). Five-day refresher training at 6 months.Knowledge improvement, mean difference in score of +11.9% (95% CI 7.2 to 16.6) and from post-training to 18-month follow-up +10.9% (95% CI 4.7 to 17.0). Both with p<0.001.
Improvement in ENC practices from baseline to endline with a difference in proportion of newborns that receive two or three ENC of +74.8% (95% CI 69.1 to 80.5) and +60.6% (95% CI 54.6 to 66.5) of newborns that received three ENC. Both p<0.001.		High
Amsalu et al33Niger, Cameroon and ChadProtracted crisisRefugeePre-post studyHelp Babies Survive training for health workers in PHC and hospitals (includes ENC and care of small babies) using a low-dose high frequency competence-building approach.No change in neonatal mortality rate (NMR) - low at baseline and potentially under-reported - but positive trend. Health facilities improved and sustained the availability of medications, supplies and newborn clinical guidelines.Low
Casey et al37Burkina Faso, DRC and South SudanProtracted conflictGeneral, refugee and IDPCross-sectionalElements of ENC (newborn resuscitation, breastfeeding support, newborn infection, thermal care, cord care).Availability and quality varied across settings. In the DRC, none of the 25 health centres provide ENC; in South Sudan, 25% of health centres and none of the hospitals provided ENC and in Burkina Faso, 66.7% of hospitals, 25% of camp health centres and 9.5% of non-camp health centres provided ENC.Medium
Chaudhary et al45NepalNatural disasterGeneral and IDPCase studyImplementation of Minimum Initial Service Package (MISP).Deployment of 33 skilled birth attendants (SBAs) to birth centres; 1100 clean delivery kits and 53 000 newborn suits were provided across the 14 districts.High
de Vries I et al34PalestineProtracted crisisGeneralCross-sectionalPostnatal home visits programme for high-risk cases and primiparous. Midwives and nurses were trained on several topics (including postnatal and newborn care), received postnatal home visit kits and had to conduct home visits within 48–72 hours post delivery.Trained staff felt more confident about their knowledge and skills to assist women with breast feeding. Women that received post natal home visits demonstrated improved breastfeeding practices and behaviour changes that reduced harmful traditional practices.Low
Dörnemann et al58Afghanistan, Pakistan, CAR, DRC, Burundi, Sierra LeoneProtracted conflict (2), active armed conflict (1) and postconflict (3)GeneralCross-sectionalMédecins Sans Frontières (MSF) Operational Centre Brussels implemented low-tech specialised neonatal care units (SNCUs) in low-resource settings. The MSF SNCU model was characterised by an absence of high-tech equipment and an emphasis on dedicated nursing and medical care. Focus was on the management of hypothermia, hypoglycaemia, feeding support and early identification/treatment of infection.Overall, 11 970 neonates were admitted, 41% of whom had low birth weight (<2500 g). The main diagnoses were low birth weight, asphyxia and neonatal infections. Overall, mortality was 17%, with consistency across the sites. Chances of survival increased with higher birth weight.High
Draiko et al57South SudanProtracted conflictGeneralControlled pre-post studyHelping Babies to Breathe training to hospital HCWs.Knowledge and skills improved after training and declined 1-year post-training. Knowledge score mean difference of 55.2 (95% CI 50.9 to 59.6) and −15.0 (95% CI −22.7 to 7.4) a year after. P<0.001 for both. Mortality due to asphyxia decreased from 30.7% pre-training to 17.9% 1 year post-training (p=0.001).Medium
Edmond et al29AfghanistanProtracted conflictGeneralControlled pre-post studyConditional cash transfers to improve the use of health facilities and consequent postnatal care (PNC) visits. Financial incentives given to community health workers (CHWs) that visited pregnant women and referred them to a health facility for delivery; to women that delivered in a health facility and education/communication about the programme in the community.Having at least one PNC visit increased in the intervention villages by 23.2%. Adjusted mean difference with control villages was 31.8%, 95% CI −0.05 to −0.68, p=0.080.High
Eze et al44YemenProtracted conflictGeneralCohort retrospective studyOutcomes of a neonatal intensive care unit with capacity for treatment of infection and jaundice, extra feeding support and oxygen therapy.Most common diagnosis in this unit was prematurity. Most neonatal deaths were preterm newborns (90.1%) and 83.1% travelled for more than an hour to reach the facility. From the analysed predictors of facility neonatal mortality, travelling for >60 min to arrive at the NICU had an aOR=2.32 (95% CI 1.07 to 5.04, p=0.033).High
Gee et al28KenyaProtracted conflictRefugeeQualitativeSocial beliefs and practices of refugee populations around newborn care.Skin-to-skin generally not practised and mothers are reluctant to practice. Women increasingly accept feeding colostrums, but mixed feeding practices are still present. Application of foreign substances to the umbilical cord is still practised.High
Hoogenboom et al46ThailandProtracted conflictRefugeeCross-sectionalElements of ENC at a PHC centre. Undefined immediate care, clean cord care and monitoring of newborn.Appropriate immediate care (not specified) and cord care done in all observations and monitoring in the first hours occurred in 30% of the observations.Low
Hynes et al47DRCProtracted conflictGeneralControlled pre-post studyNine-month health workers training using participatory quality improvement (QI) approach comparing with workers that received only the standard 12-day training on ENC. ENC elements evaluated: clean cord care, antibiotic to eyes and weight.Greater rate of change in ENC practices in group that received QI training (OR 49.62, 95% CI 2.79 to 888.28, p<0.05) and reached 100% ENC completion at endline.Medium
Iellamo et al35PalestineProtracted crisisGeneralCross-sectionalElements of ENC related to feeding, being practised by vulnerable women in the Gaza Strip.63% of surveyed mothers practised early initiation of breast feeding and 42% reported given liquids other than breast milk to their newborn in the first 3 days of life. 18% of women reported receiving information about breast feeding during the contact with healthcare professionals.Medium
Kim et al30AfghanistanProtracted conflictGeneralCross-sectionalNeonatal resuscitation in health facilities.91% of the facilities performed neonatal resuscitation in the past 3 months. In the ones that did not, lack of training was the main reason.Medium
Komakech et al48UgandaProtracted conflictRefugeeCross-sectionalElements of ENC in refugee settlements. Initiation of breast feeding, cord care and skin-to-skin.57% of mother breast fed in the first hour; 50.1% cleaned umbilical cord; 17.6% received skin-to-skin and 12.7% delayed bath. ENC was not being used and mainly not accessible to refugee mothers.High
Krause et al39JordanArmed conflictRefugeeCross-sectionalImplementation of the MISP.Newborn resuscitation and advanced care was provided (no details given); clean delivery kits were provided to SBAs and pregnant women.Medium
Kurdi et al51YemenProtracted conflictGeneralCluster randomised trialMonthly cash transfers, conditional of attendance to a monthly nutritional training session during 18–21 months.Programme increased the probability of early breastfeeding initiation by 15.6% points (p<0.05) and of correct answers on breastfeeding initiations by 17.7% points (p<0.01).High
Lam et al49Global and country/region specificHumanitarian settings (general)General—INGOsCross-sectionalSurvey of ENC reported by international and national non-governmental organisations, governments and UN Agencies.Of the respondents, 62.5% reported having policies on maternal health and few (no data) reported having policies to address newborn care. Of the 27 surveyed organisations, only 36.7% reported proving newborn health training to their staff. And 51% lack of trained staff. ENC elements reported varied from 30% to 90%, highest being immediate drying, wrapping (80.4%), skin-to-skin contact and immediate breast feeding (87.5%) and least 48.2% promotion of disinfectants for umbilical cord care.Medium
Lawry et al50South SudanProtracted conflictGeneralCross-sectionalSurvey of ENC elements (feeding, PNC and danger signs) and barriers to access services.98.2% initiated breast feeding immediately; 7.9% (95% CI 6.1 to 9.8) of women received PNC 2 days after birth; 42.9% (95% CI 34.8 to 51) and 45.8% (95% CI 42.5 to 49.2) of men and women, respectively, could identify newborn danger signs.High
Marsh et al38PakistanProtracted conflictGeneral and refugeeQualitativeIdentify uncommon practices linked to a good newborn practice to mobilise communities for behaviour change.Feeding, hygiene and thermal care practices were weak. Identified positive deviance practices on ENC and care of small and sick newborns. Communities were committed to behaviour change and to create support groups.Medium
Massad et al40PalestineProtracted crisisGeneralCross-sectionalAssess the availability of neonatal units and its resources in Palestine.Between Gaza, West Bank and East Jerusalem, 79% of neonatal units are in the West Bank. There is a shortage of equipments, medications and specialised human resources. There is a lack of referrals guidelines and challenges to do them on time.High
McPherson et al32NepalArmed conflictGeneralPre-post studyCHWs promoted desired behaviours related to maternal and newborn care through individual and group counselling.ENC increased 19%–29%; nothing on cord, wrapped immediately and delaying bath p=0.000; wiped immediately p=0.001; breast feeding in first hour p=0.06 and attendance to PNC within 1 week of delivery p=0.01.High
Miller et al52PakistanProtracted conflictRefugeeCross-sectionalTraining traditional birth attendants (TBAs) to improve the childbirth care. Included some elements of ENC (hygiene, cord care and breast feeding).Compared with untrained TBAs, there was an increase in these practices.Low
Mullany et al59MyanmarProtracted conflictIDPPre-post studyThree-tiered network of community-based providers (TBAs, health workers and maternal health workers) that covered some elements of ENC (skin-to-skin, PNC and breast feeding in first hour).Statistically significant increase in skin-to-skin prevalence rate ration (PRR)=2.70 (95% CI 1.93 to 3.78) and PNC PRR=2.07 (95% CI 1.81 to 2.37). Not significant change in breastfeeding initiation.Medium
Myers et al41NepalNatural disasterGeneral populationCross-sectionalMISP implementation.Availability of newborn care was low and equipment was malfunctioning or not available.High
Newbrander et al56AfghanistanProtracted conflictGeneralQualitativeTraditional ENC practices in rural communities.Newborns are usually immediately bathed; breast feeding is delayed until mothers clean their breasts; shame associated with seeking health services and inability for women to seek health services by themselves.High
Zainullah et al42AfghanistanProtracted conflictGeneralCross-sectionalKnowledge and skills of health workers on neonatal resuscitation and care of small and sick neonates.80.8% of doctors and 82.7% of midwives were trained in neonatal resuscitation. In some steps of EmONC decision-making skills, they scored low, that is, doctors scores 36.6% on essential actions when newborn does not cry. Knowledge about newborn infection signs/symptoms, treatment and care of LBW was below 60%.Medium
Rosales et al60South SudanProtracted conflictGeneralCross-sectionalPrevalence of ENC (breast feeding, thermal, cord and eye care) in rural community.Breast feeding (74%) and wrapping immediately after birth (98%)
1% of newborns received all elements.		Medium
Sami et al43South SudanProtracted conflictIDP and refugeeCase studyClinical training, supportive supervision and distribution of medical commodities in health facilities.Difficulties in implementation were found in across the health system layers, that is, need for improvement of skilled workers, integration of newborn interventions in policies and in humanitarian funding scope.Medium
Sami et al31South SudanProtracted conflictIDPCross-sectionalENC and care of small babies in health facilities.62.5% received thermal care; 74.8% infection prevention measures; 63.6% feeding support and 27.7% postnatal monitoring (weight and temperature taken).High
Sami et al53South SudanProtracted conflictGeneralPre-post studyTraining of CHWs and facility health workers on ENC and care of small babies.Mean knowledge scores among CHWs improved, 5.8 (SD=2.3) pre-training and 9.6 (SD=2.1) post-training; among facility-based health workers, 14.2 (SD=2.7) pre-training and 17.4 (SD=2.8) post-training. More confidence when caring for small newborns.High
Turner et al54ThailandProtracted conflictRefugeeCohortImplementation of a SNCU and staff training for the care of small and sick newborns.Between 2008 and 2011, neonatal mortality in the camp declined by 51% from 21.8 to 10.7 deaths per 1000 live births (p=0.04) and mortality in premature newborns declined from 19.3% to 4.8% (p=0.03).Low
Grey literature
 Krause et al61HaitiNatural disasterIDPQualitativeEvaluation of the MISP.Newborn care was available but varied across health facilities; access to services for sick newborns was a major concern. Recommendations to inform communities about where newborn care is available.High
 Krause et al62NepalNatural disasterGeneralQualitativeEvaluation of the MISP.Newborn care (not specified) was available varying between health facilities, lack of functioning equipment reported.Medium

  • aOR, adjusted OR; CAR, Central African Republic; DRC, Democratic Republic of the Congo; INGO, international non-governmental organisation; NICU, neonatal intensive care unit; NMR, neonatal mortality rate.