INTRODUCTION
Around 1.2 billion of the world’s population live in fragile and conflict-affected states (FCAS). These states contribute with more than 60% of the global burden of maternal mortality. The Sustainable Development Goals call for specific attention to address maternal health in the realities of armed conflict.1,2
In war-affected Yemen, a country that has historically received scarce attention in the health literature, the challenges in providing maternity care are evident. In 2014, Yemen remained with maternal death estimates between 148 and 270 per 100,000 live births, and neonatal deaths between 22 and 26 per 1000 live births.3-5Since 2015, Yemen has been in a state of armed conflict with subsequent breakdown of the health services. In 2016, 17% of the public health facilities were out of function and 38% only partly functional, due to either damage of facilities or lack of supplies or human resources.6 The United Nations have repeatedly issued warnings as demand for humanitarian assistance exceeds available capacity.7,8
While there is an urgent need for data to inform the emergency response and prepare for resurrection of the health system, health information systems in Yemen have been unreliable since the beginning of the conflict.9 Moreover, a systematic review found no studies from Asia and the Middle-East reporting exclusively on maternal health during acute conflict,10 and there is an alarming need for research exploring maternal health service access, quality and adaptive responses during acute crises.11
Taiz Houbane Maternal and Child Health (MCH) Hospital in Yemen is an example of an adaptive response to mitigate the consequences of armed conflict. The hospital was established by Médecins Sans Frontières (MSF) in November 2015 and pre-dimensioned to serve 650 women in childbirth per month. Since 2015, the hospital experienced a steady increase in demand for services. In August 2017, 1014 births took place, and the facility had provided care 50% above admission capacity for several months. To mitigate the growing demand for care, a policy was introduced to restrict admissions; it was decided that no new hospital admittances were allowed when bed occupancy reached 100%. Following, as here presented, a research evaluation assessed the restriction’s effects on the quality of intrapartum care and birth outcomes, to provide information for future provision of care and adaptive responses.