This study provides, to our best knowledge, unique data on the coverage, scope and practice of antenatal care among Syrian refugees in Lebanon. The results highlight important gaps in services and practice that must be addressed. It contributes to a growing body of literature examining health care delivery–especially antenatal care delivery–to conflict affected populations.
This study finds a relatively high percentage of pregnant women reporting at least one antenatal visit (82.9%), less than percentages for Lebanon (96%) and Syria (88%) prior to the conflict ). This figure may be higher than expected as we did not differentiate whether the visits took place in Syria or Lebanon, where the former provides free care and the latter does not. However, the number of pregnant women reporting adequate antenatal coverage, as defined by the MICS 4 criteria, is still quite low, with only 15.7% reporting four or more visits, and only 26.6% in advanced gestational age achieving four visits. In comparison, 64% of pregnant Syrian women had at least four antenatal visits prior to the conflict  and the WHO reports that in low-income countries, the percentage of women that receive at least four antenatal visits ranges between 56% for rural women to 72% for urban women with an estimated 38% in the least developed countries and 50% worldwide .
This study finds that the percentages of pregnant women with inadequate antenatal coverage is highest among refugee women not registered with UNHCR, and among refugee women living in less secure arrangements and in areas closest to the Syrian border. (At the time of the study, there was an exponential rise in the number of refugees coming into Lebanon and nearly one-third had not been registered with UNHCR. As of January 2015, only 1% of 1.17 million refugees remain unregistered ). Other explanations for the inadequate level of antenatal coverage include difficulty securing transport (particularly for those living in remote locales), shortened clinic hours (one third of the study period took place during Ramadan), lack of trained health personnel, and prohibitive costs . Despite subsidization for health services by UNHCR for two thirds of the sample, cost appears to be a prohibitive factor. Antenatal care services in Syria were quite cheap, and in many cases free , while the cost of Lebanese maternal health is more expensive . With approximately 40% of all referrals to secondary and tertiary care centers being obstetric and gynecological in nature, our study indicates that pregnant women represent a significant burden of incomplete care.
The need for antenatal care is widespread among all refugee women. However, this study shows that older women (aged 35 or above) are especially vulnerable. Pregnant women in this age group had higher percentages living in more insecure living arrangements and had the least frequent percentage of visits to antenatal care services, with most visits happening late in the pregnancy. They were also the women who most frequently were willing but unable to prevent the pregnancy.
While most women are finding it possible to make at least one antenatal visit, less than one third of women are able to receive the standard of care for antenatal coverage, even in their final trimester or later. According to WHO guidelines, services are considered adequate if patients receive at the minimum blood pressure measurement and urine sample and blood sample analyses. These three interventions have been identified as necessary for detecting complications in pregnancy. While not all antenatal care has been clearly shown to limit maternal mortality, screening for pregnancy-induced hypertension, anemia, and infection, in particular, has been shown effective in detecting, treating and preventing conditions that lead to maternal mortality . Immunization (especially tetanus toxoid) is also critical. Maternal and neonatal tetanus constitutes a high proportion of the total tetanus disease burden, mainly from difficulty in accessing immunizations as in the case of population displacement .
Predictably, increased antenatal visits improved the content of care provided to women with those receiving four or more visits having the highest levels of receiving all three interventions at 44.6%. In contrast, 18.8% of those with only one antenatal visit had all three interventions and 30.1% had none. Maternal health education was significantly lacking, especially in the border insecure areas of Bekaa and the North. With less access to health care providers, preventive messaging and early detection of complications will likely be less. Only 8.0% of women had received a tetanus vaccination, an important intervention in refugee conditions. While to our knowledge, there has not been reported tetanus cases, the recent outbreak of polio in northeast Syria and fear of reintroduction in Lebanon  stand as a reminder that immunizations are preferable before outbreaks, not after their arrival.
The antenatal visit should also include an education component on symptoms that portend potential pregnancy complications, and support health practices that can help circumvent poor outcomes for the mother and child. Conflicts are associated with increased food insecurity and marginalization, especially for pregnant women . Maternal malnutrition is associated with increased incidence of fetal loss and adverse birth outcomes for children , with iron deficiency anemia being linked to increased risk for maternal mortality , low birth weight, lowered resistance to infection, and poor cognitive development .
Due to the salubrious benefit of antenatal care coverage and content on antenatal health practices, we found the expected improved antenatal health practices—iron intake, diet high in nutrients and folic acid, and less smoking—among women who had increased access to antenatal care, with the most marked differences involving the intake of iron tablets and diet high in vitamins, minerals, and folic acid between women with and without antenatal care. Smoking, although undesirable due to the deleterious effects on the mother and fetus, is well below smoking levels observed in other Middle Eastern and Northern Africa countries (9.5% vs 28.8%) .
Proximity to the insecure border areas of the Bekaa and North Lebanon and living in more tenuous shelter was associated with less iron and less adequate dietary intake. There was an iron and dietary decline across shelter security, with those in more stable arrangements (able to rent apartments) better than those in hosted settings and shelters and in turn better than those in tents and squatter communities.
Access to family planning, including modern contraception, empowers refugees, particularly women, to make important decisions about their reproductive health. Family planning could prevent up to 30% of the approximately 287,000 global maternal deaths that occur per year by enabling women to delay their first pregnancy and to space pregnancies at safe intervals. If successive children were born three years apart, an additional 1.6 million children under the age of five would survive . The focus on family planning needs for refugee women is critical.
Less than one half the women surveyed desired their current pregnancy—with a clear differential of less preference by increasing age—and nearly three fourths sought to prevent a future pregnancy, suggesting a desire for personal agency in family planning, again with a higher preference in older women. Despite this, our study suggests displacement and forced migration to Lebanon has resulted in less contraception use, especially less use of favored methods (oral contraceptives and IUDs). This finding coupled with an increase in the use of non clinical methods for contraception such as condoms and planning based on menstrual cycle suggest increased difficulty in locating and utilizing effective forms of contraception. A mixed methods study found that barriers to contraceptive use were high cost, transport distance, inadequate number of contraceptives, and unavailability of preferred type of contraceptive . While our study aligns on access challenges with this one—undertaken one year earlier—it is not clear why the two studies differed on preferred contraception use.
Although our study did not explore the reasons for pregnancy or the factors contributing to a majority of undesired pregnancies, there has been a documented increase in the number of child marriages among Syrian refugees in Jordan . Poverty within the family unit, risk of sexual violence, and insecurity all play a role in this practice. Young maternal age is associated with pregnancy complications, low birth weight, preterm labor, and inadequate antenatal care [42-44].
Limitations of this study are those similar to other quantitative non-randomized study designs, namely the inability to make statistical inferences to the population of pregnant Syrian refugee women in Lebanon. It is not possible to quantify the weighted effect of variables with this study: lack of access to antenatal care will likely be highly associated with geographic insecurity and socioeconomic capacity but the study design can only provide descriptive percentages of those interviewed in the study. Also, convenience samples are inherently biased as respondents self-select for inclusion; many of those recruited were already seeking or intent on seeking antenatal care. The studied population is not representative of the entire Syrian pregnant refugee population since participants included were those able to access migrant centers. Also, we were unable to include the Akkar district of North Lebanon, an area of high density refugee settlement. Such insecure areas tend to have higher pockets of poverty, which could also limit access to services. Data on antenatal testing was based on a respondent’s self-report and not able to be independently verified. Based on the responses, the respondents seem knowledgeable about antenatal screening tests. However, if respondents were not fully aware of the types of testing, this could result in under-reporting. Self-reported behaviors are fraught with under-reporting and over-reporting error as respondents may either aim for some benefit (in the case of the former) or state what they think researchers may want to hear (in the case of the latter).
That said, there is value to having some descriptive understanding of the maternal and reproductive health needs of a hard-to-reach but vulnerable population of interest to the humanitarian community.