Strengthening Maternal Health Service Continuity in Wartime Sudan Through a Positive Peace Framework

Strengthening Maternal Health Service Continuity in Wartime Sudan Through a Positive Peace Framework | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Strengthening Maternal Health Service Continuity in Wartime Sudan Through a Positive Peace Framework Mona Suliman This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8669759/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Sudan continues to experience severe disruption of maternal health services due to prolonged armed conflict, resulting in reduced availability of antenatal care, skilled birth attendance, and emergency obstetric services. While humanitarian responses address immediate survival needs, they often fail to ensure sustained maternal care across pregnancy, childbirth, and the postnatal period. This paper examines how the Positive Peace framework informs feasible strategies to improve maternal health service access and continuity under wartime conditions in Sudan. A structured narrative review draws on peer-reviewed literature and institutional reports published between 2010 and 2024, focusing on maternal health service delivery in conflict-affected and post-conflict settings. Evidence is synthesized thematically and mapped onto the pillars of the Positive Peace framework to assess feasibility and relevance for the Sudanese context. Four themes emerge: disruption of maternal health services under insecurity, demand-side barriers and social constraints affecting care seeking, decentralized service delivery strategies effective in comparable settings, and the role of governance, equity, and information flow in sustaining service delivery. High-feasibility actions include mobile and outreach maternal health services, strengthened referral and emergency transport systems, integration of trained community-based providers, targeted financial protection mechanisms, and improved coordination between government and humanitarian actors. The findings indicate that improving maternal health during armed conflict requires approaches extending beyond emergency clinical care. Applying the Positive Peace framework supports alignment between maternal health interventions and broader social and institutional conditions necessary for sustained service delivery, offering a practical pathway to strengthen maternal health systems during conflict while supporting long-term resilience. Maternal health armed conflict Positive Peace health systems service continuity Sudan 1. Introduction Armed conflict poses a severe threat to the functioning of health systems and disproportionately affects women’s access to essential maternal health services. Effective maternal health care depends on the availability of skilled health workers, functional facilities, reliable supply chains, and coordinated referral systems that support continuity of care across pregnancy, childbirth, and the postnatal period. When these system components operate effectively, the majority of obstetric complications are preventable, and maternal mortality remains low. In conflict affected settings, health systems experience widespread disruption as a result of damaged infrastructure, displacement or loss of skilled health workers, shortages of essential medicines and equipment, and breakdown of referral and transport systems. These disruptions reduce access to antenatal care, skilled birth attendance, and emergency obstetric services, transforming preventable complications into life threatening conditions and interrupting continuity of maternal care. Weak governance and limited system coordination further constrain the ability of health systems to absorb shocks and sustain service delivery during periods of instability (Blanchet et al., 2017). Health system resilience therefore plays a critical role in maintaining essential services during crises, particularly in fragile and conflict affected contexts (Kruk et al., 2015). Sudan exemplifies these challenges. Even prior to the current conflict, maternal mortality levels in Sudan exceeded global averages, reflecting longstanding gaps in health system coverage, equity, and quality of care. The escalation of armed conflict has further weakened maternal health service delivery through closure or partial functioning of health facilities, severe shortages of skilled personnel, disrupted supply chains, and insecurity limiting population mobility. Women face increased financial barriers, fear of travel, and uncertainty regarding service availability, leading to delayed care seeking and fragmented maternal care pathways. Humanitarian health responses remain essential for addressing immediate life saving needs during emergencies. However, many interventions prioritise short term clinical responses and isolated episodes of care, with limited attention to sustaining maternal health services across the full continuum of pregnancy, childbirth, and the postnatal period. Without system level coordination, equitable resource allocation, and reliable information flow, maternal health services remain vulnerable to interruption and fragmentation, particularly in protracted conflict settings. Addressing maternal health during armed conflict therefore requires approaches that extend beyond emergency clinical care and engage with the broader structural conditions shaping service delivery. This study applies the Positive Peace framework to examine how governance, equity, information flow, and human capital influence maternal health service access and continuity during wartime Sudan. By linking maternal health interventions to these system level conditions, the framework provides a structured basis for identifying feasible strMaternal mortality refers to the death of a woman during pregnancy, childbirth, or within forty two days after the termination of pregnancy due to causes related to or aggravated by pregnancy or its management (World Health Organization, 2023). Most maternal deaths remain preventable through timely access to quality antenatal care, skilled birth attendance, functional referral systems, and effective emergency obstetric services. In fragile and conflict affected settings, maternal health outcomes are strongly influenced by three interrelated delays, namely delay in seeking care, delay in reaching care, and delay in receiving appropriate care. Armed conflict intensifies all three delays simultaneously by disrupting service availability, restricting population mobility, and weakening referral and communication systems. As a result, these delays overlap and reinforce one another, leading to severe disruptions in maternal health service continuity across pregnancy, childbirth, and the postnatal period (Bashour et al., 2018; Devkota et al., 2018). The Positive Peace framework conceptualises peace as the presence of social systems and institutions that enable human wellbeing rather than merely the absence of violence. The framework comprises eight pillars, including equitable distribution of resources, well functioning government, free flow of information, high levels of human capital, low levels of corruption, a sound business environment, good relations with neighbours, and acceptance of the rights of others (Institute for Economics and Peace, 2023). Addressing maternal health during armed conflict therefore requires approaches that extend beyond emergency clinical care and engage with the broader structural conditions shaping service delivery. This study applies the Positive Peace framework to examine how governance, equity, information flow, and human capital influence maternal health service access and continuity during wartime Sudan. By linking maternal health interventions to these system level conditions, the framework provides a structured basis for identifying feasible strategies that can sustain maternal health services under conditions of insecurity while supporting longer term health system resilience 2. Background and Conceptual Framework Maternal mortality is widely recognised as a core indicator of health system performance and social equity. It is defined as the death of a woman during pregnancy, childbirth, or within forty two days following the termination of pregnancy from causes related to or aggravated by pregnancy or its management (World Health Organization, 2023). Despite substantial global progress, the majority of maternal deaths remain preventable when women have timely access to quality antenatal care, skilled birth attendance, functional referral systems, and effective emergency obstetric services. When these components operate as an integrated continuum of care, maternal morbidity and mortality can be substantially reduced. In fragile and conflict affected settings, this continuum is frequently disrupted by systemic and structural constraints rather than clinical limitations alone. Maternal health outcomes in such contexts are strongly shaped by three interrelated delays, delay in seeking care, delay in reaching care, and delay in receiving appropriate care. Armed conflict intensifies each of these delays simultaneously by undermining service availability, restricting population mobility, increasing insecurity during travel, and weakening referral and communication systems. As a consequence, these delays overlap and reinforce one another, leading to severe disruptions in maternal health service continuity across pregnancy, childbirth, and the postnatal period (Bashour et al., 2018; Devkota et al., 2018). The situation in Sudan illustrates the cumulative impact of these dynamics. Insecurity, displacement, economic hardship, and uncertainty regarding the functionality of health facilities discourage early care seeking and consistent engagement with maternal health services. Damage to transport infrastructure, fuel shortages, and limited communication capacity delay access to referral facilities during obstetric emergencies. Even when women are able to reach health facilities, shortages of skilled health workers, essential medicines, blood products, and functional equipment constrain the provision of timely and appropriate care. These systemic failures transform otherwise preventable obstetric complications into life threatening events and contribute to fragmented maternal care pathways. Addressing maternal health service continuity under such conditions requires analytical approaches that extend beyond emergency clinical responses and isolated service delivery interventions. The Positive Peace framework conceptualises peace as the presence of social systems and institutions that enable human wellbeing rather than solely the absence of violence. It comprises eight interdependent pillars, equitable distribution of resources, well functioning government, free flow of information, high levels of human capital, low levels of corruption, a sound business environment, good relations with neighbours, and acceptance of the rights of others (Institute for Economics and Peace, 2023). Together, these pillars describe the structural conditions that support stability, trust, and effective service delivery within societies. Within this study, the Positive Peace framework is applied as an analytical lens to examine how these structural conditions shape access to and continuity of maternal health services during armed conflict. Each pillar reflects system level factors influencing service availability, coordination among actors, information sharing, and community trust in health systems. Linking maternal health interventions to these pillars enables a clearer understanding of why certain service delivery strategies remain feasible under conditions of insecurity while others fail. By situating maternal health within this broader systems oriented framework, the analysis moves beyond a narrow focus on clinical capacity to consider governance, equity, information flow, and human capital as central determinants of service continuity. This approach provides a structured basis for identifying maternal health strategies that can sustain essential services during active conflict while also contributing to longer term health system resilience and recovery in post conflict settings 3. Methods 3.1 Study design This study adopts a structured narrative review to synthesise evidence on maternal health service delivery in conflict affected and post conflict settings. This design is well suited to examining complex health system challenges where outcomes are shaped by governance arrangements, service organisation, and contextual constraints, and where quantitative synthesis is limited. The approach allows integration of diverse forms of evidence and supports the development of implementation relevant insights. 3.2 Data sources and search strategy Peer reviewed journal articles and institutional reports published between 2010 and 2024 were examined. Sources were identified from global health and public health journals, as well as publications produced by international organisations engaged in maternal health, humanitarian response, peacebuilding, and health system strengthening. The search strategy applied predefined keyword combinations, including maternal health, maternal mortality, skilled birth attendance, antenatal care, emergency obstetric care, armed conflict, fragile settings, Sudan, health systems, peacebuilding, and Positive Peace. 3.3 Inclusion and exclusion criteria Sources were included if they examined maternal health service delivery in conflict affected or post conflict contexts and reported barriers, enabling conditions, or interventions with clear relevance to service delivery and continuity of care. Publications based solely on opinion without implementation detail, sources lacking identifiable contextual information, and studies not directly related to maternal health service delivery were excluded. 3.4 Data synthesis Included sources were analysed thematically. Evidence was synthesised into key themes reflecting service delivery barriers, enabling system conditions, and maternal health intervention strategies. Identified interventions were subsequently mapped to the pillars of the Positive Peace framework to assess their feasibility and relevance for sustaining maternal health service continuity during active conflict in Sudan. 4. Results This section outlines the main structural and contextual factors that undermine access to and continuity of maternal health services during armed conflict in Sudan. Damage to health facilities, loss of skilled personnel, disruption of supply chains, and insecurity affecting population movement collectively weaken the maternal care pathway and increase the risk of delayed or inadequate care. The principal conflict related barriers and their implications for maternal health service continuity are summarised in Table 1 . Table 1. Conflict-Related Barriers Affecting Maternal Health Service Access and Continuity in Sudan Barrier category Description Implications for maternal health services Health facility damage Destruction or partial closure of hospitals and maternity units Reduced availability of antenatal care, delivery services, and emergency obstetric care Health workforce displacement Migration, injury, or death of skilled health workers Reduced skilled birth attendance and delayed emergency response Supply chain disruption Shortages of essential medicines, blood products, and sterile equipment Increased risk of preventable maternal complications and mortality Referral system breakdown Lack of transport, communication tools, and coordinated referral pathways Delays in reaching higher-level care during obstetric emergencies Insecurity and mobility restrictions Armed violence, checkpoints, and fear of travel Delayed care seeking and missed antenatal and postnatal visits Financial barriers Loss of income and increased cost of transport and services Reduced utilization of facility-based maternal health services In response to disruptions in facility-based care, a range of decentralised maternal health service delivery approaches has been implemented in conflict-affected settings. These approaches emphasise community-level engagement, adaptive service delivery models, and strengthened referral systems to sustain care amid insecurity. The principal decentralised maternal health interventions and their observed effects on service continuity are summarised in Table 2. Table 2. Decentralized Maternal Health Interventions Reported Effective in Conflict and Post-Conflict Settings Intervention type Description Contribution to maternal health service continuity Community health worker programs Local workers supporting antenatal linkage, follow-up, and danger sign recognition Improved early care seeking and continuity Integration of trained traditional birth attendants into formal referral systems Training and linking TBAs to referral systems Earlier identification of complications Mobile and outreach clinics Service delivery outside fixed facilities Expanded reach to displaced populations Financial protection mechanisms Vouchers or subsidies Increased facility delivery Emergency transport systems Community-supported transport Reduced delays in emergencies Basic digital tools Phone-based communication Improved coordination The continuity of maternal health services during conflict is strongly influenced by system-level conditions, including governance capacity, equitable resource allocation, information flows, and workforce availability. Linking maternal health interventions to these broader structural conditions enables a clearer understanding of why certain strategies remain operational under conditions of instability. Accordingly, maternal health actions identified in this review were mapped onto the pillars of the Positive Peace framework, as illustrated in Table 3. Table 3. Mapping Maternal Health Interventions to Positive Peace Pillars for Wartime Sudan Positive Peace pillar Enabling role Maternal health actions Equitable distribution of resources Targets highest-need populations Mobile clinics, subsidies Well-functioning government Ensures coordination Minimum service packages Free flow of information Supports timely care Community messaging High levels of human capital Improves quality Midwife upskilling Low levels of corruption Protects supplies Transparent tracking Sound business environment Enables last-mile delivery Local partnerships Good relations with neighbors Supports cross-border care Referral coordination Acceptance of the rights of others Promotes safe care Respectful maternity care Maternal health service coverage varies substantially across stable, pre-conflict, and active conflict settings. Differences in skilled birth attendance, antenatal care coverage, and facility-based delivery offer important insights into the extent of service disruption associated with armed conflict. A comparative overview of key maternal health service indicators across varying stability and conflict contexts is presented in Table 4. Table 4. Comparative Maternal Health Service Indicators in Conflict-Affected and Stable Settings (Illustrative Synthesis) Context Skilled birth attendance (%) Antenatal care ≥1 visit (%) Facility-based delivery (%) Maternal service continuity trend Stable/post-conflict settings 80–95 85–95 75–90 Maintained Pre-conflict Sudan 60–65 70–75 55–60 Moderate Wartime Sudan 30–45 40–55 25–40 Severely disrupted Other active conflict settings 35–50 45–60 30–45 Partially sustained Note: Percentages represent approximate ranges synthesized from WHO, World Bank, UNICEF, and UNFPA reports, and are presented to illustrate comparative trends rather than exact estimates. 5. Discussion The findings demonstrate that maternal health service continuity during armed conflict is shaped by systemic and institutional conditions in addition to clinical capacity. Disruptions observed in wartime Sudan reflect not only shortages in infrastructure and the health workforce but also weaknesses in coordination, information flow, and equitable resource distribution. These systemic constraints fragment the maternal care continuum and increase the risk of preventable maternal morbidity and mortality. Applying the Positive Peace framework clarifies how governance quality, equity, and information flow enable feasible maternal health interventions under conditions of insecurity. Interventions that rely on decentralised delivery platforms, protected referral pathways, and community level engagement demonstrate greater resilience than facility dependent models. Evidence from fragile and conflict affected settings indicates that everyday resilience at the frontline level plays a critical role in sustaining health services despite systemic stress and resource constraints (Gilson et al., 2017). This supports the finding that continuity of care improves when service delivery models adapt to instability rather than depend on fixed infrastructure. The novelty of this analysis lies in translating the Positive Peace framework into implementable maternal health system actions for an active conflict context. By linking peacebuilding pillars to concrete service delivery strategies, the framework provides a practical planning tool for policymakers and humanitarian actors seeking to sustain maternal health services during conflict while supporting longer term system resilience. Comparative development indicators further illustrate the broader impact of conflict on health service coverage and system performance in fragile settings (World Bank, 2023). The ongoing conflict has further reduced access to antenatal care, skilled birth attendance, and emergency obstetric services across large parts of the country, reinforcing the scale of maternal health service disruption observed in Sudan (United Nations Population Fund, 2023; United Nations Children’s Fund, 2023). 6. Recommendations These recommendations are directly derived from the thematic findings of the review and reflect interventions identified as feasible under conditions of active conflict. • Scale mobile and outreach maternal health services to reach rural, remote, and displaced populations and reduce reliance on damaged fixed facilities. • Integrate trained traditional birth attendants into formal referral systems with clear escalation pathways to improve early identification of complications. • Strengthen community health worker programs to support antenatal linkage, follow up, and recognition of maternal danger signs at the community level. • Protect emergency referral and transport pathways through community managed and partner supported mechanisms to reduce delays during obstetric emergencies. • Implement targeted financial protection mechanisms to reduce cost barriers and improve utilization of maternal health services. • Improve coordination and information flow between health authorities, humanitarian actors, and communities through shared planning mechanisms and clear communication protocols. 7. Limitations This study relies on secondary data and illustrative synthesis drawn from published literature and institutional reports. As a narrative review, causal attribution between interventions and maternal health outcomes is not possible. In addition, variability in data quality and reporting across conflict affected settings limits direct comparability of service indicators. Despite these limitations, the synthesis provides useful insights to inform feasible maternal health system actions under conditions of active conflict. 8. Conclusion Sustaining maternal health service continuity during armed conflict in Sudan requires approaches that extend beyond emergency clinical care and short term humanitarian responses. The findings of this review demonstrate that continuity of maternal health services is fundamentally shaped by governance quality, equitable resource distribution, information flow, and community trust, in addition to the availability of clinical capacity. These systemic conditions determine whether maternal health interventions remain functional under conditions of insecurity or become fragmented and inaccessible. Applying the Positive Peace framework provides a structured lens for understanding how maternal health strategies interact with broader social and institutional conditions during conflict. Decentralised service delivery models, protected referral and transport systems, integration of community based providers, targeted financial protection mechanisms, and strengthened coordination between governmental and humanitarian actors emerge as feasible and coherent actions for sustaining maternal health services in wartime settings. By aligning maternal health interventions with the pillars of Positive Peace, this approach supports both immediate continuity of care and longer term health system resilience. In the context of protracted conflict in Sudan, such alignment offers a practical pathway for safeguarding maternal health while contributing to post conflict recovery and rebuilding of the health system. Declarations Ethics approval and consent to participate Not applicable. This study is a narrative review based exclusively on secondary data from published literature and institutional reports. No human participants were involved. Consent for publication Not applicable. Availability of data and materials All data used in this study are derived from publicly available published sources cited in the reference list. Competing interests The author declares no competing financial, professional, or personal interests related to this work. Funding The author received no specific funding for this study. Authors’ contributions The author conceived the study, conducted the literature review, synthesized the findings, and drafted the manuscript. Author Information Mona Suliman Department of Information Technology University of Science and Technology, Omdurman, Sudan Corresponding author: Mona Awad Ahmed Suliman Email: [email protected] References Blanchet, K., Nam, S. L., Ramalingam, B., and Pozo Martin, F. (2017). Governance and capacity to manage resilience of health systems, towards a new conceptual framework. Social Science and Medicine, 195, 96–104. https://doi.org/10.1016/j.socscimed.2017.11.005 Bashour, H., Abdulsalam, A., Jabr, A., Cheikha, S. A., and Fouad, F. M. (2018). Maternal health services in fragile and conflict affected settings, a systematic review. Reproductive Health, 15, Article 44. https://doi.org/10.1186/s12978-018-0482-5 Devkota, B., van Teijlingen, E., and Simkhada, P. (2018). Maternal health in conflict settings, a systematic review. Conflict and Health, 12, Article 27. https://doi.org/10.1186/s13031-018-0168-7 Gilson, L., Barasa, E., Nxumalo, N., Cleary, S., Goudge, J., Molyneux, S., and Lehmann, U. (2017). Everyday resilience in district health systems, emerging insights from the front lines in Kenya and South Africa. Health Policy and Planning, 32(3), iii59–iii70. https://doi.org/10.1093/heapol/czw098 Institute for Economics and Peace. (2023). Positive peace framework. Institute for Economics and Peace. https://www.economicsandpeace.org International Federation of Red Cross and Red Crescent Societies. (2023). Maternal health initiatives in conflict affected settings. IFRC. https://www.ifrc.org Kruk, M. E., Myers, M., Varpilah, S. T., and Dahn, B. T. (2015). What is a resilient health system, lessons from Ebola. BMJ, 351, h3497. https://doi.org/10.1136/bmj.h3497 United Nations Children’s Fund. (2023). Maternal health in conflict settings. UNICEF. https://www.unicef.org United Nations Population Fund. (2023). Sudan, maternal health statistics and challenges. UNFPA. https://www.unfpa.org World Bank. (2023). World development indicators. World Bank. https://www.worldbank.org World Health Organization. (2023). Maternal mortality. World Health Organization. https://www.who.int Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8669759","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":580692667,"identity":"9ee6bef8-8699-426b-b7af-594a5559d9e9","order_by":0,"name":"Mona Suliman","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYBADxgYG5oYDQIYciHfgAXFaGMFajMFaEojVAmIkgkl8WnTbew9++NlmJzt/RmLjoRs1d9Lnhx1+CLTFTk63AbsWszPnkiV725KNN9xIbDicc+xZ7sbbaQZALcnGZgdwaLmRYyDBu405cYMESAvb4dyNsxNAWg4kbsOtxfjn3231iUCHAbX8O5xuODv9AyEtZtK82w4nNoAcltt2OEFeOoeALWfOmFnL/jtuvOHMQ6CWvsOGG6RzCg4kGODxy/Ee45tvzlTLzm9PPvw559thefnZ6Zs/fKiwk8OlBRMYgFUaEKscBOQbSFE9CkbBKBgFIwEAABUHcLdtwcIMAAAAAElFTkSuQmCC","orcid":"","institution":"University of Science and Technology Omdurman","correspondingAuthor":true,"prefix":"","firstName":"Mona","middleName":"","lastName":"Suliman","suffix":""}],"badges":[],"createdAt":"2026-01-22 12:38:50","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8669759/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8669759/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101468256,"identity":"32cb992a-9d57-4acb-9597-4c6b0bc1144a","added_by":"auto","created_at":"2026-01-30 04:24:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":765389,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8669759/v1/e918fd62-b1ad-4049-9d22-8431e53168a0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Strengthening Maternal Health Service Continuity in Wartime Sudan Through a Positive Peace Framework","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eArmed conflict poses a severe threat to the functioning of health systems and disproportionately affects women\u0026rsquo;s access to essential maternal health services. Effective maternal health care depends on the availability of skilled health workers, functional facilities, reliable supply chains, and coordinated referral systems that support continuity of care across pregnancy, childbirth, and the postnatal period. When these system components operate effectively, the majority of obstetric complications are preventable, and maternal mortality remains low.\u003c/p\u003e\n\u003cp\u003eIn conflict affected settings, health systems experience widespread disruption as a result of damaged infrastructure, displacement or loss of skilled health workers, shortages of essential medicines and equipment, and breakdown of referral and transport systems. These disruptions reduce access to antenatal care, skilled birth attendance, and emergency obstetric services, transforming preventable complications into life threatening conditions and interrupting continuity of maternal care. Weak governance and limited system coordination further constrain the ability of health systems to absorb shocks and sustain service delivery during periods of instability (Blanchet et al., 2017). Health system resilience therefore plays a critical role in maintaining essential services during crises, particularly in fragile and conflict affected contexts (Kruk et al., 2015).\u003c/p\u003e\n\u003cp\u003eSudan exemplifies these challenges. Even prior to the current conflict, maternal mortality levels in Sudan exceeded global averages, reflecting longstanding gaps in health system coverage, equity, and quality of care. The escalation of armed conflict has further weakened maternal health service delivery through closure or partial functioning of health facilities, severe shortages of skilled personnel, disrupted supply chains, and insecurity limiting population mobility. Women face increased financial barriers, fear of travel, and uncertainty regarding service availability, leading to delayed care seeking and fragmented maternal care pathways.\u003c/p\u003e\n\u003cp\u003eHumanitarian health responses remain essential for addressing immediate life saving needs during emergencies. However, many interventions prioritise short term clinical responses and isolated episodes of care, with limited attention to sustaining maternal health services across the full continuum of pregnancy, childbirth, and the postnatal period. Without system level coordination, equitable resource allocation, and reliable information flow, maternal health services remain vulnerable to interruption and fragmentation, particularly in protracted conflict settings.\u003c/p\u003e\n\u003cp\u003eAddressing maternal health during armed conflict therefore requires approaches that extend beyond emergency clinical care and engage with the broader structural conditions shaping service delivery. This study applies the Positive Peace framework to examine how governance, equity, information flow, and human capital influence maternal health service access and continuity during wartime Sudan. By linking maternal health interventions to these system level conditions, the framework provides a structured basis for identifying feasible strMaternal mortality refers to the death of a woman during pregnancy, childbirth, or within forty two days after the termination of pregnancy due to causes related to or aggravated by pregnancy or its management (World Health Organization, 2023). Most maternal deaths remain preventable through timely access to quality antenatal care, skilled birth attendance, functional referral systems, and effective emergency obstetric services.\u003c/p\u003e\n\u003cp\u003eIn fragile and conflict affected settings, maternal health outcomes are strongly influenced by three interrelated delays, namely delay in seeking care, delay in reaching care, and delay in receiving appropriate care. Armed conflict intensifies all three delays simultaneously by disrupting service availability, restricting population mobility, and weakening referral and communication systems. As a result, these delays overlap and reinforce one another, leading to severe disruptions in maternal health service continuity across pregnancy, childbirth, and the postnatal period (Bashour et al., 2018; Devkota et al., 2018).\u003c/p\u003e\n\u003cp\u003eThe Positive Peace framework conceptualises peace as the presence of social systems and institutions that enable human wellbeing rather than merely the absence of violence. The framework comprises eight pillars, including equitable distribution of resources, well functioning government, free flow of information, high levels of human capital, low levels of corruption, a sound business environment, good relations with neighbours, and acceptance of the rights of others (Institute for Economics and Peace, 2023).\u003c/p\u003e\n\u003cp\u003eAddressing maternal health during armed conflict therefore requires approaches that extend beyond emergency clinical care and engage with the broader structural conditions shaping service delivery. This study applies the Positive Peace framework to examine how governance, equity, information flow, and human capital influence maternal health service access and continuity during wartime Sudan. By linking maternal health interventions to these system level conditions, the framework provides a structured basis for identifying feasible strategies that can sustain maternal health services under conditions of insecurity while supporting longer term health system resilience\u003c/p\u003e"},{"header":"2. Background and Conceptual Framework","content":"\u003cp\u003eMaternal mortality is widely recognised as a core indicator of health system performance and social equity. It is defined as the death of a woman during pregnancy, childbirth, or within forty two days following the termination of pregnancy from causes related to or aggravated by pregnancy or its management (World Health Organization, 2023). Despite substantial global progress, the majority of maternal deaths remain preventable when women have timely access to quality antenatal care, skilled birth attendance, functional referral systems, and effective emergency obstetric services. When these components operate as an integrated continuum of care, maternal morbidity and mortality can be substantially reduced.\u003c/p\u003e\n\u003cp\u003eIn fragile and conflict affected settings, this continuum is frequently disrupted by systemic and structural constraints rather than clinical limitations alone. Maternal health outcomes in such contexts are strongly shaped by three interrelated delays, delay in seeking care, delay in reaching care, and delay in receiving appropriate care. Armed conflict intensifies each of these delays simultaneously by undermining service availability, restricting population mobility, increasing insecurity during travel, and weakening referral and communication systems. As a consequence, these delays overlap and reinforce one another, leading to severe disruptions in maternal health service continuity across pregnancy, childbirth, and the postnatal period (Bashour et al., 2018; Devkota et al., 2018).\u003c/p\u003e\n\u003cp\u003eThe situation in Sudan illustrates the cumulative impact of these dynamics. Insecurity, displacement, economic hardship, and uncertainty regarding the functionality of health facilities discourage early care seeking and consistent engagement with maternal health services. Damage to transport infrastructure, fuel shortages, and limited communication capacity delay access to referral facilities during obstetric emergencies. Even when women are able to reach health facilities, shortages of skilled health workers, essential medicines, blood products, and functional equipment constrain the provision of timely and appropriate care. These systemic failures transform otherwise preventable obstetric complications into life threatening events and contribute to fragmented maternal care pathways.\u003c/p\u003e\n\u003cp\u003eAddressing maternal health service continuity under such conditions requires analytical approaches that extend beyond emergency clinical responses and isolated service delivery interventions. The Positive Peace framework conceptualises peace as the presence of social systems and institutions that enable human wellbeing rather than solely the absence of violence. It comprises eight interdependent pillars, equitable distribution of resources, well functioning government, free flow of information, high levels of human capital, low levels of corruption, a sound business environment, good relations with neighbours, and acceptance of the rights of others (Institute for Economics and Peace, 2023). Together, these pillars describe the structural conditions that support stability, trust, and effective service delivery within societies.\u003c/p\u003e\n\u003cp\u003eWithin this study, the Positive Peace framework is applied as an analytical lens to examine how these structural conditions shape access to and continuity of maternal health services during armed conflict. Each pillar reflects system level factors influencing service availability, coordination among actors, information sharing, and community trust in health systems. Linking maternal health interventions to these pillars enables a clearer understanding of why certain service delivery strategies remain feasible under conditions of insecurity while others fail.\u003c/p\u003e\n\u003cp\u003eBy situating maternal health within this broader systems oriented framework, the analysis moves beyond a narrow focus on clinical capacity to consider governance, equity, information flow, and human capital as central determinants of service continuity. This approach provides a structured basis for identifying maternal health strategies that can sustain essential services during active conflict while also contributing to longer term health system resilience and recovery in post conflict settings\u003c/p\u003e"},{"header":"3. Methods","content":"\u003cp\u003e\u003cstrong\u003e3.1 Study design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adopts a structured narrative review to synthesise evidence on maternal health service delivery in conflict affected and post conflict settings. This design is well suited to examining complex health system challenges where outcomes are shaped by governance arrangements, service organisation, and contextual constraints, and where quantitative synthesis is limited. The approach allows integration of diverse forms of evidence and supports the development of implementation relevant insights.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Data sources and search strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePeer reviewed journal articles and institutional reports published between 2010 and 2024 were examined. Sources were identified from global health and public health journals, as well as publications produced by international organisations engaged in maternal health, humanitarian response, peacebuilding, and health system strengthening. The search strategy applied predefined keyword combinations, including maternal health, maternal mortality, skilled birth attendance, antenatal care, emergency obstetric care, armed conflict, fragile settings, Sudan, health systems, peacebuilding, and Positive Peace.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Inclusion and exclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSources were included if they examined maternal health service delivery in conflict affected or post conflict contexts and reported barriers, enabling conditions, or interventions with clear relevance to service delivery and continuity of care. Publications based solely on opinion without implementation detail, sources lacking identifiable contextual information, and studies not directly related to maternal health service delivery were excluded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Data synthesis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIncluded sources were analysed thematically. Evidence was synthesised into key themes reflecting service delivery barriers, enabling system conditions, and maternal health intervention strategies. Identified interventions were subsequently mapped to the pillars of the Positive Peace framework to assess their feasibility and relevance for sustaining maternal health service continuity during active conflict in Sudan.\u003c/p\u003e"},{"header":"4. Results","content":"\u003cp\u003eThis section outlines the main structural and contextual factors that undermine access to and continuity of maternal health services during armed conflict in Sudan. Damage to health facilities, loss of skilled personnel, disruption of supply chains, and insecurity affecting population movement collectively weaken the maternal care pathway and increase the risk of delayed or inadequate care. The principal conflict related barriers and their implications for maternal health service continuity are summarised in \u003cstrong\u003eTable 1\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Conflict-Related Barriers Affecting Maternal Health Service Access and Continuity in Sudan\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarrier category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImplications for maternal health services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eHealth facility damage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eDestruction or partial closure of hospitals and maternity units\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eReduced availability of antenatal care, delivery services, and emergency obstetric care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eHealth workforce displacement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eMigration, injury, or death of skilled health workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eReduced skilled birth attendance and delayed emergency response\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eSupply chain disruption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eShortages of essential medicines, blood products, and sterile equipment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eIncreased risk of preventable maternal complications and mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eReferral system breakdown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eLack of transport, communication tools, and coordinated referral pathways\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eDelays in reaching higher-level care during obstetric emergencies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eInsecurity and mobility restrictions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eArmed violence, checkpoints, and fear of travel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eDelayed care seeking and missed antenatal and postnatal visits\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eFinancial barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eLoss of income and increased cost of transport and services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eReduced utilization of facility-based maternal health services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eIn response to disruptions in facility-based care, a range of decentralised maternal health service delivery approaches has been implemented in conflict-affected settings. These approaches emphasise community-level engagement, adaptive service delivery models, and strengthened referral systems to sustain care amid insecurity. The principal decentralised maternal health interventions and their observed effects on service continuity are summarised in \u003cstrong\u003eTable 2.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Decentralized Maternal Health Interventions Reported Effective in Conflict and Post-Conflict Settings\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContribution to maternal health service continuity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eCommunity health worker programs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eLocal workers supporting antenatal linkage, follow-up, and danger sign recognition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eImproved early care seeking and continuity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eIntegration of trained traditional birth attendants into formal referral systems\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eTraining and linking TBAs to referral systems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eEarlier identification of complications\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eMobile and outreach clinics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eService delivery outside fixed facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eExpanded reach to displaced populations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eFinancial protection mechanisms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eVouchers or subsidies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eIncreased facility delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eEmergency transport systems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eCommunity-supported transport\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eReduced delays in emergencies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eBasic digital tools\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003ePhone-based communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eImproved coordination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eThe continuity of maternal health services during conflict is strongly influenced by system-level conditions, including governance capacity, equitable resource allocation, information flows, and workforce availability. Linking maternal health interventions to these broader structural conditions enables a clearer understanding of why certain strategies remain operational under conditions of instability. Accordingly, maternal health actions identified in this review were mapped onto the pillars of the Positive Peace framework, as illustrated in \u003cstrong\u003eTable 3.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Mapping Maternal Health Interventions to Positive Peace Pillars for Wartime Sudan\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive Peace pillar\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnabling role\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal health actions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eEquitable distribution of resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eTargets highest-need populations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eMobile clinics, subsidies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eWell-functioning government\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eEnsures coordination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eMinimum service packages\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eFree flow of information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eSupports timely care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eCommunity messaging\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eHigh levels of human capital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eImproves quality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eMidwife upskilling\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eLow levels of corruption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eProtects supplies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eTransparent tracking\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eSound business environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eEnables last-mile delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eLocal partnerships\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eGood relations with neighbors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eSupports cross-border care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eReferral coordination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eAcceptance of the rights of others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003ePromotes safe care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eRespectful maternity care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eMaternal health service coverage varies substantially across stable, pre-conflict, and active conflict settings. Differences in skilled birth attendance, antenatal care coverage, and facility-based delivery offer important insights into the extent of service disruption associated with armed conflict. A comparative overview of key maternal health service indicators across varying stability and conflict contexts is presented in Table 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Comparative Maternal Health Service Indicators in Conflict-Affected and Stable Settings (Illustrative Synthesis)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContext\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSkilled birth attendance (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntenatal care \u0026ge;1 visit (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacility-based delivery (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal service continuity trend\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eStable/post-conflict settings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e80\u0026ndash;95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e85\u0026ndash;95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e75\u0026ndash;90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eMaintained\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003ePre-conflict Sudan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e60\u0026ndash;65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e70\u0026ndash;75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e55\u0026ndash;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eWartime Sudan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e30\u0026ndash;45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e40\u0026ndash;55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e25\u0026ndash;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eSeverely disrupted\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003eOther active conflict settings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e35\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e45\u0026ndash;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003e30\u0026ndash;45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20%;\"\u003e\n \u003cp\u003ePartially sustained\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e Percentages represent approximate ranges synthesized from WHO, World Bank, UNICEF, and UNFPA reports, and are presented to illustrate comparative trends rather than exact estimates.\u003c/p\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eThe findings demonstrate that maternal health service continuity during armed conflict is shaped by systemic and institutional conditions in addition to clinical capacity. Disruptions observed in wartime Sudan reflect not only shortages in infrastructure and the health workforce but also weaknesses in coordination, information flow, and equitable resource distribution. These systemic constraints fragment the maternal care continuum and increase the risk of preventable maternal morbidity and mortality.\u003c/p\u003e\n\u003cp\u003eApplying the Positive Peace framework clarifies how governance quality, equity, and information flow enable feasible maternal health interventions under conditions of insecurity. Interventions that rely on decentralised delivery platforms, protected referral pathways, and community level engagement demonstrate greater resilience than facility dependent models. Evidence from fragile and conflict affected settings indicates that everyday resilience at the frontline level plays a critical role in sustaining health services despite systemic stress and resource constraints (Gilson et al., 2017). This supports the finding that continuity of care improves when service delivery models adapt to instability rather than depend on fixed infrastructure.\u003c/p\u003e\n\u003cp\u003eThe novelty of this analysis lies in translating the Positive Peace framework into implementable maternal health system actions for an active conflict context. By linking peacebuilding pillars to concrete service delivery strategies, the framework provides a practical planning tool for policymakers and humanitarian actors seeking to sustain maternal health services during conflict while supporting longer term system resilience. Comparative development indicators further illustrate the broader impact of conflict on health service coverage and system performance in fragile settings (World Bank, 2023).\u003c/p\u003e\n\u003cp\u003eThe ongoing conflict has further reduced access to antenatal care, skilled birth attendance, and emergency obstetric services across large parts of the country, reinforcing the scale of maternal health service disruption observed in Sudan (United Nations Population Fund, 2023; United Nations Children\u0026rsquo;s Fund, 2023).\u003c/p\u003e"},{"header":"6. Recommendations","content":"\u003cp\u003eThese recommendations are directly derived from the thematic findings of the review and reflect interventions identified as feasible under conditions of active conflict.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Scale mobile and outreach maternal health services to reach rural, remote, and displaced populations and reduce reliance on damaged fixed facilities.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Integrate trained traditional birth attendants into formal referral systems with clear escalation pathways to improve early identification of complications.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Strengthen community health worker programs to support antenatal linkage, follow up, and recognition of maternal danger signs at the community level.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Protect emergency referral and transport pathways through community managed and partner supported mechanisms to reduce delays during obstetric emergencies.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Implement targeted financial protection mechanisms to reduce cost barriers and improve utilization of maternal health services.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Improve coordination and information flow between health authorities, humanitarian actors, and communities through shared planning mechanisms and clear communication protocols.\u003c/p\u003e"},{"header":"7. Limitations","content":"\u003cp\u003eThis study relies on secondary data and illustrative synthesis drawn from published literature and institutional reports. As a narrative review, causal attribution between interventions and maternal health outcomes is not possible. In addition, variability in data quality and reporting across conflict affected settings limits direct comparability of service indicators. Despite these limitations, the synthesis provides useful insights to inform feasible maternal health system actions under conditions of active conflict.\u003c/p\u003e"},{"header":"8. Conclusion","content":"\u003cp\u003eSustaining maternal health service continuity during armed conflict in Sudan requires approaches that extend beyond emergency clinical care and short term humanitarian responses. The findings of this review demonstrate that continuity of maternal health services is fundamentally shaped by governance quality, equitable resource distribution, information flow, and community trust, in addition to the availability of clinical capacity. These systemic conditions determine whether maternal health interventions remain functional under conditions of insecurity or become fragmented and inaccessible.\u003c/p\u003e\n\u003cp\u003eApplying the Positive Peace framework provides a structured lens for understanding how maternal health strategies interact with broader social and institutional conditions during conflict. Decentralised service delivery models, protected referral and transport systems, integration of community based providers, targeted financial protection mechanisms, and strengthened coordination between governmental and humanitarian actors emerge as feasible and coherent actions for sustaining maternal health services in wartime settings.\u003c/p\u003e\n\u003cp\u003eBy aligning maternal health interventions with the pillars of Positive Peace, this approach supports both immediate continuity of care and longer term health system resilience. In the context of protracted conflict in Sudan, such alignment offers a practical pathway for safeguarding maternal health while contributing to post conflict recovery and rebuilding of the health system.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This study is a narrative review based exclusively on secondary data from published literature and institutional reports. No human participants were involved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data used in this study are derived from publicly available published sources cited in the reference list.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares no competing financial, professional, or personal interests related to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author received no specific funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author conceived the study, conducted the literature review, synthesized the findings, and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMona \u0026nbsp;Suliman\u003c/p\u003e\n\u003cp\u003eDepartment of Information Technology\u003c/p\u003e\n\u003cp\u003eUniversity of Science and Technology, Omdurman, Sudan\u003c/p\u003e\n\u003cp\u003eCorresponding author:\u003c/p\u003e\n\u003cp\u003eMona Awad Ahmed Suliman\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBlanchet, K., Nam, S. L., Ramalingam, B., and Pozo Martin, F. (2017). Governance and capacity to manage resilience of health systems, towards a new conceptual framework. Social Science and Medicine, 195, 96\u0026ndash;104. https://doi.org/10.1016/j.socscimed.2017.11.005 \u003c/li\u003e\n\u003cli\u003eBashour, H., Abdulsalam, A., Jabr, A., Cheikha, S. A., and Fouad, F. M. (2018). Maternal health services in fragile and conflict affected settings, a systematic review. Reproductive Health, 15, Article 44. https://doi.org/10.1186/s12978-018-0482-5 \u003c/li\u003e\n\u003cli\u003eDevkota, B., van Teijlingen, E., and Simkhada, P. (2018). Maternal health in conflict settings, a systematic review. Conflict and Health, 12, Article 27. https://doi.org/10.1186/s13031-018-0168-7 \u003c/li\u003e\n\u003cli\u003eGilson, L., Barasa, E., Nxumalo, N., Cleary, S., Goudge, J., Molyneux, S., and Lehmann, U. (2017). Everyday resilience in district health systems, emerging insights from the front lines in Kenya and South Africa. Health Policy and Planning, 32(3), iii59\u0026ndash;iii70. https://doi.org/10.1093/heapol/czw098 \u003c/li\u003e\n\u003cli\u003eInstitute for Economics and Peace. (2023). Positive peace framework. Institute for Economics and Peace. https://www.economicsandpeace.org \u003c/li\u003e\n\u003cli\u003eInternational Federation of Red Cross and Red Crescent Societies. (2023). Maternal health initiatives in conflict affected settings. IFRC. https://www.ifrc.org \u003c/li\u003e\n\u003cli\u003eKruk, M. E., Myers, M., Varpilah, S. T., and Dahn, B. T. (2015). What is a resilient health system, lessons from Ebola. BMJ, 351, h3497. https://doi.org/10.1136/bmj.h3497 \u003c/li\u003e\n\u003cli\u003eUnited Nations Children\u0026rsquo;s Fund. (2023). Maternal health in conflict settings. UNICEF. https://www.unicef.org \u003c/li\u003e\n\u003cli\u003eUnited Nations Population Fund. (2023). Sudan, maternal health statistics and challenges. UNFPA. https://www.unfpa.org \u003c/li\u003e\n\u003cli\u003eWorld Bank. (2023). World development indicators. World Bank. https://www.worldbank.org \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. (2023). Maternal mortality. World Health Organization. https://www.who.int\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Maternal health, armed conflict, Positive Peace, health systems, service continuity, Sudan","lastPublishedDoi":"10.21203/rs.3.rs-8669759/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8669759/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSudan continues to experience severe disruption of maternal health services due to prolonged armed conflict, resulting in reduced availability of antenatal care, skilled birth attendance, and emergency obstetric services. While humanitarian responses address immediate survival needs, they often fail to ensure sustained maternal care across pregnancy, childbirth, and the postnatal period. This paper examines how the Positive Peace framework informs feasible strategies to improve maternal health service access and continuity under wartime conditions in Sudan.\u003c/p\u003e \u003cp\u003eA structured narrative review draws on peer-reviewed literature and institutional reports published between 2010 and 2024, focusing on maternal health service delivery in conflict-affected and post-conflict settings. Evidence is synthesized thematically and mapped onto the pillars of the Positive Peace framework to assess feasibility and relevance for the Sudanese context.\u003c/p\u003e \u003cp\u003eFour themes emerge: disruption of maternal health services under insecurity, demand-side barriers and social constraints affecting care seeking, decentralized service delivery strategies effective in comparable settings, and the role of governance, equity, and information flow in sustaining service delivery. High-feasibility actions include mobile and outreach maternal health services, strengthened referral and emergency transport systems, integration of trained community-based providers, targeted financial protection mechanisms, and improved coordination between government and humanitarian actors.\u003c/p\u003e \u003cp\u003eThe findings indicate that improving maternal health during armed conflict requires approaches extending beyond emergency clinical care. Applying the Positive Peace framework supports alignment between maternal health interventions and broader social and institutional conditions necessary for sustained service delivery, offering a practical pathway to strengthen maternal health systems during conflict while supporting long-term resilience.\u003c/p\u003e","manuscriptTitle":"Strengthening Maternal Health Service Continuity in Wartime Sudan Through a Positive Peace Framework","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-27 09:16:54","doi":"10.21203/rs.3.rs-8669759/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cebc966a-452c-48b4-b856-03999cf71cc9","owner":[],"postedDate":"January 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-30T04:24:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-27 09:16:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8669759","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8669759","identity":"rs-8669759","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}