Despite global efforts, sub-Saharan Africa continues to account for 70% of maternal deaths, yet systematic cause-specific analyses across African regions remain limited. We examined 33-year trends in maternal mortality to identify epidemiologic divergence and guide differentiated intervention strategies. Using the 2023 Global Burden of Disease Study, maternal mortality ratios (MMR), cause-specific deaths, and age-specific patterns were analysed across five African regions (Central, Eastern, Northern, Southern, and Western Africa) from 1990 to 2023. Absolute and relative changes, average annual rates of change, cause-specific mortality proportions, and progress against Sustainable Development Goal targets were assessed. MMR reduction varied dramatically across regions. Northern Africa achieved the greatest decline (65.0%; 241.2 to 84.4 per 100,000 live births), while Central Africa achieved only 16.7% reduction (818.1 to 681.3). Cause-specific patterns diverged strikingly: HIV-related causes accounted for 87.3% of maternal deaths in Southern Africa versus 34.2% in Central Africa, while direct obstetric causes showed inverse patterns (6.3% vs. 39.9%). HIV-related maternal deaths increased 76%-454% across most regions despite antiretroviral therapy (ART) scale-up. Age-extreme populations faced 1.3- to 7.2-fold elevated risks; adolescents in Central Africa had an MMR of 852.3, and women aged 45-49 years reached 2233.0. Central Africa's MMR remained 3.6 times the global average, with sepsis burden (15.3%) more than double other regions (4%-7%). African regions demonstrate distinct epidemiologic profiles requiring tailored intervention strategies. Universal maternal health approaches inadequately address HIV-dominant versus obstetric-dominant regional burdens or age-extreme vulnerability. Central Africa's minimal progress signals that standard interventions fail under protracted humanitarian crises. Post-2025 strategies must integrate linked HIV-maternal care, emergency obstetric services, crisis-adapted approaches, and age-targeted programming while recognizing within-region heterogeneity to achieve equitable maternal health outcomes.

The two-year armed conflict in the Tigray Region of Northern Ethiopia (2020-2022) created a humanitarian crisis marked by widespread sexual violence, healthcare disruption, and displacement of health personnel. However, reliable epidemiological evidence on the contribution of conflict-related sexual violence to HIV transmission remains scarce. This study addresses this gap by quantifying the impact of conflict-related rape on HIV incidence and prevalence in Tigray. A dynamic risk equation model was developed to capture HIV transmission during conflict. In this framework, conflict intensity influences key transmission drivers, including rape prevalence, number of perpetrators, trauma severity, reduced post-exposure prophylaxis (PEP) use, and healthcare service degradation. Data from the Central Statistics Agency of Ethiopia, UNAIDS regional estimates, World Health Organization, Ethiopian Public Health Institute, and relevant literature were used. Uncertainty analyses were conducted, complemented by global sensitivity analysis and numerical simulations. This model-based study indicates that mass rape could cause a median of 122 (interquartile range, IQR: 13-681) new HIV infections, indicating conflict-related mass rape could cause a median increase of 13.8% (IQR: 1.9%-62.5%), while the median increase in prevalence could be 0.002% (IQR: 0.00027%-0.0089%). These results suggest the increase in incidence due to rape is epidemiologically notable though the effect on population prevalence is small, reflecting that escalating conflict intensity characterized by increased rape frequency, declining health system capacity, and reduced PEP coverage further amplifies HIV transmission. Integrated strategies, including prevention of sexual violence, timely PEP access, and mobile health services, are essential to mitigate HIV transmission. Humanitarian agencies and conflicting parties should act on both public health and human rights grounds.

Shelter and settlement are critical determinants of health in humanitarian crises, yet their impacts on health outcomes remain underexplored. This review synthesizes published evidence on how shelter and settlement interventions impact health outcomes in humanitarian crises. A systematic review of peer-reviewed literature was conducted to identify studies examining the association between shelter and settlement interventions and health outcomes in humanitarian crises. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines a protocol was developed and three databases were searched for studies published between 2005 and 2025. Relevant data were extracted and thematically analysed. A total of 138 articles were found. Thematic analysis identified six themes (living conditions, accommodation type, camp and site planning, displacement status, essential household items and cash-based interventions). Three cross cutting themes of gender, climate change and vulnerability were also identified. Two themes (living conditions and accommodation type) are presented here. Poor living conditions including damaged shelters, poor housing design and materials were associated with increased risks of communicable diseases such as malaria, diarrhoea, and soil-transmitted helminth infections while overcrowding heightened injury risk and psychological distress. Accommodation type influenced health outcomes with short-term shelters linked to acute mental health challenges and increased injuries; medium-term shelters with increased risk of non-communicable disease; and long-term housing with deteriorations in chronic disease management. This systematic review synthesises the evidence base showing how shelter and settlement interventions play a role in influencing health outcomes in humanitarian crises. It shows that shelter is a critical yet often under recognised determinant of health in these settings. Health outcomes are influenced by housing quality, accommodation type and duration, camp and settlement planning, displacement dynamics including frequency and length of displacement, and access to essential household items. Poor shelter conditions are likely to increase the risk of communicable diseases and mental health issues and have the potential to worsen chronic disease outcomes and risk. A key contribution of this review is the identification of shelter as a core entry point for public health action, highlighting the need for clearer operational guidance on shelter typologies, minimum standards, and their integration with health, protection and social services.

Continuance of global progress toward the eradication of malnutrition in all forms requires the steering of resources to priority areas. Armed conflict is a key driver of malnutrition, yet its impact differs given the conflict intensity, duration and type. In this study, we investigate the relationship between conflict type, specifically state-based and non-state conflict, and under-5 acute malnutrition in conflict-affected African populations. We link malnutrition data from small-scale surveys held in the Complex Emergency Database, conducted across 11 conflict-affected African populations between 1999 and 2015, with conflict data from UCDP/PRIO. We estimate associations between conflict type and the prevalence of global acute malnutrition (GAM) and severe acute malnutrition (SAM) whilst controlling for relevant covariates, using Bayesian beta-regression, which allows aggregation of survey data. Holding other factors constant, non-state conflict was significantly (p < 0.05) associated with a higher prevalence of GAM and SAM (15.27% and 4.83%) relative to state-based conflict (9.03% and 1.26%). In addition, we find heterogeneous impacts of prior military expenditure as a share of GDP, overseas development assistance (ODA) and precipitation variability on under-5 acute malnutrition by conflict type. Namely, prior military expenditure and lower-than-normal precipitation were associated with increased malnutrition prevalence under state-based conflict, yet to a lesser degree under non-state conflict. We find a significant mitigating role of ODA on GAM, irrespective of conflict type. For SAM, ODA was more negatively associated with malnutrition prevalence under non-state conflict relative to state-based conflict. The study extends the current literature by finding a heterogenous relationship between conflict type and under-5 acute malnutrition, namely we estimate a significantly higher malnutrition burden in African populations affected by non-state conflict relative to state-based conflict. Our findings underscore the importance of context-specific resource planning when addressing malnutrition burden in humanitarian crises.

Supporting the health of unaccompanied immigrant children in a humanitarian crisis: An American Academy of Nursing consensus paper.

Sexual and reproductive health needs and rights continue to be not only unmet but actively deprioritized in humanitarian settings. This disproportionately exacerbates inequities in maternal and newborn health, leading to increased maternal morbidity and mortality. Poor maternal health outcomes often go unnoticed in emergency settings in which competing priorities mean that monitoring maternal morbidity and mortality is frequently excluded from the initial response. The World Health Organization's MPDSR (Maternal Perinatal Death Surveillance and Review) system is a widely accepted standard for monitoring maternal morbidity and mortality; however, it is not recommended for the acute phase-defined as the first 6 months-of a humanitarian crisis because of feasibility constraints. This highlights the need for adapted approaches for surveillance and response during acute humanitarian crises. As part of its focus on reproductive health in humanitarian settings, Médecins Sans Frontières adapted the MPDSR tool for Tigray, Ethiopia, in 2020 and has since implemented the tool in Sudan after war erupted in April 2023. Although doing so has involved challenges, the results have been instrumental in informing programming, even during complex emergencies. This clinical perspective describes the Médecins Sans Frontières experience implementing a R-MDSR (Rapid Maternal Death Surveillance and Review) system in Sudan during the early stages of the escalating 2023 crisis. This commentary offers a reflective and, at times, critical account of the implementation of R-MDSR and demonstrates the feasibility and role of the tool in driving timely, action-oriented interventions to improve maternal health in fragile and conflict-affected settings.

There are no evaluated family-based mental health and psychosocial support (MHPSS) interventions for adolescents in Southwest Asia (known as the Middle East), and few whole-family interventions in low- and middle-income countries, despite consistent evidence for the impact of family support on mental health and well-being. This study aims to evaluate the effectiveness of a brief family systemic mental health intervention, deliverable by non-specialists in mental health. We conducted an assessor-blind type I hybrid effectiveness-implementation multi-site randomized controlled trial comparing the locally developed family intervention to a waitlist control group for randomly allocated families residing in North Lebanon and Beqa'a governorates. Eligible families presented with medium-to-high risk for child protection concerns (abuse, neglect, child labor, early marriage) and had at least one adolescent aged 12-17 who demonstrated psychological distress. Outcomes at the family, caregiver, and adolescent level were measured pre- and post-intervention, and at 3-month follow-up. Intent-to-treat analyses found a significant between-group effect of the intervention on adolescent-reported family functioning, caregiver mental health, and parenting. No change was found for adolescent psychological distress. Further analyses found effects on adolescent well-being for those who completed the intervention, and that father attendance was associated with better outcomes for adolescent well-being in the intervention group. No other significant moderators were found. At the 3-month follow-up for the intervention condition, family functioning and caregiver well-being significantly dropped from endline. The study demonstrates mixed results for a non-specialist-delivered family-systemic intervention developed in the context of humanitarian crises in Lebanon. While the intervention did not result in benefits in adolescent-reported symptoms of psychological distress, the intervention group did show greater improvements than the control group on a number of other outcomes, showing the potential impact of working with the wider family system to support adolescents in humanitarian settings.

Low dietary diversity in low- and middle-income countries (LMICs) usually results from households basing their diets on a small number of food groups beyond their staple foods. Numerous studies have demonstrated that among people in both developed and developing nations, dietary diversity is a reliable indicator of dietary quality. Humanitarian crises over the past few decades have altered the patterns of food consumption in refugee camps, where the prevalence of food insecurity has significantly grown, resulting in undernutrition and chronic diseases. Therefore, our study determined the factors associated with undernutrition among women of reproductive age living with HIV in Mahama refugee camp, Rwanda. Using a cross-sectional design, our study examined the association between undernutrition (outcome) and household diversity scores, access to kitchen gardens, and chronic illness. The study was conducted at the Mahama refugee camp, which was home to 58,248 people. Yemane's algorithm was used to recruit a sample size of 170 women of reproductive age living with HIV for this study, while utilizing a random sampling technique. Anthropometric measurements (BMI and MUAC) of the respondents were examined; SPSS version 25 was used for data analysis. According to this study, the majority of women in the refugee camp ate grains (98%) and pulses (86%). The majority had a 68% medium diversity score. Additionally, access to kitchen garden (AOR = 0.391, p = 0.014, 95% CI = 0.185-0.825), dietary scores of highest (AOR = 0.039, p = 0.001, 95% CI = 0.033-0.475) and medium (AOR = 0.125, p = 0.002, 95% CI = 0.006-0.242) were found to be significantly associated with lower odds of undernourishment in the camp. Though not statistically significant, having any other chronic illness was associated with a higher risk of undernourishment (AOR = 2.359, p = 0.102, 95% CI = 0.843-6.602). Grains, legumes, fruits, seeds, nuts, and vegetables made up the majority of the food consumed by the 170 sampled women refugees. The risk of undernutrition was also significantly reduced in women who had access to kitchen gardens and showed high and medium dietary scores; a tendency was also observed for the risk of undernutrition to increase in respondents with extra chronic conditions. To enhance dietary scores and promote fair access to the kitchen garden, comprehensive healthcare interventions should be implemented in the camp.

Globally, about 2.3million neonates die annually, most of them in low-resource and conflict-affected countries. In Yemen, ongoing humanitarian crises put children at continued risk, with neonates being the most vulnerable group. This study aimed to assess the in-hospital neonatal mortality rate and to describe the demographic and clinical characteristics. A retrospective cohort design reviewing all neonatal admissions to the Neonatal Inpatient Department (NIPD) at Al-Salam Hospital in Amran Governorate, January to December 2023. Data were extracted from hospital records entered REDCap and analyzed using R 4.3.1. Both descriptive and inferential statistics were applied: chi-square, t-tests for bivariate analysis, and logistic regression was used to identify predictors of neonatal mortality. Statistical significance at p < 0.05. A total of 882 neonates were included; 51% were inborn and 49% outborn. Median age was 1day (IQR 0-6) and a median admission weight of 2,500g (IQR 1,860-2,975), male neonates accounted for 57%. The commonest diagnoses were clinically suspected sepsis (72%), low birth weight (48%), prematurity (32%), perinatal asphyxia (20%), and meningitis (5%). Among neonates receiving oxygen (72%), HHFNC use was more common among mortalities (15% vs. 8%), no significant difference was observed for nasal cannula use (95% vs. 94%). Antibiotics were administered to 96% of neonates; among deaths, cefotaxime was most frequently used and for a shorter duration (37% vs. 17%; 1 vs. 5 days). Antibiotic regimen modification was more frequent among neonates with in-hospital mortalities (40% vs. 23%), particularly when escalating to vancomycin (27% vs. 7.2%) and meropenem (31% vs. 10%). Maternal risk factors, including PROM in 35% (45% lasting ≥18h), history of abortions, lower gestational age, and low hemoglobin, were associated with increased risk of in-hospital mortality. The overall mortality rate was 17.4%. In multivariable analysis, very low birth weight (VLBW; <1500 g), perinatal asphyxia, and meningitis were independent mortality predictors, whereas admission after 7 days of life and higher maternal hemoglobin were associated with improved survival. Neonatal mortality at Al-Salam Hospital remained high, and was associated with VLBW, prematurity, and perinatal asphyxia, highlighting the need to strengthen maternal care, neonatal resuscitation, Kangaroo Mother Care, and antibiotic stewardship in fragile humanitarian settings.

Effectiveness and cost-effectiveness of a stepped care framework for psychological interventions for reducing common mental health symptoms in Jordan: a single-blind randomised clinical trial.

Global health engagement increasingly occurs in the context of war and violent conflict. Many health-related decisions are made which should be guided by evidence. Health research is needed to provide evidence, yet conducting research in conflict settings raises multiple ethical issues. However, the ethical issues involved in conducting research during war and violent conflict have received insufficient attention. The literature suggests that these ethical issues, while similar to those of research conducted in humanitarian crises, are also distinct. This article provides a review of the ethical issues faced by researchers in conflict zones with a goal to inform future research into such issues. The review was organized around an established 8-principle ethics framework for research in low-income settings. We conclude with a number of recommendations and call for additional attention by bioethicists to this important area to protect participants and support researchers in conflict settings, whether coming from military or nonmilitary organizations.

Artificial intelligence for surgical care in war-torn sudan: Feasibility, barriers, and ethical perspectives from a conflict zone.

Digital crisis counseling during wartime: Pre\u2013post outcomes and user experience in Ukrainian and German samples

Global displacement has increased reliance on private and homestay hosting as community-based responses to humanitarian crises. While these arrangements provide immediate shelter and opportunities for social integration, they also create complex and often unequal dynamics, particularly for displaced women. This policy brief draws on emerging evidence and lived experiences from displaced Ukrainian women in Canada to highlight how homestay hosting operates at the intersection of housing, health, and social care systems. Hosting functions as both refuge and risk: it can foster safety, connection, and temporary stability, while also creating challenges related to limited privacy, unclear expectations, dependency, and unequal power relations. Gendered caregiving roles and emotional labor further shape women’s well-being, access to healthcare, and integration trajectories. Structural gaps, including fragmented policy frameworks and limited coordination with health and social services, contribute to ongoing vulnerabilities. Homestay hosting is therefore positioned as a critical yet under-recognized social determinant of health. To address these challenges, this policy brief calls for the development of a coordinated national framework that integrates hosting within health and social care systems, ensures access to trauma-informed and culturally responsive supports, and strengthens guidance for both hosts and guests. Establishing monitoring mechanisms and linking hosting to long-term housing and integration pathways are essential to promote equity, safety, and sustainable outcomes for displaced women.

The Gaza Strip has suffered from a severe humanitarian crisis for years due to the ongoing blockade and recurrent conflicts resulting from Israeli aggression. Since October 7, 2023, the Israeli occupation has launched a comprehensive and systematic campaign of genocide against the Gaza Strip. This has dramatically intensified the suffering of its population, resulting in more than 63,000 martyrs and over 160,000 injuries, in addition to thousands of missing persons. Beyond the high casualty figures, a vast number of civilians are in urgent need of humanitarian assistance. Leaving these victims without adequate humanitarian aid constitutes not only a direct threat to human life but also a profound affront to human dignity.

While the majority in the Global North have enjoyed modern drinking water systems for nearly a century, powerful actors including the World Bank and the OECD are pushing for innovations aimed at addressing access gaps in the world’s poorest communities. These efforts seek to revive private sector involvement in the water sector, which has declined significantly over the past two decades. This paper situates the drive for innovation within a broader restructuring of international development cooperation that positions private finance and technological innovation as central to achieving Sustainable Development Goal 6 (SDG 6). I conceptualize this restructuring as part of a climate-sustainable-development industrial complex (CSDIC): an assemblage of state institutions, multilateral agencies, and financial actors mobilizing sustainability discourses to open new frontiers for capital accumulation. Drawing on political ecology, water justice scholarship, and theories of racial capitalism, I examine how Africa has been constructed as both a site of humanitarian crisis and a frontier for investment, and how techno-financial reforms rescale water governance, discipline public provision, and convert racialized precarity into opportunities for private investment. The analysis combines a critical document review of global water policy interventions with solidarity-based research in Cape Town, South Africa. I show how innovations advanced under the banner of climate resilience and sustainable development contribute to ’water apartheid’, disproportionately burdening Black working-class communities while consolidating new financial claims over water infrastructure in the Global South. Drawing from a case study of grassroots resistance in Cape Town, the paper also highlights pathways for solidarity and underscores the need to reassert collective, public, and anti-colonial approaches to water governance.

BackgroundThe unfamiliar situations and complex environments encountered in evolving combat and humanitarian operations, combined with advances in practice, means that deployed military nurses are increasingly likely to become more involved in, or lead, ethical decision-making in military treatment facilities.AimHow do United Kingdom military nurses experience ethical decision-making on combat and humanitarian deployments? Question: What are the experiences of military nurses regarding ethical decision-making during war or humanitarian crisis?DesignA qualitative, interpretive, 'Big Q' design analysed through reflexive thematic analysis was used.ParticipantsThirty United Kingdom military nurses with operational experience in combat or humanitarian missions, serving or retired, were purposively recruited.EthicsEthical approval was obtained from both the Ministry of Defence Research Ethics Committee (1009/MODREC/19) and the University of Birmingham Research Ethics Committee (ERN_17-1414). All participants gave informed consent and interviews were anonymised.ResultsTwo themes were developed: 'Doing the Right Thing', with one sub theme 'Professional Codes and Guidelines as Ethical Handrails', and 'The Deployed Context'.ConclusionThe findings show how military nurses try and do the ethically right thing, but situational constraints are, perhaps, significantly different to non-military nursing making ethical decision-making especially complex. Relatedly, military nurses' attempts to manage the prioritisation of their sometimes-conflicting identities of being both a healthcare professional and military professional compound this complexity.

Armed conflict and protracted humanitarian crises profoundly affect maternal and infant health, rendering breastfeeding practices particularly vulnerable. While the existing literature largely focuses on breastfeeding rates and nutritional outcomes in conflict settings, limited attention has been given to how women experience, sustain, and make sense of breastfeeding under such conditions of violence, deprivation and displacement. This study aimed to investigate mothers' breastfeeding experiences during the Gaza War (2023-2025) within the framework of the Infant and Young Child Feeding in Emergencies (IYCF-E) standards. This qualitative study employed a phenomenological design. Sixteen forcibly displaced mothers who were actively breastfeeding during the 2023-2025 Gaza War were included using purposive sampling. Data were collected through semi-structured interviews conducted in Arabic via online platforms. Interviews were audio-recorded, transcribed verbatim, and analyzed using Braun and Clarke's six-phase thematic analysis approach, with independent coding by three researchers and consensus agreement. Five main themes were identified: (1) structural conditions of war, (2) psychological reflections of breastfeeding under war conditions, (3) physical health problems and living conditions, (4) coping and resistance mechanisms, and (5) lack of psychological and humanitarian aid. Findings indicate that chronic hunger, forced displacement, unsafe shelter conditions, and intense trauma structurally undermine breastfeeding. Mothers have experienced breastfeeding more intensely as a multidimensional tool for nutrition, soothing the baby, establishing physical closeness, providing emotional regulation, and maintaining the mother-baby attachment. This study demonstrates that protecting and supporting breastfeeding is not an option for assistance, but a non-negotiable humanitarian obligation. The example of Gaza highlights the urgency of implementing standards, integrating breastfeeding services with mental health and psychosocial support systems, and treating breastfeeding as a priority life-saving intervention in conflict settings. Not applicable. This study did not involve a healthcare intervention and therefore did not require clinical trial registration.

ABSTRACTAims and ObjectivesTo explore how the military coup, COVID‐19, and limited healthcare access affected the health and well‐being of Myanmar migrants.BackgroundMyanmar is among the poorest countries in Southeast Asia. The combined effects of COVID‐19, political instability, and civil conflict have created a humanitarian crisis, resulting in migrants having severely restricted access to food, water, healthcare, and basic rights.DesignA qualitative interview study.MethodsIn‐depth interviews were conducted with a purposive sample of 32 Myanmar migrants living in Thailand (M = 38.5 years, SD = 11.6). The study followed COREQ reporting guidelines.ResultsParticipants described their experiences with COVID‐19 prevention measures amid uncertainty, reporting substantial psychological distress and high levels of stress. Religion—particularly Buddhism—served as a central coping mechanism, helping them manage fear and emotional challenges. Many emphasised maintaining their cultural identity, expressed limited interest in acculturating to Thai society, and hoped to return to Myanmar once conditions stabilised. Some younger migrants sought support from local organisations for COVID‐19 information and resources. Overall, participants relied on personal resilience, spirituality, and informal support networks to manage their health and well‐being.ConclusionsMyanmar migrants often depend on spiritual beliefs, self‐reliance, and community connections to cope with adversity. Culturally sensitive interventions are needed to improve access to healthcare and support migrants experiencing ongoing instability, high levels of stress, and limited formal resources.Relevance to Clinical PracticeWithin the context of patient care, the findings contribute new knowledge on the status of Myanmar migrants who are facing intersecting stressors in resettlement areas of Thailand. Limited access to resources for migrants poses significant barriers to seeking professional medical help. More insight into why Myanmar migrants do not seek help despite experiencing stress and having knowledge of available resources in Thailand is needed.Patient or Public ContributionMembers of the migrant community were interviewed, and community advocates were involved in the study.Positionality StatementThe research team, with backgrounds in social work, counselling, public health, and nursing and with experience working with Southeast Asian migrant communities, recognised that this familiarity may shape interpretation. To minimise bias, we engaged in reflexive journaling, discussed assumptions in team meetings, and bracketed personal perspectives during data collection and analysis. As the researchers held no authority over the participants, the interviews emphasised respect, active listening, and minimised power differentials. These practices helped ensure that the findings reflected participants' voices rather than researchers' expectations.

This cross-sectional study examined chronic pain, mental health, and pain catastrophizing among 272 Palestinian patients at Al-Shifa Hospital in Gaza. Participants (median age 43; 57.7% female) completed assessments using the depression, anxiety, and stress (DASS-21) and pain catastrophizing (PCS) scales. Most were married (78.7%), unemployed (50%), and lived on <1,974 ILS/month (94.1%). Lower limb pain (26.8% knee) predominated, with a median pain duration of 4 years. High rates of mental health symptoms were observed: depression (83.1%), anxiety (83.8%), and stress (88.6%), with 56.3% showing extremely severe anxiety. Pain catastrophizing correlated strongly with psychological distress. Findings highlight the need for integrated, trauma-informed pain management addressing both biomedical and psychosocial factors in conflict-affected populations. Future research should explore how sociopolitical stressors and catastrophic thinking interact to exacerbate pain experiences in humanitarian crises.