Ensuring Quality Access and Learning for Mothers and Newborns in Conflict-Affected Contexts (EQUAL)

Ensuring Quality Access and Learning (EQUAL) for Mothers and Newborns in Conflict-Affected Contexts Consortium is a multi-country, multi-partner maternal and newborn health research consortium funded by UK International Development from the UK government and led by the IRC. The consortium aims to reduce maternal and perinatal mortality and morbidities among the most vulnerable, conflict-affected populations by generating evidence to improve the provision of high-quality intrapartum and immediate postpartum care in the most challenging settings. 

EQUAL’s research is being conducted in the Democratic Republic of Congo (DRC), Nigeria, Somalia, and South Sudan,four countries where maternal and newborn mortality are among the highest in the world. In each country, EQUAL’s research agenda seeks to produce operationally relevant, demand-driven evidence that is accessible to decision-makers to inform MNH policies, programming, and investments at the global, national, and sub-national levels.

The programme includes five research work streams which aim to strengthen community, facility, and health system efforts to reduce preventable maternal and perinatal mortality. 

Five research work streams

1. Political economy analysis of maternal and newborn health (MNH) policy and financing

Existing research rarely examines the unique challenges of delivering MNH care in conflict-affected settings. These challenges are related to insecurity, political will/stability, and severe funding gaps – all of which impact how issues are prioritized and policies are developed and funded.  EQUAL conducted qualitative research studies across the consortium’s four focus countries and an additional study looking at the global landscape to better understand the political, financial, and other factors that impactMNH prioritization in each context.  . Data were collected using key informant interviews and a desk review.

2. Maternal and perinatal mortality surveillance and response

Maternal and perinatal death surveillance and response offers an opportunity to not only count the number of deaths that occur, but to also understand and address the factors contributing to the deaths of women and newborns. In many crisis-affected contexts, accurate data on maternal and newborn outcomes is limited, especially when deaths occur outside of health facilities. In North and South Kivus DRC, EQUAL aims to examine the feasibility, acceptability, and effectiveness of community-based maternal and perinatal death surveillance in low-income, conflict-affected contexts in order to expand access to accurate data on maternal and perinatal mortality, making it easier to implement targeted solutions to prevent future deaths and improve the quality of MNH care. This is mixed methods formative research examining existing surveillance systems and socio-cultural practices surrounding death, followed by the codevelopment and/or strengthening and evaluation of maternal and perinatal death surveillance and response system(s).

3. Community-based delivery of MNH services

While medical care provided at a health facility is recommended, it is not always possible in crisis-affected communities where health systems are weak, facilities are damaged or distant, and trained providers are limited.  In these cases, community health systems – including the support of community health workers (CHWs) - are often the only option for delivering life-saving services. Despite this, there is limited evidence around how community health programs can be used to ensure women and newborns have consistent access to quality care.  In Somalia and South Sudan EQUAL aims to determine the potential of a community-based MNH care program to deliver evidence-based, life-saving services in rural, humanitarian contexts with high barriers to facility-based care.assessing This includes assessing the feasibility, acceptability, fidelity, cost-efficiency, and conditions required to increase the uptake and coverage of evidence-based behaviors and community-based maternal and newborn care services that have been proven to reduce mortality outcomes.  Implementation research is using a mixed methods approach including pre-and post- surveys to capture change in the uptake of services, as well as qualitative interviews, questionnaires, focus group discussions, and performance checklists.

4. Midwifery education and workforce development

Midwives educated and regulated according to international standards can provide more than 80% of the essential care needed for women and their newborn babies In NE Nigeria and in Somalia, EQUAL is leading research to understand factors affecting midwifery workforce participation, performance, retention, and resilience during periods of increased insecurity to help strengthen midwifery services and experiences in conflict-affected areas. This is mixed methods study including a rapid assessment of the quality of midwifery pre-service education programs followed by a cohort study following the experiences of midwifery students and recent graduates over several years.

5. Facility-based quality of care

While many countries have documented large increases in the number of facility-based deliveries, this has not been matched with consistent improvements to the quality of facility-based care which depends on health worker knowledge, practices, and attitudes and the availability of proper supplies, equipment, and medicines. EQUAL aims to examine the quality of routine MNH care and the management of select obstetric and neonatal complications at health facilities in the eastern DRC and in NE Nigeria. This includes examining barriers to quality care and identifying innovative solutions responsive to the unique circumstances of these settings. Cross-sectional assessments including facility inventory and record review, interviews with maternity care providers, and observations of care on the day of birth, as well as surveys, in-depth interviews, and focus group discussions with postpartum women are being conducted.