Publications

Introduction: Yemen has one of the highest rates of child marriage in the Middle East and North Africa region and is home to one of the world's worst humanitarian crises. How the conflict and resulting displacement have impacted family formation patterns is not entirely clear. In this study, we investigate the impact of displacement on child marriage and early childbearing by comparing time-to-first-marriage and time-to-first-birth among displaced and non-displaced girls.

On Sept 13, 2024, WHO announced the prequalification of the first mpox vaccine, MVA-BN.¹ WHO's Strategic Advisory Group of Experts (SAGE) on Immunization recommended this vaccine for people at high risk of mpox exposure in the current outbreak, stating that “this vaccine may be used ‘off-label’ in infants, children and adolescents, and in pregnant and immunocompromised people”. ¹ Missing from these recommendations are breastfeeding mothers. In 2022, WHO had stated that the MVA-BN vaccine could be used in breastfeeding women.² However, WHO's new 2024 guidance, which replaced the 2022 recommendations, simply states, “MVA-BN safety and efficacy has not been evaluated in breastfeeding women. Data are not available to assess…the safety of MVA-BN in breastfed infants.”³

MVA-BN contains a weakened, non-replicating virus that cannot cause mpox. Currently, some countries recommend its use in people who are breastfeeding,⁴ whereas others prefer not to make this recommendation.⁵ This contradiction has, understandably, led to confusion among health-care workers.

There has been tremendous progress in building and promoting evidence-based practice around parenting programming in low- and middle-income countries. However, there remains a dearth of evidence specifically examining gender transformative programming designed to address gender-based violence in humanitarian settings. To inform this gap, we examine how existing gender transformative programmatic material addresses the unique circumstances of parenting in humanitarian settings. Incorporating lessons from the field, we inform considerations of how to adapt future content to address gender-based violence in humanitarian settings. We reviewed two gender transformative programs in humanitarian settings: Safe at Home and Sibling Support for Adolescent Girls in Emergencies. Four thematic recommendations emerged for gender-transformative parenting programming in humanitarian settings to address gender-based violence, specifically intimate partner violence and violence against children. These recommendations include: 1) Recognize the diversity of families in humanitarian settings, 2) Prioritize participatory approaches from the start, 3) Set realistic parameters and goals for the specific humanitarian context, and 4) Ensure pathways to scale and sustainability within the initial program design. We advocate for broader application of these principals to support gender-transformative parenting programming that is tailored to address gender-based violence in humanitarian settings and that will continue to build the respective evidence base.

This study investigates the association between forced displacement and the experience of menstrual shame, highlighting age and current displacement as influential factors of menstrual wellbeing amidst humanitarian crises.

Violence and threats against health facilities and workers, both in peacetime and during armed conflict, and the criminalisation of medical care, such as abortion care, limit access to health services and result in worse health outcomes for millions of people around the world.^1,2 Combatants', governments', and the international community's abdication of responsibility to protect health workers and facilities subjects physicians, nurses, and other health personnel to verbal and physical attack and leads to needless patient deaths. As leaders of medical and nursing organisations and researchers in the field, we share the conviction that attacks against health personnel anywhere should be a matter of concern for health professionals everywhere.

Few implementation science (IS) measures have been evaluated for validity, reliability and utility – the latter referring to whether a measure captures meaningful aspects of implementation contexts. We present a real-world case study of rigorous measure development in IS that assesses Barriers and Facilitators in Implementation of Task-Sharing in Mental Health services (BeFITS-MH), with the objective of offering lessons-learned and a framework to enhance measurement utility.

The eastern Democratic Republic of Congo (DRC) has faced dual burdens of poor mental health and heightened levels of violence against women and children within the home. Interventions addressing family violence prevention may offer a path to mitigate mental distress within the eastern DRC. This exploratory analysis uses data from a pilot cluster randomized controlled trial conducted in North Kivu, DRC, assessing the impact of Safe at Home, a violence prevention intervention. Mental health was assessed at endline using the Patient Health Questionnaire-4. Statistical analyses employed multilevel linear regression.

Assuming successful randomization, impact of the Safe at Home intervention on mental health differed by participant gender. Women enrolled in the Safe at Home intervention reported statistically significant decreases in mental distress symptoms [β (95%CI) = −1.01 (−1.85, −0.17)], whereas men enrolled in Safe at Home had similar scores in mental distress to the control group [β (95%CI) = −0.12 (−1.32, 1.06)].

Ultimately, this exploratory analysis provides evidence of the potential for a family violence prevention model to improve women’s mental health in a low-resource, conflict-affected setting, although further research is needed to understand the impact on men’s mental health.

Between 2015 and 2023, 7.3 million Venezuelans have been displaced globally. We aimed to assess uptake of and factors associated with prenatal care among Venezuelan refugees and migrants in Colombia. We analyzed data from a cross-sectional survey of 6,221 urban-residing adult Venezuelans who were displaced to Colombia between 2015 and 2022. Analyses were restricted to 917 women aged 18–49 years who reported at least one pregnancy and delivered in Colombia; of these, 564 (61.5%) women completed ≥4 prenatal care visits in their most recent pregnancy. We used general linear models with negative binomial regression to identify associations and estimate the adjusted prevalence ratios (aPrR) of variables associated with completing ≥4 prenatal care visits during last complete pregnancy (WHO's pre-2016 recommendations). Having an irregular migration status was independently associated with a 12% lower likelihood (aPrR:0.88, 95%CI:0.78–0.99; p = 0.028) of completing ≥4 prenatal care visits compared to women with a regular status. Participants who reported an experience of denial of prenatal care at some point while Colombia (n = 135; 15.2%) were 42.8% less likely (aPrR:0.57, 95%CI:0.45–0.73; p < 0.001) to complete ≥4 prenatal care visits than those with no reported denial of care. Urban area of residence was also independently associated with prenatal care, while there was no evidence of association with educational attainment, literacy levels, or year of migration. Prenatal care attendance is suboptimal among Venezuelan refugees and migrants, particularly those with an irregular migration status, despite that prenatal care became officially available in 2018 to all Venezuelans in Colombia regardless of migration status. Reducing barriers to prenatal care by ensuring Venezuelan refugees and migrants are aware of available care, are supported in navigating the health system, and by preventing discrimination and stigma in the health facility are critical to ensuring the health and wellbeing of displaced people, their children, and the surrounding community.

On Aug 14, 2024, WHO declared mpox a Public Health Emergency of International Concern.¹ The Democratic Republic of the Congo is particularly affected. The importance of exclusive breastfeeding for infant survival has been widely shown, and is of particular relevance in the Democratic Republic of the Congo, where new mpox cases are increasing, including among breastfeeding women.

During outbreaks of viral pathogens, whether breastmilk or breastfeeding can transmit the relevant virus is often questioned (ie, during the COVID-19 pandemic and Ebola outbreaks). A priori, guidelines often state that breastmilk should be withheld from infants without evidence of transmission. A 2021 study estimated that many newborns separated from their mothers who were infected with SARS-CoV-2 probably had higher mortality from being denied breastmilk than from contracting the virus from mothers who were infected.²

Background Throughout the Syrian conflict, the Syrian government has intentionally attacked health facilities, violating International Humanitarian Law. Previous studies have qualitatively described health system disruptions following attacks on healthcare or established associations between armed conflict and health service utilisation, but there are no quantitative studies exploring the effects of health facility attacks. Our unprecedented study addresses this gap by quantifying the effects of health facility attacks on health service use during the Syrian conflict.

Methods This retrospective observational study uses 18 537 reports capturing 2 826 627 consultations from 18 health facilities in northwest Syria and 69 attacks on these facilities. The novel study applies case time series design with a generalised non-linear model and stratification by facility type, attack mechanism and corroboration status.

In introducing the new CHH–Lancet Commission on Health, Conflict, and Forced Displacement, Paul B Spiegel and colleagues argue that the humanitarian system to date requires systemic change.¹ We agree, but believe that the Commission's efforts will fall short without a fundamental rejection of apolitical humanitarianism. Historical and contemporary crises, such as the ongoing genocide in Gaza, illustrate that apolitical humanitarianism undermines the field's effectiveness and its ability to respond to those most affected. Avoiding engagement with politics in humanitarian action maintains a broken system that prioritises powerful interests over the needs of individuals in humanitarian crises.

The principle of apolitical humanitarianism—rooted in neutrality, impartiality, and independence—has long been a foundational concept in the humanitarian response. However, the idea of transcending political affiliation as a strength of the field was challenged in the late 20th century, particularly during the Rwandan genocide and other conflicts in which humanitarians found their aid targeted and instrumentalised.² At the time of writing this, we witness this in Gaza, where those accused of indiscriminate attacks on civilians also control the humanitarian response,^3,4 raising questions about the effectiveness of apolitical humanitarianism.

How can palliative care framings advance humanitarian discourse? The imperative for palliative care in humanitarian settings is increasingly urgent. Recent efforts by health and humanitarian organizations demonstrate increasing attention to the issue. Yet palliative care is still not adequately formally considered or enacted by humanitarian agencies in rhetoric, policy, research, or practice. Even where it is considered in humanitarian action, palliative care is often assumed to be a novel intervention, rather than a caring practice that has existed from time immemorial, including in humanitarian situations. The generation of ideas in this paper has followed a dynamic, iterative, and reflexive process through engagement with key literature, critical thinking, conversations with colleagues across both sectors, primary data, and debate amongst the authors. The paper argues that the current dominant frame of a new, specialized, professionalized, and medicalized palliative care in the humanitarian sector would perpetuate existing challenges. It contends that viewing both fields through a “new-old” lens, where historical and traditional caring practices intertwine with progressive discourse for a more just and appropriate public health response, can further humanitarianism. It posits that the humanitarian-development nexus, decoloniality, and localization thought can benefit from palliative care practice through critical interaction with a broad range of literature.

On 6 February 2023, an Mw 7.8 earthquake struck southern and central Türkiye and north-western Syria, affecting the lives of 4.6 and 2.5 million children, respectively. In such crises, infants who are dependent on commercial milk formula (CMF) face increased vulnerability to diseases and malnutrition as safe preparation of CMF becomes difficult and sometimes impossible. The Operational Guidance on Infant and Young Child Feeding in Emergencies (OG-IFE) provides guidance on protecting and supporting recommended infant and young child feeding and minimizing the risks that come with CMF feeding. In addition, the International Code of Marketing of Breastmilk Substitutes (the Code) ensures adequate nutrition for infants by protecting and promoting breastfeeding and ensuring the proper usage of CMF. This study aims to document violations of the Code and the OG-IFE during the earthquake relief efforts to help strengthen infant and young child feeding emergency responses and inform future disaster relief policies.

On 6 February 2023, an Mw 7.8 earthquake struck southern and central Türkiye and north-western Syria, affecting the lives of 4.6 and 2.5 million children, respectively. In such crises, infants who are dependent on commercial milk formula (CMF) face increased vulnerability to diseases and malnutrition as safe preparation of CMF becomes difficult and sometimes impossible. The Operational Guidance on Infant and Young Child Feeding in Emergencies (OG-IFE) provides guidance on protecting and supporting recommended infant and young child feeding and minimizing the risks that come with CMF feeding. In addition, the International Code of Marketing of Breastmilk Substitutes (the Code) ensures adequate nutrition for infants by protecting and promoting breastfeeding and ensuring the proper usage of CMF. This study aims to document violations of the Code and the OG-IFE during the earthquake relief efforts to help strengthen infant and young child feeding emergency responses and inform future disaster relief policies.

As the global humanitarian community commemorates World Humanitarian Day on Aug 19, 2024, let us honour the brave and compassionate humanitarian aid workers who support people forcibly displaced by global crisis. However, a crucial question emerges: who truly shapes the narrative of humanitarian aid? The landscape of global crises and humanitarian response has evolved significantly since the adoption of The International Humanitarian Law in 1864.

As the global humanitarian community commemorates World Humanitarian Day on Aug 19, 2024, let us honour the brave and compassionate humanitarian aid workers who support people forcibly displaced by global crisis. However, a crucial question emerges: who truly shapes the narrative of humanitarian aid? The landscape of global crises and humanitarian response has evolved significantly since the adoption of The International Humanitarian Law in 1864.

Maternal and Perinatal Death Surveillance and Response (MPDSR) systems provide an opportunity for health systems to understand the determinants of maternal and perinatal deaths in order to improve quality of care and prevent future deaths from occurring. While there has been broad uptake and learning from low- and middle-income countries, little is known on how to effectively implement MPDSR within humanitarian contexts – where disruptions in health service delivery are common, infrastructural damage and insecurity impact the accessibility of care, and severe financial and human resource shortages limit the quality and capacity to provide services to the most vulnerable. This study aimed to understand how contextual factors influence facility-based MPDSR interventions within five humanitarian contexts.

The global population impacted by humanitarian crises continues to break records each year, leaving strained and fractured health systems reliant upon humanitarian assistance in more than 60 countries. Yet little is known about implementation of maternal and perinatal death surveillance and response (MPDSR) within crisis-affected contexts. This scoping review aimed to synthesise evidence on the implementation of MPDSR and related death review interventions in humanitarian settings.

Maternal and Perinatal Death Surveillance and Response (MPDSR) systems provide an opportunity for health systems to understand the determinants of maternal and perinatal deaths in order to improve quality of care and prevent future deaths from occurring. While there has been broad uptake and learning from low- and middle-income countries, little is known on how to effectively implement MPDSR within humanitarian contexts – where disruptions in health service delivery are common, infrastructural damage and insecurity impact the accessibility of care, and severe financial and human resource shortages limit the quality and capacity to provide services to the most vulnerable. This study aimed to understand how contextual factors influence facility-based MPDSR interventions within five humanitarian contexts.