Impact of Armed Conflicts on Neonatal Health: A Scoping Review

2.1. Inclusion and Exclusion Criteria

Articles were eligible for inclusion if they reported neonatal health outcomes among neonates (0-28 days old) in conflict-affected settings. Studies involving pregnant women or mothers were eligible when maternal or pregnancy-related factors were reported in relation to, or provided relevant content for, neonatal health outcomes. The review focused on articles published between 2006 and 2025 to capture evidence from a period marked by increasing frequency, intensity, and protracted nature of armed conflicts globally. Since the mid-2000s, armed conflicts and humanitarian crises have escalated substantially, resulting in widespread displacement, destruction of healthcare infrastructure, and growing threats to maternal and neonatal health. Restricting the review to this timeframe ensured the inclusion of literature reflecting contemporary conflict contexts and healthcare challenges.

Eligible literature examined the effects of armed conflict, civil war, armed violence, military attacks, or conflict-related displacement on neonatal health outcomes. A broad range of study designs was considered, including qualitative, quantitative, mixed-methods, descriptive, retrospective, analytical studies, and systematic reviews, provided they were published in English. Articles were excluded if they focused solely on maternal, toddler, or child health outcomes without reporting neonatal outcomes. Articles involving populations not exposed to armed conflict, war, or armed violence were also excluded. In addition, grey literature, editorials, opinion papers, commentaries, conference abstracts, and letters to the editor were not included in this review.

2.2. Literature Search and Shortlisting

A comprehensive electronic search strategy was developed to identify relevant peer-reviewed studies. Searches were conducted in MEDLINE/PubMed, Web of Science, Embase, CABI Global Health, and CINAHL. Google Scholar was also searched to identify additional potentially relevant records. Additional records were identified through manual screening of the reference lists of included articles. The database and supplementary searches were conducted on December 31, 2025. Thus, the review included studies published from January 1, 2006, through December 31, 2025.

Search terms included combinations of keywords and subject headings related to neonatal health and armed conflict, such as neonatal health, newborn, armed conflict, war, civil war, violence, internally displaced persons, and health outcomes. The search strategy was adapted for each database to maximize sensitivity and relevance. All retrieved records were initially exported into reference management software Zotero for duplicate removal. Following removal of duplicates, records underwent a multi-stage screening process conducted independently by two reviewers according to the predefined eligibility criteria. Titles and abstracts were screened for relevance, followed by full-text assessment of potentially eligible records. Articles that met all inclusion criteria were included in the final review. Any disagreements between reviewers were resolved through discussion and consensus. The study selection process was conducted in accordance with PRISMA-ScR guidelines and is presented in Fig. (1).

2.3. Data Extraction

A standardized data extraction form was developed and pilot-tested using a subset of included studies to ensure consistency and comprehensiveness. Extracted data included author(s), publication year, country or setting, study design, study population, type of conflict, neonatal health outcomes, maternal and pregnancy-related factors relevant to neonatal health, and key findings related to the impact of armed conflict on neonatal health. Maternal and pregnancy-related information was extracted when it described conflict exposure, maternal health or healthcare access, psychosocial stress, pregnancy-related factors, or other pathways relevant to neonatal outcomes. Maternal clinical outcomes such as abortion, postpartum hemorrhage, gestational diabetes, eclampsia, and maternal mortality were not treated as separate primary outcomes of this review. Data were extracted independently by two reviewers, and any discrepancies were resolved through discussions and consensus.

2.4. Data Analysis and Synthesis

Extracted data were analyzed using descriptive and thematic synthesis approaches. Descriptive analysis was used to summarize study characteristics, geographical distribution, conflict types, study populations, and reported neonatal health outcomes. For the qualitative synthesis, the key findings and relevant outcome-related information extracted from each included study were reviewed systematically by two reviewers to identify recurring concepts, patterns, and relationships across studies. An inductive thematic analysis approach was used, whereby codes were generated from the findings reported in the included literature rather than being imposed a priori.

The synthesis proceeded iteratively through several stages. First, both reviewers independently reviewed the extracted findings and identified preliminary codes representing recurring neonatal outcomes, conflict-related exposures, contextual factors, and pathways affecting neonatal health. Second, related codes were compared, grouped, and organized into broader categories. Third, categories with conceptual similarities were examined across studies and consolidated into candidate themes and subthemes. The reviewers then independently reviewed the emerging thematic structure against the extracted data to assess whether the themes adequately represented the evidence across the included studies. Differences in coding, categorization, or interpretation were discussed between the reviewers and resolved through discussion and consensus. Through this iterative process, four overarching themes were agreed upon: (1) war-driven neonatal adversity, (2) health system collapse impact, (3) alternative practices-related risks, and (4) stress-associated epigenetic changes. Thematic synthesis was used to integrate findings across the heterogeneous study designs and settings while preserving the contextual characteristics of the evidence.

3.1. Characteristics of the Included Sources

The database and supplementary searches identified 3,383 records, including 3,223 records retrieved from electronic databases and Google Scholar and 160 additional records identified through reference-list screening. Before screening, 1,173 records were removed, including 900 duplicate records and 273 records removed for other reasons, leaving 2,210 records for screening. Following title and abstract screening, 1,344 records were excluded because they were not relevant to the review topic. The remaining 866 records underwent further abstract screening, of which 799 records were excluded. Subsequently, 67 full-text articles were assessed for eligibility, and 38 articles were excluded because they were not related to neonatal health outcomes or were not conducted in an armed conflict context. A total of 29 sources met the inclusion criteria and were included in the final review. The complete study selection process is presented in Fig. (1).

Across the 29 included articles published between 2006 and 2025, evidence was drawn from a wide range of conflict-affected settings spanning the Middle East, Africa, Latin America, Asia and Europe. The literature represented countries and territories including Afghanistan, Colombia, Ethiopia, Iraq, Mexico, Nepal, Nigeria, Palestine/Gaza, the Democratic Republic of Congo, Türkiye, South Sudan, Syria, and Yemen. Most articles focused on low-and middle-income countries experiencing prolonged armed conflict, civil war, political violence, or displacement crises.

The included literature employed diverse methodological approaches, reflecting the complexity of examining neonatal health in humanitarian and conflict settings. These included retrospective and cross-sectional studies, cohort studies, mixed-methods studies, quantitative descriptive analyses, regression analyses, retrospective analyses, qualitative studies, household surveys, case studies, and review articles. Retrospective and cross-sectional approaches were among the most frequently used designs, commonly drawing on hospital records, birth registries, national datasets, and household surveys.

The populations represented across the included literature included newborns, pregnant women, mothers, refugee populations, healthcare professionals, and community members living in conflict settings. The included sources examined a broad range of neonatal health outcomes, including low birth weight, congenital anomalies, preterm birth, neonatal mortality, neonatal intensive care unit admissions, immunization coverage, neonatal infections, neonatal service utilization, and developmental vulnerabilities. Table 1 summarizes the characteristics of the included sources.

3.2. Impact of Armed Conflicts on Neonatal Health

Analysis of the included sources using the iterative thematic synthesis process identified four overarching themes describing the multifaceted impact of armed conflict on neonatal health: (1) War-driven neonatal adversity, (2) Health system collapse impact, (3) Alternative practices-related risks, and (4) Stress-associated epigenetic changes. Across diverse geographical settings, the evidence consistently demonstrated that armed conflict adversely affects neonatal survival, growth, development, and access to essential healthcare services through interconnected biological, environmental, and health system pathways.

3.3. War-Driven Neonatal Adversity

3.4. Health System Collapse Impact

Armed conflict profoundly disrupted healthcare systems and significantly undermined neonatal survival and access to essential maternal and newborn services. Several studies described how prolonged conflict weakened healthcare infrastructure, reduced service availability, and intensified shortages of skilled healthcare personnel.

Studies conducted among Syrian refugee populations in Türkiye reported increased neonatal intensive care unit admissions among refugee newborns, reflecting both increased vulnerability and greater healthcare needs among displaced populations [27]. In northeastern Nigeria, evidence from mixed-methods studies showed severely compromised newborn health indicators before humanitarian interventions were implemented in conflict-affected regions [28]. Similarly, qualitative evidence from Yemen revealed that weakened healthcare systems, destruction of health facilities, and competing public health crises, including cholera outbreaks and severe acute malnutrition, diverted limited healthcare resources away from neonatal care services [29]. In South Sudan, armed violence was associated with substantial declines in facility-based deliveries and neonatal service utilization due to insecurity, poverty, damaged infrastructure, and transportation barriers [30]. Conflict also contributed to shortages of skilled healthcare professionals, increased costs of medical services, and deterioration in the quality of maternal and neonatal care.

Unsafe working conditions for healthcare providers further constrained neonatal service delivery. In the eastern Democratic Republic of Congo, neonatal healthcare providers reported exposure to violence, insecurity, and unsafe travel conditions while commuting to healthcare facilities [31]. These conditions limited workforce capacity and reduced continuity of neonatal care. Despite these challenges, several studies highlighted interventions implemented in humanitarian settings to improve neonatal outcomes. These interventions included neonatal resuscitation, kangaroo mother care, infection prevention strategies, postnatal follow-up, HIV prevention programs, and health worker training initiatives [32]. However, implementation was frequently hindered by ongoing insecurity, population displacement, limited funding, and shortages of trained healthcare personnel.

3.5. Alternative Practices Related Risks

In settings where formal healthcare services were inaccessible or disrupted, families frequently relied on alternative, traditional, or informal neonatal care practices. The available literature suggested that these practices were influenced not only by limited access to formal healthcare but also by sociocultural beliefs, established caregiving traditions, economic constraints, and the need to adapt to crisis conditions. Thus, reliance on non-formal care should be understood within the broader social and cultural context of conflict-affected families rather than solely as a consequence of individual choices or lack of health knowledge.

In South Sudan, qualitative interviews and focus group discussions with healthcare providers and refugee populations identified widespread use of harmful neonatal practices, including herbal infusions for neonatal illness, mixed feeding practices, and application of ash or oil to the umbilical cord [33]. The study also described how newborn care practices were shaped by sociocultural beliefs and prevailing community practices, while financial constraints and limited access to healthcare further influenced families' care-seeking decisions. In the context of displacement and humanitarian crisis, these practices may represent familiar and accessible approaches to newborn care when formal services are perceived as unavailable, unaffordable, difficult to reach, or inappropriate to the family's circumstances. Some practices, however, may increase the risk of neonatal infection or delay timely healthcare-seeking [33].

A systematic review examining maternal and newborn care in conflict settings also identified extensive reliance on untrained birth attendants in countries such as Yemen, Nepal, and Iraq [34]. The review described multiple barriers to formal maternal and newborn care, including geographical, financial, and social constraints, as well as established community practices. It also reported low rates of breastfeeding initiation within the first hour of birth, limited healthcare-seeking behavior, and reduced uptake of neonatal vaccination services. In Nepal and Iraq, breastfeeding initiation rates ranged from 7% to 57%, while many mothers did not seek medical assistance for newborn illnesses or complete recommended immunization schedules [34]. These findings suggest that caregiving practices during conflict are shaped by an interaction between cultural norms, household circumstances, and the availability and accessibility of formal healthcare.

Conflict-related disruption of immunization programs was particularly evident in Iraq, where armed violence contributed to declining neonatal polio immunization coverage and interruptions in routine newborn preventive services [35]. These findings highlight that reliance on alternative or informal care during conflict may reflect a complex combination of cultural beliefs, established practices, resource constraints, and health-system disruption. Interventions should therefore engage communities and understand local caregiving practices while promoting accessible, culturally responsive, evidence-based neonatal care.

3.6. Stress-Associated Epigenetic Changes

Emerging evidence suggests that maternal exposure to chronic stress and trauma during armed conflict may influence neonatal health through biological and epigenetic mechanisms. Studies from the Democratic Republic of Congo provided important insights into the intergenerational effects of conflict-related stress exposure. A study involving 24 mother-newborn dyads examined the relationship between maternal stress exposure during pregnancy and fetal development in a conflict-affected setting [36]. The study reported associations between prenatal maternal stress and alterations in DNA methylation patterns in genes involved in regulation of the hypothalamic-pituitary-adrenal axis, including NR3C1 and CRH, with methylation patterns also associated with birth weight and indicators of fetal stress regulation [36]. However, these findings should be interpreted cautiously, as the observed epigenetic differences cannot be assumed to be attributable exclusively to prenatal stress. Postnatal and perinatal environmental factors, including nutritional status, infection, socioeconomic conditions, and continued exposure to conflict-related adversity, may also influence epigenetic patterns and neonatal outcomes.

Subsequent research conducted in the same setting reported associations between maternal exposure to war trauma and BDNF methylation in mothers and newborns, including samples obtained from maternal blood, placental tissue, and umbilical cord blood [37]. Given the role of BDNF in neurodevelopment and stress regulation, these findings provide preliminary evidence of a possible biological pathway linking maternal conflict-related trauma with fetal and neonatal development. Nevertheless, the available evidence does not establish that the observed methylation changes were caused solely by prenatal stress, particularly because multiple environmental and social exposures may co-occur in conflict-affected populations.

Collectively, the evidence suggests a potential relationship between maternal conflict-related stress and epigenetic alterations during pregnancy, but the extent to which these changes are independently attributable to prenatal stress remains uncertain. The findings therefore represent an emerging biological pathway rather than definitive evidence of causal epigenetic changes from armed conflict. Further longitudinal studies that measure prenatal exposures alongside nutritional, environmental, psychosocial, and postnatal factors are needed to clarify these relationships and determine whether conflict-related epigenetic changes persist beyond the neonatal period.

4.1. Implications for Policy and Practice

The findings of this review underscore the urgent need to prioritize neonatal health within humanitarian response and conflict-recovery frameworks. Strengthening health system resilience in conflict settings is essential to ensure continuity of maternal and newborn healthcare services, improve access to skilled birth attendants, maintain neonatal intensive care capacity, and protect healthcare workers operating in insecure environments. International organizations have emphasized the importance of strengthening both facility-based and community-based newborn care in fragile settings, including improving recognition of neonatal danger signs, expanding access to essential services, and supporting female healthcare professionals working in conflict zones [49].

The World Health Organization further recommends strengthening healthcare delivery systems in conflict-affected countries by improving maternal and newborn care services, expanding surveillance systems, and addressing preventable causes of neonatal mortality [50]. Integrating maternal mental health and psychosocial support into antenatal and postnatal care is equally critical given the emerging evidence linking maternal stress exposure to adverse neonatal and epigenetic outcomes. Expanding evidence-based interventions such as kangaroo mother care, neonatal resuscitation, breastfeeding support, and Helping Babies Survive programs may further improve neonatal survival in resource-constrained humanitarian settings.

Importantly, infant and young child feeding, including the protection, promotion, and support of breastfeeding, should be explicitly incorporated into emergency preparedness and response policies for conflict and other humanitarian emergencies. WHO guidance recognizes breastfeeding and appropriate infant feeding as essential components of emergency response and recommends that national emergency policies and contingency plans include measures to protect and support breastfeeding, minimize unnecessary reliance on breast-milk substitutes, and ensure that health workers are equipped to provide appropriate infant-feeding support during emergencies [51, 52]. In armed-conflict settings, this requires integrating breastfeeding support into maternal and newborn health services, ensuring continued access to skilled breastfeeding counselling, protecting mother-infant proximity where feasible, and incorporating infant-feeding considerations into humanitarian coordination, health-worker training, and emergency supply planning. Such measures are particularly important where displacement, insecurity, disrupted water and sanitation systems, and health-system interruptions may increase the risks associated with inappropriate or unsafe infant feeding.

Future research should prioritize longitudinal and interdisciplinary studies examining the long-term developmental, neurobiological, and epigenetic consequences of prenatal conflict exposure on neonatal and child health outcomes. There is also a need for more robust evidence evaluating context-specific interventions that can effectively strengthen neonatal care in conflict settings. Expanding research in underrepresented conflict-affected regions and improving the inclusion of community-based and displaced populations will further strengthen the global evidence base on neonatal health during armed conflict.

4.2. Strengths and Limitations

This scoping review provides a comprehensive synthesis of the existing evidence on neonatal health in conflict settings using a systematic and transparent methodological approach. The inclusion of diverse methodological designs enabled a broad understanding of both clinical outcomes and contextual factors influencing neonatal health during armed conflict. The review also captured evidence from multiple geographical regions and different forms of armed conflict, including civil wars, military attacks, insurgencies, and displacement crises.

However, several limitations should be acknowledged. As a scoping review, this study aimed to map the breadth of available evidence and did not formally assess the methodological quality or risk of bias of included articles. Nevertheless, several methodological limitations were apparent across the included literature and should be considered when interpreting the findings. A substantial proportion of the studies used retrospective, cross-sectional, or routinely collected health-record data, which may be affected by incomplete documentation, selection bias, and limitations in exposure or outcome measurement. Some studies also relied on self-reported information regarding conflict exposure, maternal experiences, healthcare utilization, or neonatal care practices, which may be subject to recall and reporting bias, particularly among populations experiencing trauma or displacement. In addition, heterogeneity in the measurement of conflict exposure and neonatal outcomes, limited adjustment for potential confounding factors, and relatively small sample sizes in some studies constrained direct comparison across studies and limited causal interpretation. These limitations do not invalidate the observed associations but indicate that the findings should be interpreted as evidence of patterns and potential pathways rather than definitive causal effects of armed conflict on neonatal health. The strength of evidence for specific biological pathways, particularly the emerging epigenetic evidence, should therefore be interpreted cautiously. In particular, the epigenetic studies included in this review did not allow definitive attribution of observed DNA methylation patterns to prenatal conflict-related stress alone. Conflict-affected mothers and newborns may experience multiple overlapping prenatal, perinatal, and postnatal exposures, including malnutrition, infection, poverty, displacement, and continued psychosocial stress, which may independently or jointly influence epigenetic patterns and neonatal outcomes. The extent to which these potential confounding factors were measured or controlled for varied across the available evidence. Therefore, the epigenetic findings should be considered preliminary and associative rather than evidence of a causal effect of prenatal conflict exposure.

Moreover, only English-language articles published between 2006 and 2025 were included, which may have excluded relevant evidence published in other languages or earlier periods. Although the review included 29 sources spanning several countries and territories, the geographical distribution of the evidence remained uneven, with limited representation from some conflict-affected regions. Furthermore, variations in study design, sample size, outcome measures, and healthcare contexts limited direct comparison across articles.

Additionally, although the included studies spanned 2006 to 2025 and represented conflicts of varying duration and intensity, the review was not designed to conduct a formal temporal analysis. Differences in study designs, periods of data collection, conflict characteristics, populations, and outcome measures limited direct comparison of neonatal health impacts across older and more recent conflicts. Consequently, the review could not determine whether the magnitude or nature of neonatal health impacts has changed over time. Evidence from prolonged conflicts suggested that cumulative disruptions to healthcare systems, displacement, food security, and continuity of maternal and neonatal care may compound neonatal vulnerabilities; however, these observations should be interpreted as contextual patterns rather than evidence of a temporal trend. An additional limitation is that neonatal health cannot be considered entirely independent of the intrauterine period. Although some included studies considered maternal or prenatal exposure to armed conflict, the review was primarily structured around neonatal health outcomes and did not systematically examine the continuum from in-utero exposure through pregnancy to extrauterine neonatal health. Consequently, the complex temporal and biological pathways linking prenatal conflict exposure with subsequent neonatal outcomes may not have been fully captured.

Despite these limitations, this scoping review provides important insights into the multifaceted impact of armed conflict on neonatal health and highlights critical areas for policy, practice, and future research.