Roadmap to Accelerate Progress
for Every Newborn in Humanitarian Settings
2020 – 2024

About Roadmap to Accelerate Progress for Every Newborn
in Humanitarian Settings 2020–2024
The Roadmap is designed to further the global commitment to improve the health of themost vulnerable mothers and newborns who live in humanitarian settings. The developmentof the Roadmap is based on global evidence-based guidance and lessons learned fromcountry-level implementation. Over 100 experts from non-governmental organizations, United
Nations agencies, national governments, donors and academic institutions participated in thereview of the Roadmap, and more than 50 interviews were conducted with key stakeholders
to understand current priorities in maternal and newborn health, gaps in the health system,and partners to leverage in humanitarian settings. Global experts reviewed and finalized the
document in a 2019 multi-sectoral meeting and recommended actions to accelerate progressover the next five years.

Published April 2020
© Save the Children

Roadmap to Accelerate Progress
for Every Newborn in Humanitarian Settings
2020 – 2024

Table of Contents

4

Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

Acknowledgments

2

Acronyms

3

Introduction

4

Vision and Goals

8

Strategic Objectives

9

Guiding Principles

13

Key Actions for Newborn Health in Fragileand Humanitarian Settings

16

1 Strengthen the mother-newborn dyad in humanitarian crises
2 Expand access to dignified and quality care during pregnancy,

delivery, and post-partum

16
17

3 Deliver appropriate care for small and sick newborns

22

4 Register every birth and count every newborn death and stillbirth24

5 Strengthen linkages with key humanitarian sectors across thecontinuum of care
6 Facilitate coordination across the humanitarian-development nexus
7 Empower communities and governments through partnershipsthat promote innovative and sustainable services
8 Explore innovative approaches and conduct research to support

service delivery in humanitarian settings
9 Increase the visibility of newborns in humanitarian settings

25
29
30
32
34

Partnership, Participation, & Financing

36

Monitoring Progress

38

Year One Action Plan

40

References

42
Table of Contents1

Acknowledgments
I would like to express my profound appreciation and gratitude to the dedicated experts,
colleagues, and friends who have contributed to this initiative through interviews, working
groups, countless debates, and rounds of reviews:
Alessandro Iellamo, Allisyn Moran, Ann Burton, Anna af Ugglas, Anna Frellsen, Basil
Rodriques, Bianca Drebber, Brandao Co, Bushra Al-Makaleh, Catrin Schulte-Hillen, Claire
Merchon, Clive Omoke, Cyril Engmann, Daniel Martinez, Diana Estevez, Dilys Walker, Dina
Jardaneh, Elaine Scudder, Elvira Thissen, Emily Monaghan, Emmanuele Capobianco, Endang
Handzel, Fatima Gohar, Fiona Smith, Fouzia Shafique, Gebrewold Petros, Gillian McKay,
Gwenaelle Garnier, Hajra Daly, Hannah Tappis, Hattie Ruysen, Henia Dakkak, Hilary Wartinger,
Hussein Had, Jane Newnham, Janna Patterson, Jean Armas, Jennifer Schlecht, Jim Litch,
Josep Vargas, Joshua Bress, Joy Lawn, Julie Taft, Juliet Whitley, Katie Morris, Kimberly Gire,
Koen Joosse, Lale Say, Lara Martin, Laura Archer, Lee Pyne-Mercier, Lily Kak, Linda Doull,
Lisa Thomas, Loulou Kobeissi, Luna Mehrain, Lynn Freedman, Manuel Carballo, Marcy Hersh,
Maria Asuncion Silvestre, Marie-Claude Bottineau, Mariella S. Castillo, Mary Ellen Stanton,
Mary Thompson, Meg French, Mianne Silvestre, Moazzem Hossain, Mohira Boboeva, Nabila
Zaka, Nada Elattar, Nadine Cornier, Naoko Kozuki, Natalia Vartapetova, Neal Russell, Neelam
Bhardwaj, Neha Singh, Nelly Staderini, Nicolas Joannic, Niloofar Zand, Nora Hobbs, Nuzhat
Rafique, Nyra Mahmood, Ornella Lincetto, Paul Wise, Peter Morrison, Rabih El Chammay,
Rachael Cummings, Rajat Khosla, Rebecca Tavares, Ribka Amsalu, Richard Guidotti, Roberta
Petrucci, Rodolfo Rossi, Salim Sohani, Sameer Elias Putros, Samira Aboubaker, Samira Sami,
Sandra Krause, Sarah Moxon, Sarah Williams, Saverio Bellizzi, Shaimaa Ibrahim, Shanon
McNab, Sharifa Khan, Sheena Currie, Smita Kumar, Stephanie Gee, Steve Wall, Tedbabe
Degefie Hailegebriel, Thiago Luchesi, Tore Lærdal, Valerie Bemo, Viviana Mangiaterra, Winnie
Mwebesa, Yulia Widiati, Zulfiqar Bhutta
The energy, persuasiveness, and passion of the many contributors underpins the document andwill continue to drive the Roadmap to its true impact: the saved and changed lives of newborns,
pregnant women, and mothers caught in humanitarian emergencies around the world. SamiraSami and Neal Russell deserve special notice and deepest thanks for their outstanding andtireless work to distill vast inputs into this important and strategic document.
The Roadmap is dedicated to Jennifer Schlecht, a devoted advocate for the rights of womenand girls in crisis situations. To honor Jennifer and her invaluable contributions, the global
health community shall continue to elevate sexual and reproductive health, and maternal andnewborn care, as a human right deserved of the most vulnerable in crisis-prone countries andin each and every humanitarian response. We miss you, Jenn.
HRH Princess Sarah Zeid
Patron, Maternal & Newborn Health UNHCR
Special Advisor, Maternal & Child Health and Nutrition, WFP

2Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

Acronyms
BCG

Bacille Calmette-Guerin vaccine

BMS

Breast milk substitutes

EmONC

Emergency obstetric and newborn care

ENAP

Every Newborn Action Plan

EPI

Expanded Programme on Immunization

EWEC

Every Woman Every Child

HAI

Hospital-acquired infections

IPC

Infection prevention and control

IYCF-E

Infant and Young Child Feeding in Emergencies

KMC

Kangaroo mother care

MISP

Minimum Initial Service Package

MPDSR

Maternal and perinatal death surveillance and response

SDGs

Sustainable Development Goals

TBA

Traditional birth attendant

WASH

Water, sanitation and hygiene

More Information
Throughout this process, stakeholders participated in drafting a global declaration and an
advocacy document that identifies key messages for prioritizing maternal and newborn
health in humanitarian settings.
Documents are available at www.healthynewbornnetwork.org/issue/emergencies/

Recommended Citation
Save the Children, WHO, UNICEF, UNHCR. 2020. Roadmap to Accelerate Progress forEvery Newborn in Humanitarian Settings 2020–2024. Washington, DC: Save the Children.

Acknowledgments & Acronyms

3

Introduction

4

Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

5

Reaching the Sustainable Development
Goals (SDGs) for neonatal mortality
and stillbirths by 2030 requireprioritizing lifesaving maternal andnewborn interventions and supporting
health workers during
humanitarian crises.
Women and children are 14 times more likely
than men to die during a natural disaster(1). In
fragile and humanitarian settings, an estimated
500 women and girls die from complications ofpregnancy and childbirth every day(2). Newborns
are uniquely vulnerable; reliant on specialized careand dependent on the health of mothers whoare impacted by crisis. For too long, newborns
have been overlooked in humanitarian response
efforts. Essential newborn interventions
remain underfunded and few interventions aredesigned with the mother in mind. Improving
newborn survival requires a renewed focus on
the unique needs of children born into crisis anda commitment to strengthening maternal andnewborn health in humanitarian settings. The
perinatal period represents a critically importanttime of risk for mothers and their newborns(3).
India, Nigeria, Pakistan, Ethiopia and Democratic
Republic of Congo are the top five countries
with the greatest number of neonatal deaths(4).
More than 80% of the high-mortality countries
have suffered either a recent conflict, recurring
natural disasters, or both(5). Among the 49
countries that experienced an acute or protracted
humanitarian crisis in the past five years, 75%
fall short of the SDGs for neonatal mortality(6).
Countries facing conflict have the highest rates
of neonatal mortality and stillbirths; alarmingly
at 39 deaths per 1000 live births or higher(7).

6

The Global Strategy for Women, Children, andAdolescents’ Health 2016-2030 aims to reducenewborn mortality to 12 per 1000 live births in all
countries by 2030, and this is aligned with the target
for Sustainable Development Goal 3.

Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

This goal requires urgent action in fragileand humanitarian settings.

Almost 70% of neonatal deaths and
40% of maternal deaths and stillbirths
are preventable, including in mostchallenging situations.
Humanitarian settings are diverse becauseof varying baseline mortality, economic
development, health system capacity, population
dynamics, and local burden of disease. People
affected by crises may include vulnerable
populations, such as refugees, internallydisplaced persons, migrants, or local populations.
They may live in remote rural areas or camps,
but increasingly they reside in urban areas.
Communities, including the health care system,
hosting displaced populations often lack thewill or capacity to meet the basic needs of the
population. The challenges in conflict settings arecompounded by insecurity and the natural focus
of services on preventing infectious disease
outbreaks. Humanitarian settings are increasingly
protracted, with the average crisis lasting longer
than 9 years, and these crises are contributing toa growing number of displaced people(8).
During the preparedness, emergency andrecovery phase of a humanitarian response,
priorities for newborn health need to be clearly
articulated in coordination and advocacy
platforms. Global initiatives such as Every
Women Every Child (EWEC) and Every Newborn
Action Plan have brought together multistakeholder partners to prioritize key actions
for reducing newborn mortality by 2030. Better
integration of development initiatives that bolster
emergency response in preparedness andresilience-building can mitigate the long-term
impact of crisis on the health of womenand children.
The distinction between a humanitarian anddevelopment setting is often unclear, and efforts
to improve maternal and newborn health must

bridge both situations and be well coordinated.
This Roadmap to Accelerate Progress for Every
Newborn in Humanitarian Settings addresses
newborn heath across diverse contexts withrecommendations that can be applied generally
but may be relevant to some specific contexts
more than others.
Newborn health cannot be considered inisolation and must be addressed in the context
of maternal health. Any intervention aimed at
improving newborn health should be framed in
the context of maternal and newborn health.
Lessons from previous crises strongly suggestthat efforts for maternal and child health often
overlook newborn care, including nurturing care,during humanitarian crises. Progress has been
made in financing and delivering reproductive,
maternal, and child health interventions duringcrisis, but significant gaps remain in the financingof emergency obstetric and newborn care(9).
Therefore, improving newborn survival during
humanitarian crises will require a greater focus on
newborns as part of the continuum of care.
Taking into account different initiatives currently
addressing newborn health and survival, theRoadmap calls for action to accelerate the healthof women and their newborns across all contexts
and phases of an emergency using a healthsystems approach. Stakeholders from acrosshumanitarian and development sectors need to
be engaged to ensure newborns survive andthrive even in the most difficult circumstances.
This includes having a common vision, approachand commitment to expand the quality andcoverage of maternal and newborn services in
populations affected by acute and protracted
conflicts and natural disasters.
The audience for this document is stakeholders
from both the development and humanitariancommunity, from both maternal and newborn
health communities, and across sectors of thehumanitarian response. This document sets out
a vision for how improvements can be made formothers and newborns in humanitarian settings.

Introduction

7

VisionA world in which mothers and newborns receive the lifesaving healthservices they need, whoever they are and whatever the emergency situation.

Goals
Goal 1: Eliminate preventable maternal and neonatal deaths inhumanitarian settings.
Goal 2: Work towards global targets for reduction of maternal andneonatal mortality and stillbirth.
Goal 3: Ensure newborns thrive by preventing maternal and childmorbidity and promoting early childhood development.

8

During the emergency phase ofa humanitarian crisis:

During the recovery phase of ahumanitarian crisis:

Prevent excess stillbirths andneonatal deaths by reducing mortality
to below thresholds defined bycontext specific pre-crisis or
national rates

Align efforts with global targets for the
SDGs to reduce the neonatal mortality
rate to 12 per 1,000 live births or less,and reduce the stillbirth rate to 12 per
1,000 total births or less by 2030

Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

Strategic Objectives
The key action areas of the Roadmap are grouped under three overarchingstrategic objectives articulated by the EWEC Global Strategy as survive,
thrive, and transform.

1) SURVIVE
End preventable deaths

2) THRIVE
Ensure health and wellbeing3) TRANSFORM
Expand enabling environments

Executive Summary

91) SURVIVE
End preventable deaths§§Strengthen the maternal-newborn dyad inhumanitarian crises§§Expand access to dignified and quality care during
pregnancy, delivery and post-partum§§Deliver appropriate care for small and sick newborns§§Register every birth and count every newborn deathand stillbirth

10 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

2) THRIVE
Ensure health and wellbeing§§Strengthen linkages with key humanitarian sectors
across the continuum of care§§Facilitate coordination across the humanitariandevelopment nexus

Executive Summary 113) TRANSFORM
Expand enabling environments§§Empower communities and governments
through partnerships that promote innovativeand sustainable services§§Explore innovative approaches and conduct researchto support service delivery in humanitarian settings§§Increase the visibility of newborns inhumanitarian settings§§

12 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

Guiding Principles

Evidenceinformed

Newborn deaths
and stillbirths
are preventable

Mothers &newborns arerights holders

Familycentered care

Newborns do
better with
their caregivers

Newborns &stillbirths inhumanitariansettings countContext-specificinnovations

Respectfulmaternal &newborn care

Accountability

High-quality
care that meetsthe needs ofcommunities

Empowering
women &
Gender equality
girls improves
newborn survival

Health systemstrengthening

Invest in healthcare providers

Preparedness
and resilience
improvesustainability

Human
resourcesfor health

Executive Summary 13

What can we doto save newborn lives
and prevent stillbirths
in fragile andhumanitariansettings?
14 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

Key Actions for Newborn Health in Humanitarian Settings 15

Key Action Areas for Newborn Healthin Humanitarian Settings
1
1. Strengthen the mother-newborn dyad in humanitarian crises
Humanitarian settings are often characterisedby disrupted access to services, and delayed or
insufficient international and national assistancethat may be unable to reach mothers who are themost underserved. The mother is the best chancefor the newborn’s survival. Protecting the motherbaby dyad is crucial in any setting, particularly
during humanitarian responses, to ensure skinto-skin care, early and exclusive breastfeeding,and a nurturing environment for early childhood
development. However, the importance of thisrelationship is often underestimated or overlooked,

ACTIONS

Keep newborns with their mothers and caregivers for the mostreliable source of warmth, feeding and protection in crises

Models of care that keep newborns with theirmothers and caregivers, such as kangaroo
mother care (KMC) and family-centered care,are evidence-based, cost-effective and feasible
in any setting. Maternal and newborn services
should be designed to minimize separation of
mother and baby from birth, during the postnatal
period and during referral in cases of neonatal

ACTIONSand simple, essential lifesaving interventions
are often de-prioritised during humanitarian
response despite their cost-effectiveness.
Interventions risk being counterproductive if themother-newborn dyad is weakened because
care can become compromised, even if the initialinterventions appeared to be effective. The dyad
is often compromised in emergencies, which isreflected in the increased rate of maternal deathand orphaned newborns. In such situations,permanent, nurturing alternatives must be foundas soon as possible.

health complications. Focus on the mothernewborn dyad should be ensured at every level,
including leadership and governance, clinical care,referral pathways, and monitoring and evaluation.
Where keeping a newborn with their mother is
impossible, efforts should be made to quickly
ensure a sustainable caregiver for the newborn.

Protect, promote and support early and exclusive breastfeedingin humanitarian settings

Disruption of breastfeeding in humanitariansettings is particularly dangerous because
access to safe water and sanitation is often
compromised. Promotion of and support forearly initiation and exclusive breastfeeding
are lifesaving interventions that should be apriority during humanitarian response for all
newborns(10-16). A key priority must be tocreate a safe and enabling environment topromote early and exclusive breastfeedingin facilities and the community. This includes

supplies for breastmilk expression, storage andalternative feeding methods; training of healthworkers; advocacy media communication; andpsychosocial and peer-to-peer support. Breast
milk substitute (BMS) provision should be limited
to medical needs(17) and linked to a contextspecific, coordinated package of care and skilled
support to ensure adequate water, sanitation andhygiene(18). Existing initiatives should be built
upon Netcode(19) and the baby-friendly
hospital initiative.(20)

16 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

2
2. Expand access to dignified and quality care during pregnancy,

delivery, and post-partum

The focus in humanitarian settings should beon providing quality, equitable and culturally
acceptable care that is relevant to the setting,promotes maximum benefits, and is potentiallysustainable. Evidence-based interventions
during pregnancy, delivery and post-partum
should be implemented and include timely

ACTIONS

access to comprehensive emergency obstetricand newborn care from the initial onset ofan emergency (see Box 1). These must be
delivered by an adequate number of healthworkers who have the necessary training,support and resources. Preparedness is key tothis being done efficiently and cost-effectively.

Provide access to emergency obstetric and newborn carearound the time of birth

Basic emergency obstetric and newborn care is
an immediate priority in all emergencies, withpreparation to rapidly transition to comprehensive
health services. Services must be accessible
to all, ensuring that populations who would
otherwise lack access are not ‘left behind’.
Contextual factors in humanitarian and fragile

settings, such as insecurity, heavily influence
access to labour, delivery and emergency care.
Mothers must be empowered with informationon their individual level of risk during pregnancy
and they should have contingency plans toaddress unpredictable disruptions to care.

BOX 1.

Basic and comprehensive emergency obstetricand newborn care (EmONC)
The Inter-Agency Field Manual on Reproductive Health in Humanitarian Settings (IAFM)
includes the following list of essential interventions:
Ensure basic EmONC at all health centres. This means that staff are skilled and have the resources to:
1. Administer parenteral antibiotics for treatment of sepsis
2. Administer uterotonic drugs (i.e., parental oxytocin or misoprostol tablets) for treatment of postpartum
hemorrhage and administer intravenous tranexamic acid in addition to standard care for womenwith clinically diagnosed postpartum hemorrhage
3. Administer parenteral anticonvulsant drugs (i.e. magnesium sulfate) to manage severe
preeclampsia and eclampsia
4. Perform assisted vaginal delivery (e.g. vacuum extraction)
5. Manually remove the placenta
6. Remove retained products of conception after delivery or an incomplete abortion
7. Perform basic neonatal resuscitation (e.g. with bag and mask)
Ensure comprehensive EmONC at hospitals. This means that staff are skilled and have the resources
to support interventions 1-7 above plus:
8. Perform surgery (e.g. caesarean section)
9. Perform safe blood transfusion observing universal infection prevention precautions

Key Actions for Newborn Health in Humanitarian Settings 17

ACTIONS

Strengthen and scale up essential newborn care

Essential newborn care interventions
should be prominent in national policies
and guidelines, health assessments, donor
proposals, humanitarian response plans
and supply lists for facility- and communitybased programmes. Every health worker
who provides newborn care and is deployed

to an emergency setting should have thecapacity to deliver lifesaving and time-sensitive
interventions immediately after birth. These
interventions are described in the Newborn
Health in Humanitarian Settings Field Guide(see Box 2).

BOX 2.

Essential Newborn Care
The Newborn Health in Humanitarian Settings Field Guide (NBFG) includes the following list of essential interventions:§§ Thermal care: Drying, warming, skin-to-skin contact, delayed bathing§§ Infection prevention: Clean birth practices, handwashing, and clean cord/ skin/eye care.
Use of chlorhexidine for cord care is recommended for newborns born at home and in settings
where the neonatal mortality rate is above 30 deaths per 1000 live births§§ Initiation of breathing: Thorough drying, clearing the airway only if needed, stimulation throughrubbing the back, and basic neonatal resuscitation using a self-inflating bag and mask for babies
who do not spontaneously breathe§§ Feeding support: Skin-to-skin contact, support for immediate and exclusive breastfeeding,and not discarding colostrum (or first milk)§§ Monitoring: Frequent assessment for danger signs of serious infections and other conditions
that require extra care outside the household or health post§§ Postnatal care checks: Three postnatal checks during the first month: on Day 1 (the first 24 hours,
which are the most critical), Day 3 and between Days 7-14. After birth, every effort should be madeto reach babies born at home as soon as possible§§ Preventive interventions: Delayed cord clamping, vitamin K and topical ocular prophylaxis within
the first hour of life, and vaccinations within the first week of life

ACTIONS

Establish a referral system that is flexible and resilient to healthsystem shocks

During emergencies, reliable transportationand communication systems must be available,using community participation and leadershipwhere possible, to facilitate timely referralof mothers and newborns when danger
signs are detected pre-, during, and postpregnancy. Communities and health workers

must be educated on danger signs and referralmechanisms. Emergency care protocols should
include stabilization prior to referral and for
management during transfer. These protocols
should include transferring the mother andbaby together, if postpartum, preferably in skinto-skin contact to prevent hypothermia.

18 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

ACTIONS

Establish the Minimum Initial Service Package for facility- andcommunity-based care at the onset of an emergency

The Minimum Initial Service Package(MISP) for reproductive health should becomplemented with specific interventions
to address neonatal asphyxia, infection andprematurity. Substantial evidence exists forthe most effective interventions aimed at
reducing neonatal mortality, with interventions
during the intrapartum and early postnatal
period having the greatest impact(21). The
Newborn Health in Humanitarian Settings Field
Guide summarises these WHO evidencebased guidelines(22) and highlights the mostcritical health services for every newborn in

ACTIONS

Ensure universal access to prevention and treatment of malaria,
tetanus, syphilis and HIV

Progress in humanitarian settings is
crucial to achieving global strategies onmalaria(23), syphilis(24) and HIV(25) as wellas the Maternal-Neonatal Tetanus Elimination
initiative(26). To prevent adverse outcomesfrom malaria in pregnancy, agencies should
ensure coverage of long-lasting insecticidetreated nets and intermittent preventive
treatment in pregnancy. For tetanus, thefocus must be on prevention via maternal
vaccination, clean delivery, and strengthening
routine Expanded Programme on Immunization(EPI). Reporting neonatal tetanus cases, aspart of routine disease surveillance, provides auseful indicator for monitoring access to cleandelivery and antenatal vaccination coverage.
ACTIONS

community-based settings, primary healthfacilities, and hospitals. This starts with quality
antenatal care, including counselling, screening,supplementation, and prevention of verticallytransmitted and non-communicable diseases,
and continues with prompt treatment ofcomplications and adequate postnatal follow up
for health promotion and linkage to treatment
and other services. This minimum service
package should be integrated into national
preparedness and response plans, donor
funding opportunities, and standards of caredelivered by healthcare organizations.

Surveillance should also be strengthened forcongenital syphilis, with linkage to prevention
and treatment approaches during pregnancy.
The global strategy on HIV(25) aims for no
infant to be born with HIV; this applies tohumanitarian contexts as much as any other.
Prevention in fragile and humanitarian settings
should encompass voluntary counselling andtesting, post-exposure prophylaxis in the caseof sexual violence, antiretroviral treatment,
universal testing during antenatal care and/or
labour and delivery, testing and prophylaxis for
newborns, and counselling on infant feeding.
Emergency preparedness plans should include
mechanisms to ensure uninterrupted supplies
to prevent mother-to-child transmission.

Procure and preposition lifesaving maternal and newborn commodities

The Newborn Health in Humanitarian Settings
Field Guide and the Inter-agency Field Guide
for Reproductive Health provide a list of
essential medicines and commodities tosupport safe delivery and newborn survival
during emergencies. These supplies can beprocured through UNICEF and UNFPA, andthey should be integrated in the national

essential medicines list and supply lists ofhealthcare organizations. Commodities should
be contextualized to align with national policies
and chosen with consideration of the local
context. Preparedness planning should include
pre-positioning supplies that are needed insettings that are deemed to be fragile or at riskof a humanitarian emergency(27).

Key Actions for Newborn Health in Humanitarian Settings 19

ACTIONS

Ensure access to care for women and newborns wherever
and whoever they are

All interventions should uphold the right tohealth for all; ensuring no woman or child isleft behind. Special attention should be paid
to vulnerable groups such as the displaced,refugees, and migrants. The principle ofuniversal health coverage means that careshould not be limited by the requirement toprove identity, residency, or immigration status,
or due to fear of financial hardship.
ACTIONS

Situational assessments should be carried out
to identify where women and newborns cansafely access services, and security proceduresshould be accounted for. Innovative strategies
are needed to reach rural and urban settings,
and the link between different points of careshould be strengthened while investing in thequality of care at referral facilities inhost communities.

Ensure respectful maternal and newborn care in humanitarian response

Promote a culture of respectful maternal andnewborn care as a common agenda(28) aimed
at saving lives and relieving suffering and distressfor both the mother and the newborn. Respectfulcare includes supporting the woman’s choices
during labour and delivery, keeping the mother andher child together when possible, and avoiding
unnecessary pain or harm including providing
palliative care where appropriate. Raise awarenessamong humanitarian workers and within maternal
and newborn programs about the importance ofrespectful care using trainings, guidelines, andprotocols. Create mechanisms for monitoring
disrespect and abuse by giving service users
opportunities to provide feedback. Inclusion andemployment of female health workers should
be promoted where they are scarce, and local
health workers, particularly midwives, shouldbe employed wherever possible. Ensure that all
women are permitted a birth companion whenaccessing health services. Efforts should bemade to have a community dialogue early in thehumanitarian response to explore context-specificfactors that improve the acceptability of services.

20 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

ACTIONS

Gather data to monitor quality of care and coverage of essential
newborn interventions

Quality of care is instrumental for reducing
maternal and newborn morbidity and mortality.
Reporting on humanitarian interventions
often focuses on quantity rather than quality,
and there is little published data to assess
service provision during humanitarian crisis.
The risk of poor quality of care in fragile andhumanitarian settings is high due to numerous
challenges, including recruitment of anadequately resourced, trained, and supervised
health workforce. Some interventions, such as
controlled oxytocin(29) and instrumental andsurgical interventions, can pose a greater risk ofharm if poorly implemented, and these should
receive greater supervision(30).
Intrapartum monitoring of fetal well-being
is particularly challenging in humanitariansettings and requires close supervision. Quality
intrapartum monitoring is required to detect
fetal distress and direct interventions to prevent
intrapartum stillbirths and asphyxia whenappropriate to intervene for fetal indications.
It is particularly important that inappropriate
intervention is avoided if it may place themother at greater risk in future pregnancies andif access to family planning and obstetric careis unpredictable. Organisations must therefore
review their interventions to ensure they arebased on appropriate indications, and adapt
recommendations based on context-specificrisks and realistic quality of monitoring. Quality
should be promoted according to establishedstandards(31) and measures such as contextspecific training, supportive supervision,

peer support, mentoring and feedback. Keyinterventions such as neonatal resuscitation
should include mandatory pre-service training
with ongoing refresher trainings. Innovative
tools for remote supervision and training
such as telemedicine, use of mobile devices(m-health), and internet-based platforms(e-health) should be explored and evaluatedin humanitarian contexts. Agencies should
monitor and share data to promote support for
quality improvement initiatives.
Data from programme assessments, as
recommended by the Global Health Cluster,should be used to monitor gaps in service
delivery. This includes where and who is
primarily affected and what barriers prevent
access to essential newborn care. Standardized
indicators on coverage of newborn-specificinterventions across the health sector should
be captured with different data collection
platforms and tools. These data should bereported into the overarching humanitarian
coordination platform, such as the healthcluster or the reproductive health working
group, where all actors can access data for
public health action. Strengthen national datasystems, in collaboration with Countdown
to 2030, to ensure robust and usable dataon coverage of essential newborn care arecollected and reported to monitor trends,
assess quality of delivered interventions,and evaluate impact and accountability of allconcerned and relevant stakeholders.

Key Actions for Newborn Health in Humanitarian Settings 21

3
3. Deliver appropriate care for small and sick newborns
Ensuring care for small and sick newborns
can significantly reduce neonatal mortality
rates and ensure these children thrive laterin life. Standards of care and evidence-based
interventions need to be adapted to fit within
the health system of fragile and humanitarian

ACTIONS

Train and support staff to care for small and sick newborns

Ensuring that all staff are trained in essential
newborn care is the first priority in the earlystages of a humanitarian response. Whenescalating the levels of care, a greater numberof staff with specialist training,
ACTIONS

community, according to WHO guidelines, should
be considered(32). Ensure staff are trained on
neonatal resuscitation to address asphyxia andimplement KMC, feeding support and monitored
oxygen for premature babies.

Provide appropriate facility-based care for small and sick newborns

Facility-based care for small and sick newborns
is highly variable in humanitarian settings. Thisis highlighted by a lack of context-specificguidance on which core interventions areappropriate in different contexts. Efforts should
be made to avoid missed opportunities toprovide less intensive, high impact interventions.
In settings with low health system capacity,
the priority should be essential newborn care
for all neonates. Cost-effective and sustainable
ACTIONS

especially in high quality nursing, in neonatal
care is required. Basic standards andacceptable provider-to-patient ratios must be
carefully considered and established when
making decisions on the complexity of care.

Prioritise treatment of the main causes of neonatal mortality

Ensure antibiotic treatment is available totreat newborns with possible severe bacterial
infection. Where possible, this should be provided
in facilities. When referral is not possible, theoption of providing antibiotic treatment in the
ACTIONS

settings. Complete guidance on small and sicknewborns can be found in the WHO/UNICEF
document Survive and thrive: Transformingcare for every small and sick newborn, which is
fully aligned with the other major initiatives thisdocument is built upon.

interventions should be implemented for thoseborn small or sick, such as KMC and cup
feeding, that can be supported by trained healthworkers including midwives. There is a need todevelop standards for newborn care; outlining
which interventions to prioritise dependingon the context, baseline mortality, and facility
delivery rates. The current work on signal
functions for small and sick newborns should be
adapted for humanitarian settings.

Prevent hospital-acquired infections

Humanitarian and fragile settings arechallenging environments to ensure adequate
quality of care, and in these circumstancesneonatal interventions such as uncontrolled
oxygen in preterm newborns can easily cause
harm(30) leading to retinopathy of prematurity

and blindness(33). Similarly, poor infection
prevention and control practices can cause
avoidable infections and the development of
antimicrobial resistance. Hospital-acquired
infections (HAI) are common in low-resource
settings(34) and outbreaks of multi-resistant

22 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

infections have been detected in neonatal
facilities in humanitarian settings whenmicrobiology has been available(35).
Healthcare organizations should develop
mechanisms for monitoring the minimum
infection prevention and control (IPC)
standards and surveillance tools for HAI thatare user-friendly and adapted to settings
when microbiological facilities are unavailable.
ACTIONS

Prevent inappropriate use of antibiotics

Access to appropriate antibiotics for neonatal
sepsis is a primary concern in humanitariansettings. However, inappropriate antibiotic
therapy in humanitarian and fragile settings
is also a growing concern especially whenpoor IPC and WASH facilitate greater spreadof antibiotic resistance(35-40). Antibiotic
stewardship encourages evidence-basedprescribing in order to combat the overuseof antibiotics and prevent antimicrobial
resistance. This requires greater considerationin protracted crises and settings where

ACTIONS

regulatory frameworks are weak orcompromised or when drug donations
are inappropriate and unmonitored(41,42).
Humanitarian and fragile settings should
be included in the WHO Global Action Plan
on Antimicrobial Resistance(43), and WHO
guidelines on drug donations should be
reinforced with antibiotic donations
carefully considered based on known
microbiological epidemiology and therisk of introducing resistance.

Develop protocols for managing complex conditions when accessto definitive care is impossible

Definitive care—the recommended treatment
for management of a disease or condition—
might be unavailable for many newborn
conditions including congenital abnormalities.
It is important to develop local protocols withalternative solutions for addressing the needsof newborns with complex conditions in
ACTIONS

Guidelines for IPC and water, sanitationand hygiene (WASH) should include an
explicit focus on maternal and newborn care,including integration with essential newborncare practices. New technologies should
be carefully considered and introduced, on
the condition that they are accompanied byadequate IPC guidelines and training andpractice can be maintained and monitored.

humanitarian settings, which are in line with
global standards, local context and resources.
In all cases, there should be respectful
approaches to care, counselling of parents,
relief of suffering and palliative care, andprevention during future pregnancies where
possible (e.g. folic acid for neural tube defects).

Prepare for infectious disease outbreaks

Pregnant or lactating women and newborns
face unique challenges during infectious disease
outbreaks. Preparedness and response planningfor humanitarian interventions should include
awareness among health workers about theprevention of infection among this population andappropriate care guidelines should be developed
at the onset of the outbreak. Data and research to
inform the outbreak response should not exclude
pregnant women and newborns.

Key Actions for Newborn Health in Humanitarian Settings 23

4
4. Register every birth and count every newborn death and stillbirth
Newborn deaths and stillbirths are often
under-reported in humanitarian responses(44).
Their importance is often diminished whenaggregated within the under-five emergency
mortality threshold. Many mortality surveys
and publications neglect to mention newborn
deaths and stillbirths. Interventions also tend
to focus on the post-neonatal under-five
period. Additionally, the misclassification of
newborn deaths and stillbirths can impact theaccuracy of estimates.

ACTIONS

What caught our attention is our weekly
mortality and surveillance data, and werealized the number of deaths had gone up!
It is very unlikely that newborns are prioritizedin humanitarian settings because responders
focus on food, water, and primary health care.

as rights holders including the right to beregistered and to health, according to the United
Nations Convention on the Rights of the Childand the International Covenant on Economic
Social and Cultural Rights.

Improve reporting of neonatal deaths, stillbirths, and proportion ofunder-five deaths among newborns

Mortality statistics are often limited by underreporting and misclassification of neonatal
deaths and stillbirths(44,45). All births,
newborn deaths, and stillbirths should becounted. This can be accomplished throughimproved training and quality assurance

ACTIONS

Humanitarian worker
in South Sudan

Recognise and guarantee the rights of newborns including
birth registration and legal status

Newborns born in humanitarian and fragile
settings may face barriers to legal status andcitizenship, which is often due to discrimination
against race, ethnicity, religion, language or
minority status. This can lead to barriers whenaccessing care. Newborns should be recognised

ACTIONSSPOTLIGHT

to encourage better reporting, including
distinguishing between stillbirths and neonatal
deaths. Ensure that neonatal deaths are
disaggregated in surveys and surveillance.
Innovative methods of surveillance and surveys
should also be explored to improve data quality.

Implement maternal and perinatal death surveillance and response(MPDSR) where possible

Maternal and perinatal death review, as
well as verbal autopsy, is a powerful tool
to improve public health prevention andresponse at referral level facilities when usedappropriately. MPDSR requires capacity andtraining, adaptation to different legal andcultural environments, national guidelines,
and multi-stakeholder engagement inclusiveof communities(46). As part of quality of care
improvement efforts, adapt and implement
tools to conduct mortality audits and reviewsof stillbirths and maternal and neonatal deaths
where possible. Implementation researchis also needed to monitor context-specificbarriers and facilitators and outcomesfor MPDSR.

24 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

55. Strengthen linkages with key humanitarian sectors acrossthe continuum of care

Gains in maternal and newborn health rely
heavily on investments in other sectors suchas family planning, nutrition, immunization,
mental health, and WASH. The maternal andnewborn community must take a multi-sectoral

ACTIONS

Increase routine training on newborn care for managers
and health providers

Trainings on maternal and newborn healthshould include sessions relevant for program
managers and supportive staff to understandthe key lifesaving maternal and newborninterventions that should be included in

ACTIONS

program proposals. Program managers should
also lead the development of action plans thathighlight key gaps and activities for maternal
and newborn health, including medical
equipment and supplies.

Advocate for newborn health in the planning and coordinationof the response

The design and provision of temporary,semi-permanent, and permanent
facilities should consider the needs ofmothers and newborns. This includes
adequate space for breastfeeding,breastmilk expression, KMC, andmanagement of sick newborns. Everyeffort should be made to minimize
overcrowding of maternity wards
to reduce the risk of HAI amongnewborns. Communities should also
be consulted on the design of culturally
acceptable facilities and staffing.

ACTIONS

approach and engage other actors as core
partners to achieve improvements, and othersectors should explore how their services canbe improved to meet the needs of mothers
and newborns.

SPOTLIGHT

Humanitarian worker in
Rohingya Crisis
Targeted violence against the Rohingya community in
Myanmar has resulted in distrust of public health services.
Community health workers have strengthened trust
through community engagement and support to facilitate
uptake of services. Newborns face challenges in receiving
postnatal care since women are also encouraged to stayindoors for 40 days after birth. Reaching women in thiscontext with critical information depends on effective
community-based programming.

Integrate care in community health programs particularly in settings
with low rates of institutional delivery

Humanitarian settings often disrupt continuous
access to facility-based care. When thishappens, community-based services are an
essential mechanism to maintain or increase
coverage of interventions. Community healthprograms can be resilient to disruptions resulting
from insecurity(47) and can stimulate demand
for facility-based care(48). During humanitarian

emergencies, maternal and newborn care canbe integrated into existing community-based
platforms, such as integrated community
case management programs. This requiresconsideration of national programs andthoughtful investment in community
health worker training, supplies, andsupportive supervision.

Key Actions for Newborn Health in Humanitarian Settings 25

ACTIONS

Link mothers to family planning services

Integration of family planning during antenatal
and postnatal care can improve newborn
outcomes by encouraging early initiation andexclusive breastfeeding and improving spacing
between pregnancies. Reproductive, maternal,
newborn, and child health organisations

ACTIONS

should build partnerships and share data tomaximise opportunities. Partnership withinitiatives such as Family Planning 2020 can
expand collaboration with non-humanitarianand country level actors to promote integrationof services.

Leverage existing nutrition interventions so newborns canhave a healthy start

Food security can be a major challenge
in humanitarian and fragile settings.
Improving maternal and newborn healthbegins with ensuring access to foodand maternal nutritional counselling andsupport, in addition to iron and folic acidsupplementation. Humanitarian actors should
ensure that maternal, infant and young
child nutrition interventions are delivered
as an integrated package of maternal,
newborn and child health interventions.
These interventions include support forearly initiation of breastfeeding; protection,
promotion and support of exclusive
breastfeeding during the first six months oflife; and recognition, diagnosis and treatmentof maternal acute malnutrition prenatally andpostnatally. In the first days and weeks after
birth, breastfeeding counselling and support
for exclusive breastfeeding are crucial to themother and the newborn.
Newborn care is also integral to infant andyoung child feeding programmes, based on the2017 Operational Guidance on Infant and YoungChild Feeding in Emergencies (IYCF-E)(18). A
partnership with the nutrition sector is required
to achieve effective monitoring of inappropriate
donations of BMS, and the inappropriate useof feeding equipment such as bottles andteats. Maternal, newborn and child health

SPOTLIGHT

Humanitarian worker
in Indonesia
During the 2006 earthquake in Yogyakarta,
Indonesia, BMS donations were uncontrolled
and widespread. In a study of 831 children
aged 0-23 months, 75% of households
had received donated infant formula, which
was associated with more than double therisk of diarrhoea. This demonstrated how
inappropriate BMS donations in emergencies
can undermine child health.

interventions should be integrated in nutritionand community health funding proposals toensure growth and development monitoring
and the continuum of care between the
newborn and infant period. Linkages withIYCF safe spaces like mother baby areas and
IYCF-E corners should be in place to ensurethat both the mother and the newborn
receive ongoing support and nutritionalcare. Further research is needed to address
the evidence gap in re-lactation strategies
and management of malnutrition under six
months of age(49) and to develop relevant
preparedness policies.

26 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

ACTIONS

Incorporate routine EPI activities in postnatal care

Programs providing maternal and newborncare in humanitarian settings often occur
in parallel to routine EPI activities and thiscreates missed opportunities for vaccination of
newborns and young infants. Health partners
should coordinate EPI activities and postnatal
care between maternity and immunization
programs, particularly for vaccines given at birthin high-incidence settings or in the newborn
period, including those for hepatitis B, BacilleCalmette-Guerine (BCG) for tuberculosis, andpolio. Delivery of early vaccinations and otherinjections should be harmonised with thepromotion of early and exclusive breastfeeding.
Staff in routine EPI activities should be trained topromote essential newborn care and recognize
and refer sick newborns.

ACTIONS

Integrate a nurturing care framework to improve earlychildhood development

Children born in humanitarian crises are athigh risk of adverse developmental outcomes,
with potential negative intergenerational
consequences(50). Interventions should beconsidered through the lens of WHO’s 2018
document Nurturing Care for Early Childhood
Development: A Framework for Helping Children
Survive and Thrive to Transform Health andHuman Potential(51). The framework details thepolicies, programmes and services needed topromote child development, and this framework
ACTIONS

is relevant to the humanitarian sector. Nurturing
care enables communities and caregivers
to promote the health and nutrition of theirchildren and creates opportunities for earlylearning through stimulation and responsive
and supportive interactions(51). Programs
should take a holistic approach by empowering
caregivers with the needed resources and skills
to provide developmentally supportive care, andnewborn services can be linked to these earlychildhood development programs(51).

Link with WASH partners to minimize the risk of infection

Newborns are particularly vulnerable toinfections related to poor water and sanitation,
particularly when breastfeeding is compromisedor when traditional practices include provisionof water. Mothers and caregivers of newborns
should be a priority audience in WASH activities,

and interventions should be specificallytailored to their needs in the community andhealth facility. There is a need to develop anddisseminate IPC- and WASH-specific standards
for maternity wards in humanitarian settings.

Key Actions for Newborn Health in Humanitarian Settings 27

ACTIONS

Promote maternal mental health and psychosocial support

Humanitarian crises are often associated withsignificant distress. Within established referral
protocols, pregnant and lactating women should
be prioritized for psychosocial services for theirown mental health and the potential impact
on their newborn’s health due to disrupted
breastfeeding. Maternal and newborn healthprograms should be linked to mental health
ACTIONSEngage with child protection services and pathways

Child protection challenges are complex andcontext specific, which requires agencies
and stakeholders to share experiences,learning, guidance and information whereappropriate. Addressing child protection requires
communication and coordination between
ACTIONSsupport for a full range of scenarios including
but not limited to psychiatric disorders, posttraumatic stress disorder, depression, sexual
violence, and pregnancy or neonatal loss.
Responses may include non-clinical andinnovative approaches, such as women’s groups
and peer-to-peer support.

agencies to link health services with childprotection pathways. Newborns should
be included in strategies that establish
minimum standards for child protection inhumanitarian response(52).

Implement conditional cash transfers for social protection

Challenges and competing priorities faced by
pregnant women, new mothers, and caregivers
in humanitarian and fragile settings may
undermine their capacity to provide care for theirnewborns, particularly small or sick newborns

requiring prolonged care. Innovative approaches
such as enhanced cash or in-kind transfersthat are sensitive to the needs of mothers
and newborns should be the focus of further
implementation research.

28 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

6
6. Facilitate coordination across the humanitarian-development nexus
Although mortality may decline after theacute phase of a humanitarian crisis(53),the need for maternal and newborn healthservices continues. In protracted crises, thedistinction between humanitarian response anddevelopment can become blurred. Collaboration
between the two approaches can lead tobetter outcomes, reduce risks and build upon

ACTIONSTransition from the MISP to comprehensive reproductive healthservices when rebuilding the national package of health services

There is often a delayed transition from
the MISP to comprehensive reproductive
health services once the acute phase of theemergency is over. Coordination and planning

ACTIONS

platforms, especially during activities such as
joint assessments and gap analyses, and whendeveloping national health strategies is crucial
for maternal and newborn health.

Implement an Every Newborn Action PlanThe Every Newborn Action Plan (ENAP)
provides a framework, including indicators andtargets, for newborn health that is increasingly
being adopted by countries affected by ahumanitarian crisis. Countries should ensurethat maternal and newborn care are includedin national emergency preparedness plans,
and these plans should include newborn
ACTIONS

across the humanitarian-development nexus
should improve the transition to comprehensive
reproductive health services.

Strengthen collaboration between national governments andhumanitarian and development actors where possible

Humanitarian and development actors andnational governments often function withparallel coordination mechanisms and limited
communication or integration. In protracted
situations, collaboration in coordination
ACTIONS

the comparative advantages of a diverse
range of actors. Care must be taken, however,as development is sometimes consideredinherently political; keeping the distinction
between ‘humanitarian’ and ‘development’
activities may in some contexts help
humanitarian organisations tomaintain neutrality.

interventions that should be implemented anda dedicated budget in case of a humanitariancrisis. Communication and coordination,
including sharing of information and tools,
between the development and humanitarian
sectors can align humanitarian activities toaddress national and global targets for
newborn health.

Ensure sustained funding for protracted emergencies

Explore innovative financing and engagementof donors who traditionally provide
development assistance. Maternal andnewborn health is particularly sensitive to
weak health systems during the transition

from the humanitarian to development phase.
Humanitarian and development funding should
be integrated and sustained with longer
funding cycles.

Key Actions for Newborn Health in Humanitarian Settings 29

7
7. Empower communities and governments through partnershipsthat promote innovative and sustainable services
Communities play a significant role in the provisionof newborn health services especially when there
is limited access to health facilities. Humanitarian
actors can reinforce linkages between the different
levels of care in partnership with the community.
Strong leadership by national and local governments,
particularly during emergency preparedness, cancontribute to rapid improvements in maternal andnewborn survival during crisis. This leadership is vital
towards maintaining sustainable progress. Governments
can develop policies and allocate resources to ensure
mothers, pregnant women and newborns receive thecare they need during an emergency.

ACTIONS

Humanitarian worker
in Philippines
In the case of a disaster, positioning essential
newborn care as a preparedness intervention
is the main lesson we learned. This includes
having a national health policy in place,
mapping service delivery capacity, defining
training capacities among local health workers,
and having an emergency information system
in case records are destroyed.

Integrate newborn care in national policies and strategies

Key actions from the Global Strategy for
Women’s, Children’s and Adolescent’s Healthshould be adopted in national strategies andpolicies in humanitarian and fragile settings.
Governments should ensure that newborn care

ACTIONSSPOTLIGHT

is addressed in national policies and integrated
in national curricula for midwifery and nursing
training institutions, health information systems
and essential medicines list.

Invest in the public health system to prevent newborn deaths
and stillbirths during an emergency

Strengthen resilience at national andsub-national levels by integrating priority
maternal and newborn health interventions in
preparedness and response plans. Responseplans and maternal and newborn healthguidelines can be promoted through forums
that bring together national, local, international
humanitarian and development actors.

Standard operating procedures should be in place for:1. National plans on provision of maternal and newborn services
2. Availability of a skilled health workforce for newborn care including regular training and task sharing
3. Infrastructure for maternity wards
4. Essential medicines and commodities
5. Universal access to services at each level of care
6. Community-based newborn services
7. Health information system with a minimum set of maternal and newborn indicators
8. Safe referral and transportation system for mothers, pregnant women and newborns
9. Guaranteeing human rights and safeguarding dignity
10. Counselling on re-lactation and newborn feeding in adherence with the WHO International
Code for BMS
30 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

ACTIONS

Invest in training and supportive supervision for health workers

Training, support, and adequate resourcesmust be put in place in order for frontline
health workers– from midwives, nurses andcommunity health workers to the physicians
and specialist nurses in referral hospitals to the
support staff who keep emergency responses
ACTIONS

Invest in women’s health groups and community health workers

Community engagement can be a powerful
method to increase trust and cooperation
among host and crisis-affected populations.
This can build trust towards emergency
responder and help the dissemination of
information about maternal and newborn care.
Ensuring sufficient numbers of community
health workers are trained, equipped andadequately supervised can promote activities
and retention. Where they already exist or
can be created, women’s health groups canpromote uptake of antenatal care, facility
deliveries, postnatal care, breastfeeding
support, and family planning. Engage with
ACTIONSother community networks (e.g. adolescents,
religious leaders and health committees) topromote maternal and newborn health andreinforce linkages with health facilities along
the referral continuum. Although evidence does
not support having traditional birth attendants(TBAs) conduct deliveries, engaging TBAs tostrengthen recognition and referral for danger
signs can be beneficial. Further research should
be conducted in humanitarian settings on the
training and supervision of lay health workers
and to explore how to engage women’s healthgroups in maternal and newborn care.

Promote a family-centred approach

Family-centred care includes minimizing
separation of the mother and newborn andcreating a supportive environment for families
to care for their newborns in the health facility
and their community. This approach should
be used to create enabling environments for
ACTIONS

running– to do their jobs effectively. In the longterm, such investments are vital for building up
health systems, in anticipation of the time thatstability is achieved, and affected
countries return to the normal tasks ofdelivering health care.

families to care for their newborns by adapting
facility-based care where possible and withenhanced support in the community in theform of nutrition, in-kind support, WASH,
and social protection.

Engage the community on ethical issues

Maternal and newborn care in humanitarian and fragile
settings often presents difficult ethical decisions, such astreatment for extremely low birth weight babies, congenital
anomalies, palliative care, and caesarean sections for fetal
indications, in regions with potentially unsustainable accessto comprehensive emergency obstetric care. Promote
discussion with women and their communities and families
about ethical issues to encourage joint ownership of ethicalframeworks between communities and health actors. The
establishment of ‘ethical committees’ should be considered,including local women, and integrating these within decisionmaking processes at the health cluster level.

Amplify the role ofcommunities in thedelivery of maternal andnewborn health services;
recognizing they areboth the immediate andlong-term responders inhumanitarian settings.

Key Actions for Newborn Health in Humanitarian Settings 31

ACTIONS

Partner with the private sector to encourage accountability
and equity

The private sector is an important partner inhumanitarian response when interventions areproperly supervised and regulated according tohigh procurement standards. Perverse incentives
which lead to inappropriate interventions, suchas high rates of caesarean sections, should be
ACTIONS

actively monitored and limited. Accountability
mechanisms should be in place for private sector
providers for maternal and newborn care, while
avoiding conflicts of interest as recommended
by the independent accountability panel of Every
Woman Every Child.

Invest in training and supportive supervision for health workers

Training, support, and adequate resourcesmust be put in place in order for frontline
health workers– from midwives, nurses andcommunity health workers to the physicians
and specialist nurses in referral hospitals
to the support staff who keep emergency

responses running– to do their jobs
effectively. In the long term, such investments
are vital for building up health systems,
in anticipation of the time that stability isachieved, and affected countries return to thenormal tasks of delivering health care.

8
8. Explore innovative approaches and conduct research to support

service delivery in humanitarian settings

Evidence from various settings has identified
effective newborn interventions that reduce
mortality across the continuum of care.
However, limited information exists on theimplementation of these interventions inhumanitarian contexts. Using methodology
developed by the Child Health and Nutrition
Research Initiative, a research agenda has beenused to generate priority questions to improvenewborn survival in humanitarian settings(54).
Further implementation research is needed tounderstand the models of care best suited forcontexts with limited health system capacity,
including cost implications. Innovation, withsupport from global partnerships, can provide
novel opportunities to reach populations with

ACTIONS

limited accessibility and to build the capacity of
local institutions.

Disseminate scientific evidence to encourage uptake ofnewborn interventions

At the global level, findings from studies thathighlight evidence-based interventions for newborns should be shared widely using the Healthy
Newborn Network and other relevant platforms.
Implementing partners and UN agencies should

be responsible for the timely dissemination offindings to policymakers in humanitarian andfragile settings to ensure rapid uptake and scale
up of evidence-based interventions in a responsive and contextualized manner.

32 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

ACTIONS

Invest in implementation research to inform the delivery of evidencebased interventions in diverse contexts

Evidence-based interventions tested inresource-limited settings are can be highly
applicable to humanitarian settings. This
includes community-based newborn care,chlorhexidine for cord care (if newborn
mortality is greater than 30 deaths per 1,000
livebirths)(55-58), simplified antibiotic regimens
ACTIONS

Explore training frameworks for task-sharing

Humanitarian situations are frequently
associated with severe human resources
shortages, meaning task-shifting becomes
inevitable. Legal frameworks often preventtask-sharing, which may or may not always beappropriate. Emergency preparedness plans
should consider capacity building to allow for
ACTIONS

the expansion of the roles of health workers
to ensure adequate coverage of essential
interventions during crisis. Partnerships with
community-based midwives, through training
and task-shifting strategies that include propermonitoring, can increase access to care whenfacility-based services are disrupted.

Evaluate the use of new technologies in humanitarian settings

Several new technologies adapted to lowresource settings are relevant in certain
humanitarian settings (e.g. bubble continuous
positive airway pressure, low flow oxygen
metres, upright resuscitators, color-coded
thermometers, IV drip rate regulators, point ofcare testing, light-emitting diodes phototherapy,
low cost incubators, and oxygen delivery
mechanisms). However, interventions that
increase the complexity of care can haveunintended consequences on competing
priorities and quality of basic care such as
essential newborn care or infection prevention
and control(63). The evidence base for existing

ACTIONSat the community level when referral is notpossible(59,32), KMC(60-62), and others.
Implementation studies are needed tounderstand factors that influence the successor failure of evidence-based interventions
when they are translated to practice inhumanitarian settings.

technologies may not always apply to lowcost adaptations; therefore, introduction of
new technology should carefully consider thecontext including existing human resources,
IPC standards, and sustainability and whether
adapted technologies offer the expected benefitsof the original intervention. Procedures should
evaluate locally adapted equipment to ensure itis achieving the desired effect and not causing
unanticipated harm. Implementation research
can assess the outcomes, cost-effectiveness,and impact of new technologies on competing
priorities in humanitarian settings.

Leverage digital advances to strengthen the capacity ofhealth workers

Digital technologies such as mHealth, eHealth,telemedicine and telemonitoring are becoming
available and have the potential to improve
communication, training, quality of care, taskshifting and data collection in difficult-to-reachlocations. Digitization can also provide accessto decision-making support and specialist
advice. In planning the implementation ofmaternal and newborn care, digital technology
should be assessed for its ability to increase
quality, capacity, competency andcost reduction.

Key Actions for Newborn Health in Humanitarian Settings 33

99. Increase the visibility of newborns in humanitarian settings
Experience suggests that newborn health isoften missed as a priority during a humanitarian
response and is often regarded as a‘development sector’ activity to be left until
the later stage of the emergency. Publicizing
high maternal and neonatal mortality rates andstillbirth estimates and gaps and priorities innewborn care is essential for galvanizing attention(see Box 5). Ultimately, it is hoped that this willlead to improved program funding and wider
implementation and integration of newborn
services in the affected communities. Civil
society organizations, including humanitarian
actors, community members and local
government leaders, should be involved early on
to help define needs and existing resources for
newborn health. This participatory process can

ACTIONSThe first thing is having an evidence-based
advocacy plan to influence national counterparts
and to use it to plan and monitor activities. We
inserted newborn health-related indicators in
the health management information system,
and we used this information very loudly andtactfully in every meeting.

formalize contributions to the health system andpromote supportive attitudes towards preventing
newborn mortality and stillbirths.

agencies, representation of newborn healthat the health cluster level, and ensuring thatguidelines and standard operating procedures
and monitoring and evaluation frameworks
address maternal and newborn health.

Define and communicate alert levels for neonatal mortality
and stillbirths in every crisis

Emergency mortality thresholds exist for
overall populations and under-fives, notably thecrude mortality rate and the under-five morality
rate. However, no specific definitions exist for
emergency thresholds or unacceptable rates
for neonatal mortality, stillbirths and maternal

ACTIONS

Humanitarian worker
in Iraq

Elevate newborn health on the agenda of humanitarian response
planning, prioritization and coordination

Humanitarian health actors need to assess
the extent to which humanitarian response
planning has included newborn health priorities
throughout the phases of the emergency. Thisshould include during coordination between

ACTIONSSPOTLIGHT

deaths. Each humanitarian response should
consider defining and communicating alertlevels of neonatal mortality, stillbirths andmaternal deaths, based on on pre-crisis or
national level estimates.

Ensure maternal and newborn indicators are central to decisionmaking across the humanitarian-development nexus

Maternal and neonatal mortality rates are usefulindicators of the strength of the health system,and these rates can be used as important
indicator of the level of assistance required. Thisdata should be considered alongside crude andunder-five mortality rates and factored in thedecision-making process related to humanitarianassistance and ongoing health system support.

34 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

ACTIONS

Encourage positive attitudes toward newborn survival
in emergencies

As documented throughout this report, most
newborn deaths can be prevented withcost-effective, lifesaving interventions evenin difficult circumstances. Field experiencestrongly suggests that there is often limited
awareness of the preventability of newborn
deaths and an overreliance on highly

medicalised care, while essential newborncare is overlooked and undervalued. In thecommunity, messaging campaigns about
lifesaving newborn care can improve social
perceptions and norms about newborn survival
and inspire behaviour change.

Key Actions for Newborn Health in Humanitarian Settings 35

Partnership, Participation,& Financing

To effectively implement the Global Strategy
for Women, Children, and Adolescents’ Health2016-2030 and achieve the SDGs, the global
community must continue to advocate, innovate,
expand, coordinate, and push forward a
progressive agenda aimed at ensuring high quality
health care for the most vulnerable populations—
every mother and newborn—in these especiallychallenging environments. New sources of funding
and innovative financing mechanisms are needed
to support the acute phase of an emergency
in addition to multi-year planning in protracted
situations. The role of national governments
should be enhanced to ensure sustainability
through the allocation of financial resources formaternal and newborn care in the context ofthe humanitarian-development nexus. Decision

makers need to commit to collective action toaddress newborn survival in humanitarian andfragile settings.
The existing workstream on newborn health inhumanitarian settings within ENAP should be
expanded to include humanitarian actors such as
UNHCR, Save the Children, Inter-agency Working
Group for Reproductive Health in Crises (IAWG),
Global Health Cluster, and other relevant bodies
who are empowered to oversee progress andhold partners accountable. This workstream
should coordinate efforts related to the provisionof guidance, resource mobilisation, measuring
progress, advocacy and awareness raising, liaison
with key initiatives, and technical assistance.

36 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

Partnerships to Leverage Newborn Survival
Global policymakers§§ Strengthen policy guidance on integrating
maternal and newborn health services
in national and regional emergency
preparedness, response, and recovery plans.

§§ Engage private sector and professionalsocieties to innovate and implement
healthcare technology and training resourcesin humanitarian and fragile settings.

§§ Integrate newborn health indicators in crosssectoral coordinated needs assessments andmonitoring frameworks.

§§ Strengthen guidance to address the needsof pregnant women and newborns insurveillance, prevention, and response
activities during infectious disease epidemics§§ Strengthen guidance to address the needsof pregnant women and newborns insurveillance, prevention, and response
activities during infectious disease outbreaks§§ Engage private sector and professionalsocieties to innovate and implement
healthcare technology and training resourcesin humanitarian and fragile settings.

Implementing organizations§§ Implement priority newborn healthinterventions, consistent with global
guidance, at the onset of humanitarian
emergencies.
§§ Build capacity of healthcare providers throughtraining, mentoring, or similar performance
improvement approaches to ensure they havecompetencies in all seven signal functions ofbasic emergency obstetric, essential newborncare, and care for small and sick newborns,
which are underpinned by respectfulmaternity care.
§§ Preposition supplies to ensure life-saving
commodities are available at onset ofhumanitarian emergencies.
§§ Challenge organizational norms to strengthen
collaboration between maternal and newborn

health and other priority sectors, and between
humanitarian and development actors§§ Engage in respectful partnerships with
communities to promote newborn healthservices and behaviors.
§§ Partner with academic institutions to strengthen
the evidence base of effective interventions,
including community-based approaches for
newborn health in humanitarian settings.
§§ Collect data and report on field implementationof maternal and newborn care interventions.
§§ Partner with academic institutions tobuild evidence of effective communitybased approaches for newborn health inhumanitarian settings.

Donors§§ Encourage and fund partnerships that aim tosupport and enhance the maternal-newborn
dyad and local service delivery efforts during
emergencies.
§§ Require reporting on core newborn healthindicators when funding health activities fromthe onset of an emergency.

§§ Support research activities that build theevidence-base of effective newborn healthinterventions in humanitarian and fragile settings.
§§ Expand multi-year, flexible funding to support
newborn health across the humanitarian-development nexus and contribute to rapid funding
mechanisms for humanitarian emergencies.

Partnership, Participation, & Financing 37

MONITORING PROGRESS
Global Milestones
Year

Global Benchmarks§§ Focal person or global secretariat is established to oversee and monitor
implementation of strategy§§ Existence of a convening mechanism for newborn health inhumanitarian and fragile settings

2020§§ Roadmap is endorsed by Global Health Cluster Strategic Advisory Group§§ Work plan for newborn health in humanitarian is drafted§§ Key actions within the strategy are integrated in other priority sectors’
action plans§§ Global targets to track newborn health are refined, as needed, to reflect
humanitarian settings and targets are endorsed by global leads§§ Newborn mortality is disaggregated when reporting child mortality inall humanitarian reporting2021§§ Health funding appeals include core newborn indicators andinterventions at the onset of an emergency§§ Joint needs assessments address gaps in newborn health§§ Humanitarian health agencies designate a focal person
for newborn health§§ Essential drug lists or supply kits include recommended newborn
supplies from Newborn Care Supply Kits for Humanitarian Settings§§ Newborn policies are integrated in preparedness plans

2022§§ Humanitarian health organizations develop policies and guidelines on
perinatal death audits§§ Training protocols for humanitarian health organizations at thecommunity and facility level include newborn care§§ Work plan for newborn health in humanitarian settings is costed with
an identified funding mechanism for the next five years§§ Humanitarian health organizations adopt and train community-based
cadres on newborn care2023§§ Every Newborn Action Plans are developed for countries with ahumanitarian or fragile setting§§ At least 55 countries adopt a minimum set of indicators for newborn
health in humanitarian settings

2024§§ Neonatal mortality and stillbirth rate are reduced in
10 humanitarian settings§§ 15 research studies are conducted (or in progress) on priority
questions for maternal, stillborn, or newborn care in humanitariansettings from 2020-2024

38 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

Minimum Set of Indicators for Maternal and Newborn Health in
Humanitarian Settings
Indicator type

Indicator type

Settings

Type of reporting(definition)(core/extended)(acute/protracted)(facility/population-based)Core

Acute,
protracted

Facility,
population-basedCore

Acute,
protracted

FacilityCore

Acute,
protracted

Facility,
population-basedCore

Acute,
protracted

Facility,
population-based

ExtendedProtracted

Facility

ExtendedProtracted

Facility,
population-basedCore

Acute,
protracted

Facility,
population-based

ExtendedProtracted

FacilityCore

Protracted

FacilityCore

Acute,
protracted

FacilityCore

Acute,
protracted

FacilityCore

Acute,
protracted

FacilityCore

Protracted

FacilityCore

Acute,
protracted

Facility

Possible severe bacterial infection (PSBI)
treatment coverage:

ExtendedProtracted

Facility

Hepatitis B birth dose coverage:

ExtendedProtracted

Facility

ExtendedProtracted

FacilityCore

Acute,
protracted

Facility

ExtendedProtracted

Facility

ImpactNeonatal mortality:# of deaths in the first 28 days of life / 1000
live births, disaggregated by early neonatal(<7 days after birth) and late neonatal (8-28
days after birth)

Cause of death by age (days):# of newborn deaths by age and cause of death(preterm, intrapartum, infection, congenital, other)

Stillbirth:# of fetuses and newborns born after 28
weeks gestation or ≥ 1000g with no sign of life
life / 1000 live births, disaggregated by freshand macerated stillbirthMaternal mortality:# of maternal deaths / 100,000 livebirths

Coverage/Outcome
Perinatal death reviews:# of perinatal death reviews

Newborn morbidities identified during
postnatal care:# of newborns with any health condition
attributed to or aggravated by pregnancy andchildbirth identified during postnatal care

Low birth weight:# of live born neonates with weight< 2500g at birth

Infants weighed at birth:# of newborns weighed at birth

KMC at facilities:# of health facilities that provide KMC

Availability of BEmOC facilities# of facilities with delivery services able toprovide all 7 signal functions of BEmOC

Availability of CEmOC facilities# of facilities with delivery services able toprovide all 9 signal functions of BEmOC

Small and sick newborn care coverage:# of small and sick newborns that received
care (KMC, inpatient care, NICU)

Neonatal resuscitation at facilities:# of health facilities with delivery services thatare able to provide neonatal resuscitation

Newborn admission to hospital care:# of newborns admitted to KMC or NICU

# of newborns with PSBI that receive treatment# of newborns who received Hepatitis B birth dose

Early initiation of breastfeeding coverage:# of newborns breastfed within 1 hour of birthor prior to discharge

Postnatal care coverage:# of newborns who had a postnatal care visit
within 2 days

Birth registration:# of children registered or with a birth certification

Monitoring Progress 39

YEAR ONE ACTION PLAN
During the February 2019 global expert meeting, stakeholders came together and agreed on these key
priorities for the next year. The action plan will continue to be updated on an annual basis.

TASKS§§ Publish paper on process of Newborn Strategy§§ Disseminate MNH advocacy paper and advocacy
briefer on newborns§§ Launch Declaration§§ Develop infographics and social media strategy

Strategy launchat upcoming
high-level events§§ Develop a ’cheat sheet’ of entry points to use
during messaging at inter-cluster meetings§§ Promote inclusion of maternal and newborn
porin joint needs assessments and indicators

Identificationof entry points
in sectors

TASKS§§ Improve messaging on investment priorities forpre-crisis and recovery MNH activities§§ Integrate MNH priorities in contingency plans
and national policies§§ Explore alternate funding mechanisms

Identification of
investment priorities
during pre-crisis andrecovery phase

TASKS§§ Disaggregate neonatal mortality in childmortality reports§§ Count stillbirths in health information systems§§ Harmonize indicators and data collection tools§§ Measure broader program implementation

40 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

Improvement ofmortality measurementand data collection
and useActivitiesTASKSTASKS
Advancement ofcommunity-based
newborn care§§ Widely utilize and focus community-based
interventions on supporting essential newborn care§§ Identify and monitor task sharing roles forcommunity-based health workers and traditional
birth attendants

TASKS
Priortisation offacility-based
newborn care§§ Build internal technical skills required for maternal and newborncare in implementing organizations§§ Identify referral pathways for levels of care early on and support
the referral chain, including those in host communities§§ Measure quality of care at health facilities§§ Utilise contact with mother to refer for other services
including nutrition and mental health support

Activities

TASKS
Use technology
and innovative
approaches§§ Train midwives to use portable ultrasound remotely connected to aradiologist to review images§§ Set up social media groups for health care providers to sharelessons learned§§ Produce print materials and low-cost newborn simulators to support
Helping Babies Breathe in humanitarian and fragile settings§§ Disseminate the Safe Delivery App for training skilled birthattendants on safe delivery and care for small babies

TASKS

Improve coordination
between humanitarian anddevelopment actorss§§ Empower a global focal point or secretariat for newborn care in humanitariansettings to coordinate the strategy execution alongside partners and initiatives§§ Influence existing platforms to expand newborn health portfolio in humanitariansettings within the health cluster and ENAP§§ Identify focal points at country level within health cluster to work alongside
the newborn focal person at Ministries of Health§§ Work with Ministries of Health to develop preparedness plans that includes
newborn care including through the ENAP§§ Use ENAP annual assessments to measure level of preparedness planningat the country level§§ Support planning for human resources for health including training programmes

Year One Action Plan 41

References
1. Womens UN Report Network. Reaching out to women when disaster strikes. Soroptimist:
Philadelphia, 2011. (https://wunrn.com/2011/03/soroptimist-reaching-out-to-women-whendisaster-strikes/, accessed 16 March 2020).
2. United Nations Population Fund (UNFPA). Humanitarian action 2019 Ooverview. UNFPA: New
York, 2019. (https://www.unfpa.org/sites/default/files/pub-pdf/UNFPA_HumanitAction_2019_
PDF_Online_Version_16_Jan_2019.pdf, accessed 16 March 2020).
3. Maternal and perinatal health. World Health Organization (WHO), WHO. (https://www.who.int/
maternal_child_adolescent/topics/maternal/maternal_perinatal/en/, accessed 16 March 2020).
4. United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). Levels &trends in child mortality: Report 2019, Estimates developed by the United Nations Interagency Group for Child Mortality Estimation. United Nations Children’s Fund. New York,2019. (https://www.who.int/maternal_child_adolescent/documents/levels_trends_child_mortality_2019/en/, accessed 16 March 2020).
5. United Nations Children’s Fund (UNICEF). The state of the world’s children. UNICEF: NewYork 2014. (https://www.unicef.org/publications/files/SOWC2014_In_Numbers_28_Jan.pdf,
accessed 16 March 2020).
6. Inter-Agency Working Group (IAWG) on Reproductive Health in Crises. Surviving day one:
Caring for mothers and newborns in humanitarian emergencies on the day of childbirth.
IAWG: New York, 2019. (http://iawg.net/resource/surviving-day-one-caring-mothersnewborns-humanitarian-emergencies-day-childbirth/, accessed 16 March 2020).
7. Wise PH et al. Confronting stillbirths and newborn deaths in areas of conflict and politicalinstability: a neglected global imperative. Paediatr Int Child Heal, 2015,
doi:10.1179/2046905515Y.0000000027
8. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). Global
Humanitarian Overview 2019. OCHA: Geneva, 2018. (https://www.humanitarianresponse.
info/en/programme-cycle/space/document/global-humanitarian-overview-2019,
accessed 16 March 2020).
9. Foster AM et al. The 2018 inter-agency field manual on reproductive health in humanitariansettings: revising the global standards. Reprod Health Matters, 2017,
doi:10.1080/09688080.2017.1403277
10. Victora CG et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong
effect. Lancet, 2016, doi:10.1016/S0140-6736(15)01024-7
11. Rollins NC et al. Why invest, and what it will take to improve breastfeeding practices?
Lancet, 2016, doi:10.1016/S0140-6736(15)01044-2
12. Prudhon C et al. Informing infant and young child feeding programming in humanitarian
emergencies: An evidence map of reviews including low and middle income countries.
Matern Child Nutr, 2018, doi:10.1111/mcn.12457

42 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

13. Shaker-Berbari L et al. Infant and young child feeding in emergencies: Organisational policies andactivities during the refugee crisis in Lebanon. Matern Child Nutr, 2018, doi:10.1111/mcn.12576
14. Debes AK et al. Time to initiation of breastfeeding and neonatal mortality and morbidity: asystematic review. BMC Public Health, 2013, doi:10.1186/1471-2458-13-S3-S19
15. Yotebieng M et al. Ten steps to successful breastfeeding programme to promote early
initiation and exclusive breastfeeding in DR Congo: a cluster-randomised controlled trial.
Lancet Glob Heal, 2015, doi:10.1016/S2214-109X(15)00012-1
16. Ayoya MA et al. Protecting and improving breastfeeding practices during a major emergency:
lessons learnt from the baby tents in Haiti. Bull World Health Organ, 2013, doi:10.2471/
BLT.12.113936
17. WHO, UNICEF. Acceptable medical reasons for use of breast-milk substitutes. WHO:
Geneva, 2009. (https://www.who.int/maternal_child_adolescent/documents/WHO_FCH_
CAH_09.01/en/, accessed 16 March 2020)
18. IFE Core Group. Infant and young child feeding in emergencies: Operational guidance for
emergency relief staff and program managers (Version 3.0). UNICEF: New York, 2017.
(https://www.ennonline.net/attachments/2673/Ops-G_2017_WEB.pdf, accessed 16 March 2020)
19. WHO. Network for global monitoring and support for implementation of the international
code of marketing of breast-milk substitutes and subsequent relevant World Health Assembly
Resolutions (NetCode). (https://www.who.int/nutrition/netcode/en/, accessed 16 May 2020)
20. UNICEF. Protecting, promoting and supporting breastfeeding in facilities providing maternity
and newborn services. WHO: Geneva, 2017. (https://apps.who.int/iris/bitstream/handle/10665/272943/9789241513807-eng.pdf?ua=1, accessed 16 March 2020)
21. Bhutta ZA et al. Can available interventions end preventable deaths in mothers, newborn
babies, and stillbirths, and at what cost? Lancet, 2014, doi:10.1016/S0140-6736(14)60792-3
22. WHO. WHO recommendations on newborn health. WHO: Geneva, 2017.
(https://apps.who.int/iris/bitstream/handle/10665/259269/WHO-MCA-17.07-eng.pdf,
accessed 16 March 2020)
23. WHO. Global technical strategy for malaria 2016-2030. WHO: Geneva, 2017.
(https://www.who.int/malaria/areas/global_technical_strategy/en/, accessed 16 March 2020)
24. WHO. Global health sector on sexually transmitted infections, 2016-2021. WHO: Geneva,
2016. (https://apps.who.int/iris/bitstream/handle/10665/246296/WHO-RHR-16.09-eng.
pdf?sequence=1, accessed 16 March 2020)
25. WHO. Global health sector strategy on HIV, 2016-2021. WHO: Geneva, 2016. (https://apps.
who.int/iris/bitstream/handle/10665/246178/WHO-HIV-2016.05-eng.pdf?sequence=1,
accessed 16 March 2020)
26. WHO. Maternal and neonatal tetanus elimination (MNTE). WHO: Geneva, 2018.
(https://www.who.int/immunization/diseases/MNTE_initiative/en/index4.html,
accessed 16 March 2020)

References 43

27. IAWG. Newborn Health in Humanitarian Settings: Field Guide (revised edition). Save theChildren: Washington, DC, 2018. (https://www.healthynewbornnetwork.org/resource/
newborn-health-humanitarian-settings-field-guide/, accessed 16 March 2020)
28. Sacks E et al. Respectful maternal and newborn care: building a common agenda.
Reprod Health, 2015, doi:10.1186/s12978-015-0042-7
29. Shah S et al. Unregulated usage of labour-inducing medication in a region of Pakistanwith poor drug regulatory control: characteristics and risk patterns. Int Health, 2016,
doi:10.1093/inthealth/ihv051
30. Every Preemie. Every preemie scale: Do no harm technical briefs. USAID: Washington, DCA,
2017. (https://www.everypreemie.org/donoharmbriefs/, accessed 16 March 2020)
31. WHO. Standards for improving quality of maternal and newborn care in healthfacilities. WHO: Geneva, 2016. (https://apps.who.int/iris/bitstream/handle/10665/249155/9789241511216-eng.pdf?sequence=1, accessed 16 March 2020)
32. WHO. Managing possible serious bacterial infection in young infants whenreferral is not feasible. WHO: Geneva, 2015. (http://apps.who.int/iris/bitstream/
handle/10665/181426/9789241509268_eng.pdf?sequence=1, accessed 16 March 2020)
33. WHO. Oxygen therapy for children: a manual for health workers. WHO: Geneva, 2016.
(https://apps.who.int/iris/bitstream/handle/10665/204584/9789241549554_eng.
pdf?sequence=1, accessed 16 March 2020)
34. Zaidi AK et al. Hospital-acquired neonatal infections in developing countries. Lancet, 2005,
doi:10.1016/S0140-6736(05)71881-X
35. Lenglet A et al. Nosocomial outbreak of clinical sepsis in a neonatal care unit (NCU) in
Port-Au-Prince Haiti, July 2014 - September 2015. PLoS Curr, 2018, doi:10.1371/currents.
outbreaks.58723332ec0de952adefd9a9b6905932
36. Abbara A et al. Antimicrobial resistance in the context of the Syrian conflict: Drivers before
and after the onset of conflict and key recommendations. Int J Infect Dis, 2018, doi:10.1016/j.
ijid.2018.05.008
37. Ronat J-B et al. Highly drug-resistant pathogens implicated in burn-associated bacteremia inan Iraqi burn care unit. PLoS One, 2014, doi:10.1371/journal.pone.0101017
38. Murphy RA et al. Prevention of common healthcare-associated infections in humanitarian
hospitals. Curr Opin Infect Dis, 2016, doi:10.1097/qco.0000000000000285
39. Talley LE et al. Challenges to the programmatic implementation of ready to use infant formulain the post-earthquake response, Haiti, 2010: a program review. PLoS One, 2013, doi:10.1371/
journal.pone.0084043
40. Woerther P-L et al. Massive increase, spread, and exchange of extended Spectrum
β-Lactamase–Encoding genes among intestinal enterobacteriaceae in hospitalized children
with severe acute malnutrition in Niger. Clin Infect Dis, 2011, doi:10.1093/cid/cir522

44 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

41. Berckmans P et al. Inappropriate drug-donation practices in Bosnia and Herzegovina, 1992 to
1996. N Engl J Med, 1997, doi:10.1056/nejm199712183372512
42. Cañigueral-Vila N et al. Improvements for international medicine donations: a review of theWorld Health Organization Guidelines for Medicine Donations, 3rd edition. J Pharm policy
Pract, 2015, doi:10.1186/s40545-015-0045-3
43. WHO. Gobal Action Plan on Antimicrobial Resistance. WHO: Geneva, 2015.
(http://apps.who.int/iris/bitstream/handle/10665/193736/9789241509763_eng.pdf?sequence=1,
accessed 16 March 2020)
44. Checchi F et al. Public health information in crisis-affected populations: a review of methods
and their use for advocacy and action. Lancet, 2017, doi:10.1016/S0140-6736(17)30702-X
45. Checchi F et al. Documenting mortality in crises: what keeps us from doing better. PLoS
Med, 2008, doi:10.1371/journal.pmed.0050146
46. Koblinsky M. Maternal death surveillance and response: A tall order for effectiveness inresource-poor settings. Glob Heal Sci Pract, 2017, doi:10.9745/GHSP-D-17-00308
47. Kozuki N et al. The resilience of integrated community case management in acute emergency:a case study from Unity State, South Sudan. J Glob Health, 2018, doi:10.7189/jogh.08.020602
48. Edmond KM et al. Can community health worker home visiting improve care-seeking andmaternal and newborn care practices in fragile states such as Afghanistan? A populationbased intervention study. BMC Med, 2018, doi:10.1186/s12916-018-1092-9
49. Prudhon C et al. Research priorities for improving infant and young child feeding inhumanitarian emergencies. BMC Nutr, 2016, doi:10.1186/s40795-016-0066-6
50. Devakumar D et al. The intergenerational effects of war on the health of children. BMC Med,
2014, doi:10.1186/1741-7015-12-57
51. WHO. Nurturing care for early childhood development: a framework for helping children
survive and thrive to transform health and human potential. WHO: Geneva, 2018.
(https://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf,
accessed 16 March 2020)
52. Global Protection Cluster Child Protection. Minimum Standards for Child Protection in
Humanitarian Settings. UNICEF: New York, 2012. (https://www.unicef.org/iran/Minimum_
standards_for_child_protection_in_humanitarian_action.pdf, accessed 16 March 2020)
53. Checchi F et al. Interpreting and using mortality data in humanitarian emergencies:
A primer for non-epidemiologists. Humanitarian Practice Network: London, 2005.
(https://www.ennonline.net/attachments/886/networkpaper052.pdf,
accessed 16 March 2020)
54. Morof DF et al. Neonatal survival in complex humanitarian emergencies: setting an evidencebased research agenda. Confl Health, 2014, doi:10.1186/1752-1505-8-8References 45

55. Soofi S et al. Topical application of chlorhexidine to neonatal umbilical cords for prevention ofomphalitis and neonatal mortality in a rural district of Pakistan: A community-based, clusterrandomised trial. Lancet, 2012, doi:10.1016/S0140-6736(11)61877-1
56. Arifeen S El et al. The effect of cord cleansing with chlorhexidine on neonatal mortality inrural Bangladesh: A community-based, cluster-randomised trial. Lancet, 2012, doi:10.1016/
S0140-6736(11)61848-5
57. Sinha A et al. Chlorhexidine skin or cord care for prevention of mortality and infections in
neonates. Cochrane Database Syst Rev, 2015, doi:10.1002/14651858.CD007835.pub2
58. Sankar MJ et al. Umbilical cord cleansing with chlorhexidine in neonates: A systematic
review. J Perinatol, 2016, doi:10.1038/jp.2016.28
59. Lokangaka A et al. Simplified antibiotic regimens for treating neonates and young infants withsevere infections in the Democratic Republic of Congo: A comparative efficacy trial. Matern
Heal Neonatol Perinatol, 2018, doi:http://dx.doi.org/10.1186/s40748-018-0076-2
60. Lawn JE et al. Born too soon: Accelerating actions for prevention and care of 15 million
newborns born too soon. Reprod Health, 2013, doi:10.1186/1742-4755-10-S1-S6
61. Lawn JE et al. Born Too Soon: Care for the Preterm Baby. Reprod Health, 2013,
doi: 10.1186/1742-4755-10-S1-S5
62. Lawn JE et al. ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birthcomplications. Int J Epidemiol, 2010, doi: 10.1093/ije/dyq031
63. Lissauer T et al. Nasal CPAP for neonatal respiratory support in low and middle-income
countries. Arch Dis Child Fetal Neonatal Ed, 2017, doi:10.1136/archdischild-2016-311653

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46 Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020 – 2024

Published
April 2020
© Save the Children

The following agencies also supported the development of this Roadmap:• Bill & Melinda Gates Foundation• International Committee of the Red Cross• Médecins Sans Frontières