Approaches to protect and maintain health care services in armed conflict - meeting SDGs 3 and 16

Impact of COVID-19 on the Health of Migrant Children in the United States: From Policy to Practice

In this article, the authors provide an overview how the COVID-19 pandemic impacted the health and wellbeing of migrant children in conflict zones, in transit and post-settlement in the United States. In particular, the authors explore how policies implemented during the pandemic directly and indirectly affected migrant children and led to widening disparities in the aftermath of the pandemic. Given these circumstances, the authors provide recommendations for child health care providers caring for migrant children to mitigate and bolster resilience and health.

Exploring existing malaria services and the feasibility of implementing community engagement approaches amongst conflict-affected communities in Cameroon: a qualitative study

BACKGROUND

Cameroon is one of the countries with the highest burden of malaria. Since 2018, there has been an ongoing conflict in the country, which has reduced access to healthcare for populations in affected regions, and little is known about the impact on access to malaria services. The objective of this study was to understand the current situation regarding access to malaria services in Cameroon to inform the design of interventions to remove barriers and encourage the use of available services.

METHODS

A qualitative research study was carried out to understand the barriers preventing communities accessing care, the uptake of community health worker (CHW) services, and to gather perceptions on community engagement approaches, to assess whether these could be an appropriate mechanism to encourage uptake of community health worker (CHW) services. Twenty-nine focus group discussions and 11 in-depth interviews were carried out between May and July 2021 in two regions of Cameroon, Southwest and Littoral. Focus group discussions were held with CHWs and community members and semi-structured, in-depth interviews were conducted with key stakeholders including regional government staff, council staff, community leaders and community-based organisations. The data were analysed thematically; open, descriptive coding was combined with exploration of pre-determined investigative areas.

RESULTS

The study confirmed that access to healthcare has become increasingly challenging in conflict-affected areas. Although the Ministry of Health are providing CHWs to improve access, several barriers remain that limit uptake of these services including awareness, availability, cost, trust in competency, and supply of testing and treatment. This study found that communities were supportive of community engagement approaches, particularly the community dialogue approach.

CONCLUSION

Communities in conflict-affected regions of Cameroon continue to have limited access to healthcare services, in part due to poor use of CHW services provided. Community engagement approaches can be an effective way to improve the awareness and use of CHWs. However, these approaches alone will not be sufficient to resolve all the challenges faced by conflict-affected communities when accessing health and malaria services. Additional interventions are needed to increase the availability of CHWs, improve the supply of diagnostic tests and treatments and to reduce the cost of treatment for all.

A mini-review on safeguarding global health amidst a "Pandemic" of armed conflicts

The year 2022 witnessed an alarming surge in state-based armed conflicts globally, reaching a staggering 56, with major hostilities in Ukraine, Myanmar, and Nigeria resulting in over 10,000 estimated conflict-related deaths. This trend continued with the onset of a significant conflict between Israel and Hamas in October 2023. The escalating frequency of armed conflicts, reaching the highest number since 1946, poses a critical threat to global health. This paper explores the multifaceted health impacts of armed conflicts, encompassing physical injuries, infectious diseases, malnutrition, and profound mental health consequences. Healthcare systems in conflict zones face severe strain, and achieving Sustainable Development Goals by 2030 becomes increasingly challenging. The surge in armed conflicts globally is characterized as a "pandemic," justifying urgent attention. The paper identifies and discusses strategies to safeguard public health in conflict zones, emphasizing humanitarian response, protecting healthcare workers and infrastructure, building preparedness and resilience, and promoting mental health support. In navigating this "pandemic" of armed conflicts, comprehensive strategies are imperative to address the intricate challenges and secure a healthier global future.

The Effect of War on STEMI Incidence: Insights from Intensive Cardiovascular Care Unit Admissions

(1) Background: The impact of armed conflicts on public health is undeniable, with psychological stress emerging as a significant risk factor for cardiovascular disease (CVD). Nevertheless, contemporary data regarding the influence of war on CVD, and especially on acute coronary syndrome (ACS), are scarce. Hence, the aim of the current study was to assess the repercussions of war on the admission and prognosis of patients admitted to a tertiary care center intensive cardiovascular care unit (ICCU). (2) Methods: All patients admitted to the ICCU during the first three months of the Israel-Hamas war (2023) were included and compared with all patients admitted during the same period in 2022. The primary outcome was in-hospital mortality. (3) Results: A total of 556 patients (184 females [33.1%]) with a median age of 70 (IQR 59-80) were included. Of them, 295 (53%) were admitted to the ICCU during the first three months of the war. Fewer Arab patients and more patients with ST-segment elevation myocardial infraction (STEMI) were admitted during the war period (21.8% vs. 13.2%, p < 0.001, and 31.9% vs. 24.1%, p = 0.04, respectively), whereas non-STEMI (NSTEMI) patients were admitted more frequently in the pre-war year (19.3% vs. 25.7%, p = 0.09). In-hospital mortality was similar in both groups (4.4% vs. 3.4%, p = 0.71; HR 1.42; 95% CI 0.6-3.32, p = 0.4). (4) Conclusions: During the first three months of the war, fewer Arab patients and more STEMI patients were admitted to the ICCU. Nevertheless, in-hospital mortality was similar in both groups.

Lived experiences of refugee women with vaginal fistula in Nakivale and Oruchinga refugee settlements, Isingiro District, Uganda

BACKGROUND

Vaginal fistula (VF) affects 2-3 million women globally, with the majority in Africa. In Uganda, it's 2%, with western Uganda having the highest prevalence. Major predisposing factors for refugee women include health system breakdowns and sexual violence during conflict. VF has severe consequences for women, relatives, and communities. There's limited information on lived experiences among refugee women with VF, and there's a need for quality prevention, treatment, and social reintegration strategies. This study aimed to understand the physical, psychosocial, and economic impacts of VF on refugee women in Nakivale and Oruchinga settlements and their coping mechanisms.

METHODS

Ten refugee women with VF were interviewed using qualitative study design, utilizing Social-Ecological and Transactional Models for data collection, analysis, and discussion.

RESULTS

Ten refugee women aged 24-50 years with or who had experienced VF participated in the study. They lived with VF for at least 2-15 years and had multiple stillbirths. Obstetric Fistula (OF) was the leading cause, followed by rape and cancer. Post-fistula, they faced social discrimination, emotional disturbances, survival difficulties, poverty, and lack of support. They struggled with stigma, social isolation, and marital sexual challenges.

CONCLUSION

Refugee women experience physical, emotional, financial, social, and sexual trauma due to VF. Discrimination and stigmatization from loved ones and society lead to isolation, depression, and suicidal thoughts. Despite successful repair, their social and emotional healing remains a burden for their lives. There is a need to provide a supportive environment for VF survivors.

Effectiveness of the Gratuité user fee exemption policy on utilization and outcomes of maternal, newborn and child health services in conflict-affected districts of Burkina Faso from 2013 to 2018: a pre-post analysis

BACKGROUND

Evidence on effectiveness of user fee exemption policies targeting maternal, newborn, and child health (MNCH) services is limited for conflict-affected settings. In Burkina Faso, a country that has had its fair share of conflicts, user fee exemption policies have been piloted since 2008 and implemented along with a national government-led user fee reduction policy ('SONU': Soins Obstétricaux et Néonataux d'Urgence). In 2016, the government transitioned the entire country to a user fee exemption policy known as Gratuité. Our study objective was to assess the effect of the policy on the utilization and outcomes of MNCH services in conflict-affected districts of Burkina Faso.

METHODS

We conducted a quasi-experimental study comparing four conflict-affected districts which had the user fee exemption pilot along with SONU before transitioning to Gratuité (comparator) with four other districts with similar characteristics, which had only SONU before transitioning (intervention). A difference-in-difference approach was initiated using data from 42 months before and 30 months after implementation. Specifically, we compared utilization rates for MNCH services, including antenatal care (ANC), facility delivery, postnatal care (PNC) and consultation for malaria. We reported the coefficient, including a 95% confidence interval (CI), p value, and the parallel trends test.

RESULTS

Gratuité led to significant increases in rates of 6th day PNC visits for women (Coeff 0.15; 95% CI 0.01-0.29), new consultations in children < 1 year (Coeff 1.80; 95% CI 1.13-2.47, p < 0.001), new consultations in children 1-4 years (Coeff 0.81; 95% CI 0.50-1.13, p = 0.001), and uncomplicated malaria cases treated in children < 5 years (Coeff 0.59; 95% CI 0.44-0.73, p < 0.001). Other service utilization indicators investigated, including ANC1 and ANC5+ rates, did not show any statistically significant positive upward trend. Also, the rates of facility delivery, 6th hour and 6th week postnatal visits were found to have increased more in intervention areas compared to control areas, but these were not statistically significant.

CONCLUSIONS

Our study shows that, even in conflict-affected areas, the Gratuité policy significantly influences MNCH service utilization. There is a strong case for continued funding of the user fee exemption policy to ensure that gains are not reversed, especially if the conflict ceases to abate.

Evolution of assisted deliveries at primary healthcare centres in an unstable security context in Mali

INTRODUCTION

In Mali, healthcare systems are severely affected by conflict. However, several studies suggest a lack of knowledge about its impact on maternal healthcare. Frequent and repeated attacks increase insecurity, limit access to maternal care, and thus represent a barrier to accessing care. The objective of this study is to understand how assisted deliveries are being reorganised at the health centre level, and how they are adapting to the security crisis.

METHOD

This is a mixed sequential and explanatory study. The quantitative approaches combine a spatial scan analysis of assisted deliveries by health centres, an analysis of health centre performance using an ascending hierarchical classification, and a spatial analysis of violent events in two health districts in central Mali: Mopti and Bandiagara. The qualitative phase analyses semidirective and targeted interviews with managers (n=22) of primary healthcare centres (CsCOM) and two agents of international institutions.

RESULTS

The study reveals an important territorial heterogeneity of assisted deliveries. The primary health centres with high rates of assisted deliveries have mainly high-performance levels. This high level of use can be explained by the movement of the population to areas less exposed to attacks. The centres with low rates of assisted deliveries are those where qualified health workers refused to practice, where populations had few financial resources, and where they limited their travel to reduce their exposure to insecurity.

CONCLUSION

This study confirms that combining methodological approaches is essential to explain significant use in the local context. The analysis of the number of assisted deliveries in conflict zones must consider the number of procedures, the nearby security context, the number of internally displaced persons and the presence of camps in which humanitarian organisations offer programmes.

Responding to health policy recommendations on managing opioid use disorder during Russia's invasion of Ukraine: Divergent responses from the frontline to the west

Russia's invasion of Ukraine on February 24, 2022, followed by Ukraine's Martial law, has disrupted the routine delivery of healthcare services, including opioid agonist treatment (OAT) programs. Directors (chief addiction treatment physicians) of these programs in each region had flexibility with implementing a series of adaptations to their practice to respond to war disruptions like mass internal displacement and legislation updates allowing more flexibility with OAT distribution policies and take-home dosing regulations. We conducted 8 in-depth interviews with directors from seven regions of Ukraine to describe their experiences providing OAT during a specific time during the war and the local crisis-response approach under the emergency policy updates. We categorized their experiences according to the level of exposure to conflict in each region and displacement of patients across the country, which may provide future guidance for OAT provision during the conflict.

Towards Green and Sustainable Healthcare: A Literature Review and Research Agenda for Green Leadership in the Healthcare Sector

The health sector is one of the keys to sustainable development. Although it is directly related to only one Sustainable Development Goal (Goal 3, "Ensuring a healthy life and promoting well-being at all ages"), the sector itself, which aims to protect health, is paradoxically at the same time the main emitter of environmental pollutants that have a negative impact on health itself. Therefore, sustainability has become a key priority for health sector organizations, and leadership in this area is essential at all levels. Scientific research plays a particular role here, helping to more clearly define the links between environmental sustainability and the health effects of a polluted environment and climate change as well as indicating the direction of actions needed and disseminating good practices that can help accelerate the adoption of efforts towards climate neutrality and sustainable development of health sector organizations. The aim of this article is to present the current state of the art and future research scenarios in the field of green and sustainable healthcare through a literature review by using the Preferred Reporting Items for Systematic Reviews Meta-Analyses (PRISMA) method to perform a bibliometric analysis of papers published in 2012-2022. The Web of Science Core Collection (WoSCC) database is used for this purpose. A total of 144 papers are included for analysis, categorized based on eight fields: author(s), title, year of publication, country, journal, scientific category, and number of citations. Based on the results, themes for future research on green leadership in the healthcare sector are identified and recommended.

Medical aid to war victims in Syria in 2019: a report of organized healthcare support from a charity organization

Background

In 2011, a civil war started in Syria, which is on-going and has reached a death toll of over 400,000 people. Humanitarian organizations, including Aid to The Church in Need (ACN), have strived to provide help and medical support to the civilian victims.

Methods

We performed a retrospective analysis of data gathered in ACN projects in Syria in 2019. The datasets included descriptions of diseases, treatments, costs, cities, and hospitals. For each patient, we assigned the following additional categories: type of help (treatment, diagnosis, or nonmedical), type of treatment (medical or surgical), medical specialty, gross anatomic region, and presence of trauma.

Results

A total of 3835 patients benefited from ACN support in Syria in 2019. The majority of financial support went towards treatment (78.4%), while other support went towards nonmedical help (15.7%) or providing a diagnosis (5.9%). Among treatments, 66.6% were medical and 33.4% surgical. The most common medical specialty was internal medicine (48.4%), followed by public health (13.7%) and surgery (7.3%). Anatomic region was undefined in 68.3% of cases and, when defined, was most commonly the abdominal cavity and pelvis (13%). The vast majority of cases 95.1%) were not associated with trauma. Procedural costs were highest in the Valley of Christians region, and lowest in Tartous. Network graphs were used to visualize the three most common diagnoses and treatments for each medical specialty.

Conclusions

The present report describes the treatment of war victims in Syria in 2019. The patients lacked the most basic medical or surgical healthcare. Charity organizations, like ACN, constitute a valuable source of information about the healthcare of war victims. Unfortunately, the methods of describing medical treatment provided to civilian victims remain underdeveloped. Future studies will require the cooperation of healthcare providers, humanists, and social workers. The present findings can help to optimize the provision of humanitarian help by charity organizations, by tailoring projects to the specific needs of Syrian war victims.

Socioeconomic Inequalities and HIV Testing During Antenatal Care in High- Medium- and Low-Conflict Intensity Countries in Sub-Saharan Africa

Understanding HIV testing determinants in different settings is vital to reducing new infections. This study assessed HIV testing rates during antenatal care (ANC) in seven sub-Saharan African countries designated as high, medium, low or no conflict intensity settings. We ranked and plotted concentration curves for HIV testing by socioeconomic inequality and determined their concentration indices (CCI). Testing for HIV during ANC was highest in Zimbabwe (95.7%) and lowest in Sudan (3.6%). Countries with medium and high conflict intensity experienced higher HIV testing inequality (CCI = 0.38) than countries with low or no conflict (CCI = 0.15). Low HIV testing rates were associated with no education, rural areas, poorest wealth index quintiles and home birth, which demonstrate that determinants of HIV testing during ANC in conflict-affected areas are complex and context-based. Programme implementation and policymakers must acknowledge these complexities and local contexts in their program designs and planning.

Global prevalence of resilience in healthcare professionals: A systematic review, meta-analysis, and meta-regression

AIMS

This review aims to examine the prevalence estimate of low resilience among healthcare professionals and identify the factors affecting the prevalence.

BACKGROUND

Healthcare professionals experience high levels of stress. Understanding the healthcare professionals' resilience may provide an insight into how they perform in a highly stressed environment. Evaluation A comprehensive search of 11 databases was conducted. Studies that provided prevalence rates for low resilience among healthcare professionals working in a healthcare setting were included. Meta-analyses, sensitivity, subgroup analyses and meta-regression were conducted.

KEY ISSUES

Among 27,720 studies, 41 studies (N = 17,073) across 16 countries were included. The prevalence of low resilience was 26% (95% CI: 20-32). Subgroup analyses indicated that types of resilience measures affect resilience prevalence significantly. A higher prevalence of low resilience was observed among allied health professions during the COVID-19 pandemic in the Middle East.

CONCLUSIONS

This review indicated the prevalence of low resilience and type of resilience measurement instruments that affected the prevalence.

IMPLICATIONS FOR NURSING MANAGEMENT

This review provides a roadmap to design tailored, discipline-specific, and sustainable resilience training for nurses. Nursing managers should monitor the working hours and workload of nursing staffing in order to provide a protective working environment.

Enhancing quality midwifery care in humanitarian and fragile settings: a systematic review of interventions, support systems and enabling environments

INTRODUCTION

Women and children bear a substantial burden of the impact of conflict and instability. The number of people living in humanitarian and fragile settings (HFS) has increased significantly over the last decade. The provision of essential maternal and newborn healthcare by midwives is crucial everywhere, especially in HFS. There is limited knowledge about the interventions, support systems and enabling environments that enhance midwifery care in these settings. The aim of this paper is to identify the factors affecting an enabling environment for midwives in HFS and to explore the availability and effectiveness of support systems for midwives.

METHODS

A structured systematic review was undertaken to identify peer-reviewed primary research articles published between 1995 and 2020.

RESULTS

In total, 24 papers were included from Afghanistan, Bangladesh, Nigeria, Democratic Republic of Congo, South Sudan and Sudan, Ethiopia, Pakistan, Uganda and Liberia. There were two broad themes: (1) the facilitators of, and barriers to, an enabling environment, and (2) the importance of effective support systems for midwives. Facilitators were: community involvement and engagement and an adequate salary, incentives or benefits. Barriers included: security and safety concerns, culture and gender norms and a lack of infrastructure and supplies. Support systems were: education, professional development, supportive supervision, mentorship and workforce planning.

CONCLUSION

More efforts are needed to develop and implement quality midwifery services in HFS. There is an urgent need for more action and financing to ensure better outcomes and experiences for all women, girls and families living in these settings.

PROSPERO REGISTRATION NUMBER

CRD42021226323.

European Countries Step-up Humanitarian and Medical Assistance to Ukraine as the Conflict Continues

On the 24th of February 2022, the Russian Federation began an unprovoked invasion of Ukraine, marking the biggest military attack in Europe since the second world war. Over 4 million people have fled their homeland within the first month of the war and have triggered a large refugee crisis with impacts far beyond the Ukrainian border. People in the neighboring countries have shown tremendous support by stepping forward to donate food, clothes, medications, money, and other essential supplies. The governments and other regional stakeholders have also been supportive in accommodating and easing regulations for the incoming refugees. Herein, we summarize the humanitarian measures and medical donations that have been made by European countries as they stepped up their efforts to provide refugees with all necessary basic services. We further highlight potential oncoming challenges in Ukraine and the host countries along with relevant solutions to these challenges. The current scenario highlights the need for multi-party and multi-level collaborations (both public and private) to tackle the emerging situation.

Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: a qualitative study

Background

Healthcare associated infections (HAIs) are the most frequent adverse outcome in healthcare delivery worldwide. In conflict-affected settings HAIs, in particular surgical site infections, are prevalent. Effective infection prevention and control (IPC) is crucial to ending avoidable HAIs and an integral part of safe, effective, high quality health service delivery. However, armed conflict and widespread violence can negatively affect the quality of health care through workforce shortages, supply chain disruptions and attacks on health facilities and staff. To improve IPC in these settings it is necessary to understand the specific barriers and facilitators experienced locally.

Methods

In January and February of 2020, we conducted semi-structured interviews with hospital staff working for the International Committee of the Red Cross across eight conflict-affected countries (Central African Republic, South Sudan, Democratic Republic of the Congo, Mali, Nigeria, Lebanon, Yemen and Afghanistan). We explored barriers and facilitators to IPC, as well as the direct impact of conflict on the hospital and its’ IPC programme. Data was analysed thematically.

Results

We found that inadequate hospital infrastructure, resource and workforce shortages, education of staff, inadequate in-service IPC training and supervision and large visitor numbers are barriers to IPC in hospitals in this study, similar to barriers seen in other resource-limited settings. High patient numbers, supply chain disruptions, high infection rates and attacks on healthcare infrastructures, all as a direct result of conflict, exacerbated existing challenges and imposed an additional burden on hospitals and their IPC programmes. We also found examples of local strategies for improving IPC in the face of limited resources, including departmental IPC champions and illustrated guidelines for in-service training.

Conclusions

Hospitals included in this study demonstrated how they overcame certain challenges in the face of limited resources and funding. These strategies present opportunities for learning and knowledge exchange across contexts, particularly in the face of the current global coronavirus pandemic. The findings are increasingly relevant today as they provide evidence of the fragility of IPC programmes in these settings. More research is required on tailoring IPC programmes so that they can be feasible and sustainable in unstable settings.

I had to leave. I had to leave my clinic, my city, leave everything behind in Syria. Qualitative research of Syrian healthcare workers migrating from the war-torn country

OBJECTIVES

To explore the reasons why healthcare workers migrate from Syria, a country where conflict has been raging for over a decade.

DESIGN

A qualitative study was performed using semistructured interviews. Semistructured questions guided in-depth interviews. Content analysis was used.

SETTING

Participants were Syrian healthcare workers who had worked in the country after the conflict started in 2011, but at some point left Syria and settled abroad. The interviews took place in Turkey and Europe in 2016 and 2017.

PARTICIPANTS

We collected data from 20 participants (18 males and 2 females) through snowball sampling method.

RESULTS

Healthcare workers migrated from Syria only because of security reasons. In most cases, the decision to leave resulted from the generalised violence against civilians by different warring parties, mainly the Government of Syria and the Islamic State. Intentional attacks against healthcare workers were also one of the main reasons for leaving. Some participants had a specific notable trigger event before leaving, such as colleagues being detained or killed. Many participants simply grew tired of living under constant fear, with their families also at risk.

CONCLUSIONS

This research adds to the body of literature on violence against healthcare workers in Syria. It helps to understand the reasons why healthcare workers leave the country. The study also indicates that the international community has failed to protect Syrian healthcare workers. The intensity of the conflict has left many healthcare workers with no other option than to leave. Understanding this migration will enable the discovery of new solutions for protecting healthcare workers in current and future conflicts.

Inequalities in catastrophic health expenditures in conflict-affected areas and the Colombian peace agreement: an oaxaca-blinder change decomposition analysis

BACKGROUND

The present study analyzes inequalities in catastrophic health expenditures in conflict-affected regions of Meta, Colombia and socioeconomic factors contributing to the existence and changes in catastrophic expenditures before and after the sign of Colombian Peace Agreement with FARC-EP guerilla group in 2016.

METHODS

The study uses the results of the survey Conflicto, Paz y Salud (CONPAS) conducted in 1309 households of Meta, Colombia, a territory historically impacted by armed conflict, for the years 2014 and 2018. We define catastrophic expenditures as health expenditures above 20% of the capacity to pay of a household. We disaggregate the changes in inequalities in catastrophic expenditures through the Oaxaca-Blinder change decomposition method.

RESULTS

The incidence of catastrophic expenditures slightly increased between 2014 to 2018, from 29.3 to 30.7%. Inequalities in catastrophic expenditures, measured through concentration indexes (CI), also increased from 2014 (CI: -0.152) to 2018 (CI: -0.232). Results show that differences in catastrophic expenditures between socioeconomic groups are mostly attributed to an increased influence of specific sociodemographic variables such as living in rural zones, being a middle-aged person, living in conflict-affected territories, or presenting any type of mental and physical disability.

CONCLUSIONS

Conflict-deescalation and the peace agreement may have facilitated lower-income groups to have access to health services, especially in territories highly impacted by conflict. This, consequently, may have led to higher levels of out-of-pocket expenditures and, therefore, to higher chances of experiencing catastrophic expenditures for lower-income groups in comparison to higher-income groups. Therefore, results indicate the importance of designing policies that guarantee access to health services for people in conflict -affected regions but also, that minimize health care inequalities in out-of-pocket payments that may arouse between people at different socioeconomic groups.

Violence against healthcare in conflict: a systematic review of the literature and agenda for future research

BACKGROUND

Attacks on health care in armed conflict, including those on health workers, facilities, patients and transports, represent serious violations of human rights and international humanitarian law. Information about these incidents and their characteristics are available in myriad forms: as published research or commentary, investigative reports, and within online data collection initiatives. We review the research on attacks on health to understand what data they rely on, what subjects they cover and what gaps exist in order to develop a research agenda going forward.

METHODS AND FINDINGS

This study utilizes a systematic review of peer-reviewed to identify and understand relevant data about attacks on health in situations of conflict. We identified 1479 papers published before January 1, 2020 using systematic and hand-searching and chose 45 articles for review that matched our inclusion criteria. We extracted data on geographical and conflict foci, methodology, objectives and major themes. Among the included articles, 26 focused on assessment of evidence of attacks, 15 on analyzing their impacts, three on the legal and human rights principles and one on the methods of documentation. We analyzed article data to answer questions about where and when attacks occur and are investigated, what types of attacks occur, who is perpetrating them, and how and why they are studied. We synthesized cross-cutting themes on the impacts of these attacks, mitigation efforts, and gaps in existing data.

CONCLUSION

Recognizing limitations in the review, we find there have been comparatively few studies over the past four decades but the literature is growing. To deepen the discussions of the scope of attacks and to enable cross-context comparisons, documentation of attacks on health must be enhanced to make the data more consistent, more thorough, more accessible, include diverse perspectives, and clarify taxonomy. As the research on attacks on health expands, practical questions on how the data is utilized for advocacy, protection and accountability must be prioritized.

Antenatal care and skilled birth in the fragile and conflict-affected situation of Burundi

Burundi is a fragile and conflict-affected state characterized by persistent conflict and political violence. Amid this conflict, Burundi has one of the highest maternal mortality rates globally-548 per 100,000 births as of 2017, such deaths could be prevented with antenatal care (ANC). This cross-sectional study aimed to examine the association between conflict and ANC and skilled birth attendant (SBA) utilization. Logistic regression analysis was conducted using the 2016-2017 Burundi Demographic and Health Survey (n = 8581), as well as a Near Analysis Geographic Information System exploration. Results show that women in extremely high conflict regions were less likely to have four antenatal visits (odds ratio [OR] = 0.79, p < 0.05). However, they were more likely to use a SBA (OR = 2.31, p < 0.001) and to deliver in a hospital (OR = 1.69, p < 0.001). As well, gender equality, education, and watching television were correlated with an increased likelihood of utilization. In contrast, unwanted pregnancies and increased parity were correlated with decreased use. Moreover, with renewed violence erupting in 2015, uptake of care has likely further stagnated or declined. If Sustainable Development Goal 3.1's objective of reducing maternal mortality globally is to be achieved, women's access to maternal healthcare services in conflicted-affected areas such as Burundi must be improved.

Caught in crossfire: health care workers' experiences of violence in Syria

Health care is attacked in many contemporary conflicts despite the Geneva Conventions. The war in Syria has become notorious for targeted violence against health care. This qualitative study describes health care workers' experiences of violence using semi-structured interviews (n = 25) with professionals who have been working in Syria. The participants were selected using a snowball sampling method and interviewed in Turkey and Europe between 2016-2017. Analysis was conducted using content analysis. Results revealed that the most destructive and horrific forms of violence health care workers have experienced were committed mostly by the Government of Syria and the Islamic State. Non-state armed groups and Kurdish Forces have also committed acts of violence against health care, though their scope and scale were considered to have a lower mortality. The nature of violence has evolved during the conflict: starting from verbal threats and eventually leading to hospital bombings. Health care workers were not only providers of health care to injured demonstrators, they also participated in non- violent anti-government actions. The international community has not taken action to protect health care in Syria. For health workers finding safe environments in which to deliver health care has been impossible.

Antenatal care utilization in the fragile and conflict-affected context of the Democratic Republic of the Congo

Maternal mortality represents one of the widest gaps between developed and developing countries. Ninety-nine percent of maternal deaths occur in developing countries, with over half occurring in sub-Saharan Africa. This health indicator became a global priority when the United Nations' Sustainable Development Goal 3.1 set out to decrease the global maternal mortality rate to less than 70 per 100 000 births by 2030. In the Democratic Republic of the Congo (DRC), 473 of every 100 000 women who give birth die due to pregnancy-related complications. These deaths could be prevented through enhanced access and utilization of antenatal care services and skilled birth attendants. However, amid prolonged conflict, violence, and authoritarian governments, the Democratic Republic of the Congo has been classified as a fragile and conflict-affected situation and women are prone to face difficulties accessing maternal health services. This study examined the utilization of antenatal care and skilled birth attendants in the Democratic Republic of Congo using logistic regressions. Our findings show that women living in regions with extremely high levels of prolonged conflict were significantly less likely than those in regions with moderate levels of conflict to have their first antenatal care visit within the first trimester (OR = 0.29, p < 0.01), and to have four visits (OR = 0.46, p < 0.01). Overall, women in regions with extremely high levels of conflict (OR = 0.41, p < 0.01) were less likely to meet the World Health Organization's antenatal care recommendations compared to those in regions with moderate levels of conflict. The findings suggest that conflict-affected countries, such as the Democratic Republic of the Congo, require context-specific interventions if progress is to be made towards achieving Sustainable Development Goal 3.1.