{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,17]],"date-time":"2026-10-17T07:41:10Z","timestamp":1792222870391,"version":"4.4.0"},"reference-count":32,"publisher":"BMJ","issue":"12","license":[{"start":{"date-parts":[[2023,12,30]],"date-time":"2023-12-30T00:00:00Z","timestamp":1703894400000},"content-version":"unspecified","delay-in-days":29,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000066","name":"National Institute of Environmental Health Sciences","doi-asserted-by":"publisher","award":["R01ES031657"],"award-info":[{"award-number":["R01ES031657"]}],"id":[{"id":"10.13039\/100000066","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2023,11,29]]},"published-print":{"date-parts":[[2023,12]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Armed conflict worldwide and across history has harmed the health of populations directly and indirectly, including generations beyond those immediately exposed to violence. The 2020 war between Armenia and Azerbaijan over Nagorno-Karabakh, inhabited by an ethnically Armenian population, provides an example of how conflict harmed health during COVID-19. We hypothesised that crises exposure would correspond to decreased healthcare utilisation rates and worse health outcomes for the maternal and infant population in Armenia, compounded during the pandemic.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Following a mixed-methods approach, we used ecological data from 1980 to 2020 to evaluate health trends in conflict, measured as battle-related deaths (BRDs), COVID-19 cases, and maternal and infant health indicators during periods of conflict and peace in Armenia. We also interviewed 10 key informants about unmet needs, maternal health-seeking behaviours and priorities during the war, collecting recommendations to mitigate the effects of future crisis on maternal and infant health. We followed a deductive coding approach to analyse transcripts and harvest themes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>BRDs totalled more in the 2020 war compared with the previous Nagorno-Karabakh conflicts. Periods of active conflict between 1988\u20132020 were associated with increased rates of sick newborn mortality, neonatal mortality and pre-eclampsia or eclampsia. Weekly average COVID-19 cases increased sevenfold during the 2020 Nagorno-Karabakh war. Key informants expressed concerns about the effects of stress and grief on maternal health and pregnancy outcomes and recommended investing in healthcare system reform. Participants also stressed the synergistic effects of the war and COVID-19, noting healthcare capacity concerns and the importance of a strong primary care system.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Maternal and infant health measures showed adverse trends during the 2020 Nagorno-Karabakh war, potentially amplified by the concurrent COVID-19 pandemic. To mitigate effects of future crises on population health in Armenia, informants recommended investments in healthcare system reform focused on primary care and health promotion.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2023-076171","type":"journal-article","created":{"date-parts":[[2023,12,30]],"date-time":"2023-12-30T08:51:05Z","timestamp":1703926265000},"page":"e076171","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":11,"title":["Effects of armed conflict on maternal and infant health: a mixed-methods study of Armenia and the 2020 Nagorno-Karabakh war"],"prefix":"10.1136","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7127-7806","authenticated-orcid":false,"given":"Lara","family":"Rostomian","sequence":"first","affiliation":[{"name":"Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA"},{"name":"Wayne State University School of Medicine, Detroit, Michigan, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Araz","family":"Chiloyan","sequence":"additional","affiliation":[{"name":"Ministry of Health of the Republic of Armenia, Yerevan, Armenia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth","family":"Hentschel","sequence":"additional","affiliation":[{"name":"Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carmen","family":"Messerlian","sequence":"additional","affiliation":[{"name":"Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA"},{"name":"Department of Obstetrics and Gynecology, Massachusetts General Hospital Vincent Center for Reproductive Biology, Boston, Massachusetts, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2023,12,30]]},"reference":[{"key":"2025121600485136000_13.12.e076171.1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.324.7333.346"},{"key":"2025121600485136000_13.12.e076171.2","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1177\/1403494821993732","article-title":"The COVID-19 pandemic and war","volume":"50","author":"Gugushvili","year":"2022","journal-title":"Scand J Public Health"},{"key":"2025121600485136000_13.12.e076171.3","doi-asserted-by":"publisher","DOI":"10.1136\/jech-2020-216370"},{"key":"2025121600485136000_13.12.e076171.4","first-page":"221","article-title":"The implications of the Armenian Genocide on contemporary Armenian-Turkish relations","volume":"31","author":"Sulakian","year":"2022","journal-title":"Review of Law and Social Justice"},{"key":"2025121600485136000_13.12.e076171.5","doi-asserted-by":"crossref","DOI":"10.1186\/s40985-018-0102-y","article-title":"Assessing trauma in a transcultural context: challenges in mental health care with immigrants and refugees","volume":"39","author":"Wylie","year":"2018","journal-title":"Public Health Rev"},{"key":"2025121600485136000_13.12.e076171.6","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1080\/10926771.2015.1121191","article-title":"100 years of trauma: the Armenian Genocide and Intergenerational cultural trauma","volume":"25","author":"Mangassarian","year":"2016","journal-title":"J Aggres Maltreat Trauma"},{"key":"2025121600485136000_13.12.e076171.7","doi-asserted-by":"crossref","unstructured":"Hk A . Direct ancestry to a genocide survivor has Transgenerational effects on mental health; a case of the Armenian population. MOJPH 2018;7. doi:10.15406\/mojph.2018.07.00235 Available: https:\/\/medcraveonline.com\/MOJPH\/volume_issues?issueId=2313&volumeId=547","DOI":"10.15406\/mojph.2018.07.00235"},{"key":"2025121600485136000_13.12.e076171.8","doi-asserted-by":"crossref","unstructured":"Levy BS , Sidel VW . War and public health (2nd ed). Oxford University Press, 2008. doi:10.1093\/acprof:oso\/9780195311181.001.0001","DOI":"10.1093\/acprof:oso\/9780195311181.001.0001"},{"key":"2025121600485136000_13.12.e076171.9","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1146\/annurev-publhealth-032315-021913","article-title":"Documenting the effects of armed conflict on population health","volume":"37","author":"Levy","year":"2016","journal-title":"Annu Rev Public Health"},{"key":"2025121600485136000_13.12.e076171.10","unstructured":"Benjamin D . War and public health. Healthy Generations 2007;7."},{"key":"2025121600485136000_13.12.e076171.11","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2017-000302","article-title":"Reproductive, maternal, neonatal and child health in conflict: a case study on Syria using Countdown indicators","volume":"2","author":"DeJong","year":"2017","journal-title":"BMJ Glob Health"},{"key":"2025121600485136000_13.12.e076171.12","unstructured":"Hellerstedt W . Reproductive health and war. Healthy Generations 2007;7."},{"key":"2025121600485136000_13.12.e076171.13","doi-asserted-by":"crossref","DOI":"10.1186\/s13031-019-0220-2","article-title":"Maternal and child access to care and intensity of conflict in the occupied Palestinian territory: a pseudo longitudinal analysis (2000-2014)","volume":"13","author":"Leone","year":"2019","journal-title":"Confl Health"},{"key":"2025121600485136000_13.12.e076171.14","doi-asserted-by":"crossref","DOI":"10.2307\/2648255","article-title":"Reproductive health of war-affected populations: what do we know","volume":"26","author":"McGinn","year":"2000","journal-title":"Int Family Plan Perspect"},{"key":"2025121600485136000_13.12.e076171.15","article-title":"The effect of armed conflict on the utilization of maternal health services in Uganda: A population-based study","volume":"9","author":"Namasivayam","year":"2017","journal-title":"PLoS Curr"},{"key":"2025121600485136000_13.12.e076171.16","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1080\/09688080.2017.1378532","article-title":"Perspectives of displaced Syrian women and service providers on fertility behaviour and available services in West Bekaa, Lebanon","volume":"25","author":"Kabakian-Khasholian","year":"2017","journal-title":"Reprod Health Matters"},{"key":"2025121600485136000_13.12.e076171.17","doi-asserted-by":"crossref","DOI":"10.1093\/pubmed\/fdaa036","article-title":"Armed conflict and public health: into the 21st century (vol 42, PG E287, 2020)","volume":"43","author":"Checchi","year":"2021","journal-title":"J Public Health (Oxf)"},{"key":"2025121600485136000_13.12.e076171.18","doi-asserted-by":"publisher","DOI":"10.1097\/MLR.0b013e31817a835d"},{"key":"2025121600485136000_13.12.e076171.19","unstructured":"American Public Health Association . The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War. APHA. 2009. Available: www.apha.org\/policies-and-advocacy\/public-health-policy-statements\/policy-database\/2014\/07\/22\/13\/29\/the-role-of-public-health-practitioners-academics-and-advocates-in-relation-to-armed-conflict"},{"key":"2025121600485136000_13.12.e076171.20","unstructured":"UCDP Dataset download center, Available: https:\/\/ucdp.uu.se\/downloads\/"},{"key":"2025121600485136000_13.12.e076171.21","unstructured":"National Institute of health Armenia . Health and Healthcare Statistical Yearbook. Available: https:\/\/nih.am\/am\/publications\/report_yearbook_guide\/1"},{"key":"2025121600485136000_13.12.e076171.22","unstructured":"National Center for Disease Control Armenia . Coronavirus Disease, Available: https:\/\/ncdc.am\/coronavirus\/confirmed-cases-by-days\/"},{"key":"2025121600485136000_13.12.e076171.23","doi-asserted-by":"crossref","DOI":"10.1186\/s12874-016-0242-z","article-title":"Comparing two sampling methods to engage hard-to-reach communities in research priority setting","volume":"16","author":"Valerio","year":"2016","journal-title":"BMC Med Res Methodol"},{"key":"2025121600485136000_13.12.e076171.24","doi-asserted-by":"crossref","DOI":"10.1007\/s11113-023-09790-2","article-title":"The casualties of war: an excess mortality estimate of lives lost in the 2020 Nagorno-Karabakh conflict","volume":"42","author":"Karlinsky","year":"2023","journal-title":"Popul Res Policy Rev"},{"key":"2025121600485136000_13.12.e076171.25","unstructured":"Tsaturyan S , Scarpetti G . Health Systems in Action: Armenia. WHO Europe. 2022."},{"key":"2025121600485136000_13.12.e076171.26","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2022-009173","article-title":"Impact of war on the dynamics of COVID-19 in Ukraine","volume":"7","author":"Chumachenko","year":"2022","journal-title":"BMJ Glob Health"},{"key":"2025121600485136000_13.12.e076171.27","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-016-3685-6","article-title":"The effect of war on infant mortality in the Democratic Republic of Congo","volume":"16","author":"Lindskog","year":"2016","journal-title":"BMC Public Health"},{"key":"2025121600485136000_13.12.e076171.28","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1003810","article-title":"Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000-2019","volume":"18","author":"Jawad","year":"2021","journal-title":"PLoS Med"},{"key":"2025121600485136000_13.12.e076171.29","doi-asserted-by":"crossref","DOI":"10.1186\/s12884-018-2158-6","article-title":"Factors contributing to rapidly increasing rates of cesarean section in Armenia: a partially mixed concurrent quantitative-qualitative equal status study","volume":"19","author":"Tadevosyan","year":"2019","journal-title":"BMC Pregnancy Childbirth"},{"key":"2025121600485136000_13.12.e076171.30","doi-asserted-by":"crossref","DOI":"10.1016\/j.ajog.2013.07.003","article-title":"The combined Association of Psychosocial stress and chronic hypertension with Preeclampsia","volume":"209","author":"Yu","year":"2013","journal-title":"Am J Obstet Gynecol"},{"key":"2025121600485136000_13.12.e076171.31","unstructured":"UNHCR . Armenia situation emergency response. UNHCR comprehensive overview of response to emergencies. 2023. Available: https:\/\/www.unhcr.org\/am\/wp-content\/uploads\/sites\/123\/2023\/09\/ARM_Sit_Update_20230930v2.pdf"},{"key":"2025121600485136000_13.12.e076171.32","unstructured":"American Public Health Association . Policy statement Lb2: meeting the health and Psychosocial needs and ensuring the human rights of refugees from Nagorno-Karabakh. 2023."}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2023-076171","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T08:49:08Z","timestamp":1765874948000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2023-076171"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,12]]},"references-count":32,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2023,12,30]]},"published-print":{"date-parts":[[2023,12]]}},"alternative-id":["10.1136\/bmjopen-2023-076171"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2023-076171","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,12]]}}}