Florence Nightingale went to the Crimean War in Scutari, Turkey, in 1854 and the founder of the Red Cross, Henri Nunant, went to the Italian war in Solferino in 1859.1 Both initiated the modern practice of nursing and the focus on the special care for victims of war. Traditionally, nursing has a duty to care for patients, including the enemy who is wounded. It is difficult to think of breaking moral codes or principles that are part of international law. Two other principles include human dignity in which every person has the right to life and that the use of military force is regulated.1 There has always been a distinction between civilians and soldiers, in part, because there needs to be someone to care for the wounded and sick. Sadly, or fearfully, the protections provided to healthcare providers are being stripped away and rules of combat have become blurred.

I never thought there would be a war like the scale of Russia and Ukraine in my lifetime. I have watched the news reports and have seen nurses staying in a hospital with newborns in a level 1 or 2 nursery, who said they would not leave. That hospital, clearly marked as one, was bombed by Russian soldiers and demolished. Civilians and nurses, as well as other healthcare professionals, are clearly being targeted. In conflict areas, violence has been seen against medical facilities, medical personnel, the wounded, and medical transports.2 Because of the conflict that occurred about a decade ago in Ciudad Juarez, just across the border from El Paso, Texas, the majority of medical clinics and pharmacies have closed and nursing/medical staff have left the community because of fear.3 Nursing practice changes when nurses are under attack. There are no longer night shifts because care ends after dark, nurses wear masks and cover their name tags with tape to decrease being targeted as a caregiver, uniforms are not worn to decrease the risk of kidnapping, and because of the bombs and bullets, nurses feel hypervigilant and cannot focus on their patients.3 In addition, supplies become low or nonexistent. How do you treat wounded civilians and soldiers when there is no blood, antibiotics, bandages, and clean water? How do you care for the pregnant woman, the woman in labor, a woman with postpartum complications, the newborn, and women in general?

At the beginning of the war, there was news and videos of women and children leaving Eastern Ukraine for the West, Poland, and Germany. Because of haste and fear, there were few belongings taken with them when they boarded trains to safety. The news reported regularly how many millions of Ukrainians, mainly women, were leaving to protect their children. I would consider the migration to be a forced displacement since the population clearly wanted to remain in their homes in their own country. Worldwide, by the end of 2014, there was forceful displacement of 59.5 million people, of which 38.2 million were displaced to another area of their country, 19.5 million became refugees, and 1.8 million looked for asylum in other countries.4 Mirroring what is being seen in Ukraine, about 80% of those displaced are women and children.4 Not discussed in the news reports are the maternal-child health risks associated with forcible displacement.

Not surprisingly, maternal and child health is significantly endangered because of the risk of malnutrition and communicable and waterborne diseases. Women remain the caretakers who care for their ill family members while trying to preserve their own wellness. There is difficulty in locating maternal and child health services and, when available, may not be affordable. There is often a language barrier hindering the woman's ability to communicate her and her child's health problems. The process of childbirth increases maternal mortality by 3 times because of unavailable obstetrical/perinatal health services.4 There is increased neonatal mortality and morbidity as the stress of displacement and anxiety related to migration and resettlement increase intrauterine growth restriction and preterm labor.4

Once the family arrives at a refugee camp, the stressors related to migration may not end. The camps typically do not include the infrastructure for trained birth attendants, medical personnel/supplies, medications, and immunizations.5 It may be difficult to continue to breastfeed because of overcrowding/lack of privacy, availability of free formula, and malnutrition/dehydration. The preparation of free formula may not be prepared aseptically, the water supply may be unsafe, and bottles may not be sterilized. Consuming the formula can result in the neonate developing diarrhea, infection, malnutrition, and waterborne disease. Because of inadequate humanitarian aid, food insecurity may lead to survival sex trafficking, prostitution, increased teenage pregnancies, and increased sexually transmitted diseases.4

Specific issues related to maternal child care have not been discussed in the news because the refugee camps are not set up to deliver reproductive and pediatric healthcare, just the basics for survival. Interventions such as providing women- and children-friendly spaces would decrease the incidence of physical harm, exploitation, and physical harm. Children can be supervised with the opportunities to play and socialize which will help with resilience, mental health, and coping. Psychosocial support services could include follow-up care, social networks, behavioral therapy psychological counseling, and culturally sensitive care.4 Play therapy has been known to decrease psychological stress and fear and increase hope in children.4 Building safe, healthy infrastructures can provide healthy sanitation, bathing areas, cooking spaces, and safe drinking water to promote the health of the woman and her child. Implementing multilayered interventions is crucial to improve maternal-child health, reduce their vulnerabilities, and protect their rights.

But what about the nurses, especially the civilian ones? They put themselves at risk whether in the refugee camps, communities, or the front lines with no training in combat. In the changing face of conflict where nurses are not protected from military aggression, does the Code of Conduct still remain viable? Is there a difference who that patient is or are there new rules when hospitals and healthcare professionals are considered viable targets of the enemy? All nurses pledge to provide care without discrimination based on race, religion, gender, socioeconomic status, and ethnicity. Does the pledge need to be revised in the face of 21st-century conflict? How do we do that and maintain our ethical responsibilities to patients, especially when a non-Western country does not have the same ethical perspective? How do we train perinatal and neonatal nurses for 21st-century combat, given the vulnerabilities of their patients? How would you keep yourself safe and uninjured to continue to provide perinatal-neonatal care and, at the same time, care for adults with serious life-threating injuries sustained in battle? It is likely that nursing and healthcare will no longer receive the security it traditionally has experienced; thus, we need to consider our moral and legal obligations if the Geneva Conventions will no longer be upheld when there is no distinction between combatants and civilians. Who wants to begin the discussion?

-M. Terese Verklan, PhD, CCNS, RNC, FAAN

Professor and Neonatal Clinical Nurse Specialist

University of Texas Medical Branch

Graduate School of Biological Sciences

School of Nursing

Galveston, Texas

References