title: Barriers in the Delivery of Emergency Obstetric and Neonatal Care in Post-Conflict Africa: Qualitative Case Studies of Burundi and Northern Uganda.
abstract: OBJECTIVE
  Maternal and neonatal mortality and morbidity rates are particularly grim in conflict, post-conflict and other crisis settings, a situation partly blamed on non-availability and/or poor quality of emergency obstetric and neonatal care (EmONC) services. The aim of this study was to explore the barriers to effective delivery of EmONC services in post-conflict Burundi and Northern Uganda, in order to provide policy makers and other relevant stakeholders context-relevant data on improving the delivery of these lifesaving services.
  
  
  METHODS
  This was a qualitative comparative case study that used 42 face-to-face semi-structured in-depth interviews and 4 focus group discussions for data collection. Participants were 32 local health providers and 37 staff of NGOs working in the area of maternal health. Data was analysed using the framework approach.
  
  
  RESULTS
  The availability, quality and distribution of EmONC services were major challenges across the sites. The barriers in the delivery of quality EmONC services were categorised into two major themes; human resources-related challenges, and systemic and institutional failures. While some of the barriers were similar, others were unique to specific sites. The common barriers included shortage of qualified staff; lack of essential installations, supplies and medications; increasing workload, burn-out and turnover; and poor data collection and monitoring systems. Barriers unique to Northern Uganda were demoralised personnel and lack of recognition; poor referral system; inefficient drug supply system; staff absenteeism in rural areas; and poor coordination among key personnel. In Burundi, weak curriculum; poor harmonisation and coordination of training; and inefficient allocation of resources were the unique challenges. To improve the situation across the sites, efforts are ongoing to improve the training and recruitment of more staff; harmonise and strengthen the curriculum and training; increase the number of EmONC facilities; and improve staff supervision, monitoring and support.
  
  
  CONCLUSIONS
  Post-conflict health systems face different challenges in the delivery of EmONC services and as such require context-specific interventions to improve the delivery of these services.
authors.affiliation: Peace Research Institute Oslo (PRIO), PO Box 9229, Grønland, Oslo, Norway; Institute of Health and Society, University of Oslo, PO Box 1130, Blindern, Oslo, Norway.
authors.forename: Primus Che
authors.initials: PC
authors.lastname: Chi
authors.affiliation: International Organization for Migration, Plot 6A, Naguru Crescent, Kampala, Uganda.
authors.forename: Patience
authors.initials: P
authors.lastname: Bulage
authors.affiliation: Peace Research Institute Oslo (PRIO), PO Box 9229, Grønland, Oslo, Norway.
authors.forename: Henrik
authors.initials: H
authors.lastname: Urdal
authors.affiliation: Institute of Health and Society, University of Oslo, PO Box 1130, Blindern, Oslo, Norway.
authors.forename: Johanne
authors.initials: J
authors.lastname: Sundby
mesh_terms: D002063:Burundi; D004632:Emergency Medical Services / Q000592:standards / Q000706:statistics & numerical data*; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D007231:Infant, Newborn; D015931:Intensive Care, Neonatal / Q000592:standards / Q000706:statistics & numerical data*; D008427:Maternal Health Services / Q000592:standards / Q000706:statistics & numerical data*; D011247:Pregnancy; D011787:Quality of Health Care; D014454:Uganda