Scientific Importance of Research
Progress in reducing neonatal mortality is lagging behind improvements made in child survival after the first month of life, and South Sudan continues to have the highest NMR in Africa.(15) Evidence-based guidelines describe the most effective interventions to prevent and manage the main causes of newborn death.(16) However, countries with a high NMR have recently experienced a humanitarian emergency and the translation of newborn guidelines into public health practice during periods of on-going violence is not well understood or operationalized in these contexts.(17)
During the inception phase, the study team drafted a dissemination plan to ensure findings would be shared with partners in South Sudan and the global community. Since then, the team held several workshops in Juba with the South Sudan Reproductive Health Technical Working Group to encourage uptake of findings. IMC program managers in Juba, Malakal, and Maban also received biweekly program updates, including supply stockouts, from the study supervisors in each site. The study led to the first national workshop on newborn health in South Sudan, co-hosted by the Ministry of Health and UNICEF, which set the stage for drafting an Every Newborn Action Plan (ENAP) for the country. South Sudan’s ENAP has led to the development of a newborn service package under the main health funding mechanism in the country. The National Community Health Strategy has also been revised to incorporate community-based newborn interventions.
At the global level, learnings were used beyond humanitarian settings to inform methodologies for measuring newborn care signal functions in other low resource settings and a newborn medical supply kit for community- and facility-based care.(18,19) The findings of this research have been shared through the Newborn Health in Emergencies webpage hosted by Save the Children,(20) blogs disseminated through the Healthy Newborn Network, (20–22) a correspondence published in The Lancet,(23) a public webinar as part of Save the Children’s Health and Nutrition Series,(24) poster and oral presentations at several international conferences, and research articles in peer-reviewed journals(9-11). Several policy and programmatic changes were also made at the global level such as development of a global roadmap to accelerate newborn health program scale-up in humanitarian settings and the Newborn Health Humanitarian Settings Field Guide that included an implementation toolkit. (19,25,26)
Strategies to Address Research Challenges
Methodological Issues
Study sites experienced frequent periods of conflict and insecurity, which posed several challenges for the study methodology including staff capacity and ethical concerns. In the design phase, facility-based newborn care practices were intended to be compared pre- and post-intervention. However, attacks against health facilities and workers led IMC to limit service delivery to ensure staff and patient safety. Maternity wards were also moved to alternative locations until destroyed facilities were rebuilt and newborn supplies were shifted for other purposes. Due to high turnover of health workers at health facilities, about half of the workers who were trained as part of the study intervention remained in the sites. This limited the study to a descriptive analysis.
While insecurity in South Sudan presented many sudden challenges, study co-investigators represented a diverse group of agencies, including non-governmental organizations (NGO), Ministry of Health, and academia, that offered creative strategies for adapting research methods in the constantly changing environment. Partnerships with non-research NGOs and UN agencies such as IMC, Save the Children, United Nations High Commissioner for Refugees (UNHCR), and UNICEF, who had substantial experience adapting clinical services during acute conflict, proved vital for identifying similar methods to sustain study operations. For instance, clinical observations for measuring newborn care practices in prior studies were conducted by research assistants with a clinical background such as nursing or midwifery, but this was not an option in a country facing extreme health workforce shortages. Instead, we worked closely with NGOs to identify strong candidates in the community and designed a data collection training to meet varying educational levels. This included tools and equipment for illiterate health workers, The training introduced basic clinical practices, such as partograph use, resuscitation, essential newborn care, and kangaroo mother care, that would be observed by researcher assistants. This required allocating additional funds to extend the data collection training from an 8 to a 15-day period.
High Staff Turnover
As ethnic tensions and insecurity rose, more than half of facility-based health workers who received the study intervention left their position. This included restricting movement of non-local staff in the evening hours and temporarily staffing maternity wards with traditional birth attendants (TBA). We worked closely with the donor to allocate additional funds for a second round of training for newly hired health workers. The study team also partnered with another UN agency, UNHCR, to integrate the content in upcoming trainings in Maban. When TBAs were hired to conduct deliveries in study facilities due to evacuation of non-local midwives, we needed to carefully consider expanding the study intervention and training to include TBAs. This became a critical aspect for understanding the feasibility of implementing newborn care in contexts that most represent conflict-affected settings. Inclusion of local community members in the study team also allowed the study to continue with data collection during periods of insecurity when others were unavailable. This limited research staff turnover and improved consistency in the application of data collection methods.
Ethical and Safety Concerns
Study operations were designed to have a research coordinator in Juba and a supervisor with four to five data collectors in each site. During times of episodic violence, the safety of local researchers was the primary concern of the study team and implementing partners. Frequent discussions about staff safety included what is the degree of additional risk, if any, and how risks could be minimized. We recruited a field study team who were either from the community or lived in the camp to avoid potential ethical and safety concerns. This meant hiring staff who represented diverse ethnicities in South Sudan such as Shilluk, Dinka, and Nuer people. Because of the insecurity following the July 2016 crisis and armed groups targeting civilians based on ethnic lines, we no longer held joint data collection trainings in Juba or elsewhere for the study sites. Throughout the study, the team worked closely with security officers in partnering agencies to anticipate how and when research staff could access sites. This included adopting communication and transportation protocols used by NGO program staff to ensure the safety of the research team.
Remote Monitoring of Research Activities
Shortly after the violence in Juba in July 2016, study co-investigators were unable to return to South Sudan to conduct trainings or monitor data collection as described in the original study protocol. Mobile data collection on tablets allowed data collectors to upload quantitative data every 24 to 48 hours using wireless internet at the IMC field offices. When site supervisors and co-investigators were unable to visit study sites, they were able to conduct daily reviews of the data using the online database. Missing or erroneous data were reported immediately to the site supervisors. The close working relationship with IMC allowed us to identify practical strategies to ensure tablets were adequately maintained, charged, and safely stored in remote areas. When staff movement between facilities and IMC offices were restricted, additional tablets were purchased to reduce disruptions in data collection or uploads. Lastly, because of the targeting of ethnic minority groups and ongoing insecurity, staff were not allowed to convene in Juba. The study co-investigator, research coordinator and site supervisors met in Entebbe, Uganda for a one-week refresher training to overcome the travel restrictions that were imposed during the conflict. Supervisors then returned to their study sites and trained local data collectors. This cascade approach built the capacity of local researchers in qualitative and quantitative methods and allowed data collection to continue with remote support.
Budget Implications
South Sudan presented numerous logistical challenges because of the ongoing conflict. While costly, equipment for the study intervention were transported in the country using plane because of the high risk for armed attacks along roads. Costs associated with transporting study staff and equipment kept rising due to hyperinflation of the local currency. Because of the high staff turnover, additional funding was needed for this and to extend the study timeline to re-train health workers and reorder additional job aids and training supplies
Competing Health Priorities
In June 2016, South Sudan faced a cholera outbreak that shifted staffing and response priorities. As a result, program managers in the community and facility had limited capacity to maintain weekly supervision tasks related to the study interventions. Study supervisors were also often requested to support clinical supervision. With IMC input, the team developed a staffing plan so that each site had an adequate number of researchers to support their activities and avoid burdening program staff, which proved to be critical during the cholera outbreak and other strenuous moments on the health system. The engagement of MOH from the beginning was critical in the absorption of learning and using the research finding to inform the ENAP that was later developed for the country.