Protracted armed conflict and maternal health: a scoping review of literature and a retrospective analysis of primary data from northwest Syria

Abstract

Introduction: Syria's protracted conflict has devastated the health system reversing progress made on maternal health preconflict. Our aim is to understand the state of maternal health in Syria focused on underage pregnancy and caesarean sections using a scoping review and quantitative analysis; the latter draws on data from the Syrian American Medical Society's (SAMS) maternal health facilities in northwest Syria.

Methods: We performed a scoping review of academic and grey literature on the state of maternal health across Syria since the onset of conflict (taken as March 2011). Identified articles were screened using pre-established criteria and themes identified. We also performed a retrospective quantitative analysis of maternal health data from SAMS' facilities in a microcontext in north-west Syria between March 2017 and July 2020, analysing the trends in the proportion of births by caesarean section and age at pregnancy.

Results: Scoping review: of 2824 articles, 21 remained after screening. Main themes related to maternal mortality rates, caesarean sections, maternal age and perinatal care. 12 studies reported caesarean section rates; these varied from 16% to 64% of all births: northern Syria (19%-45%,) Damascus (16%-54%,) Lattakia (64%) and Tartous (59%.) Quantitative analysis: Of 77 746 births across 17 facilities, trend data for caesarean sections showed a decrease from 35% in March 2017 to 23% in July 2020 across SAMS facilities. Girls under 18 years accounted for 10% of births and had a lower proportion of caesarean section births. There was notable geographical and interfacility variation in the findings.

Conclusion: The quality of available literature was poor with country-level generalisations. Research which explores microcontexts in Syria is important given the different effects of conflict across the country and the fragmented health system. Our quantitative analysis provides some evidence around the changes to caesarean section rates in northwest Syria. Despite limitations, this study adds to sparse literature on this important topic.

Keywords: Maternal health; Obstetrics; Public Health; Surgery.

Figure 1

PRISMA flow chart for included and excluded academic and grey literature papers. DFID, Department For International Development; MHTF, Maternal Health Task Force; MSF, Medecins Sans Frontieres; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SAMS, Syrian American Medical Society’s; UNICEF, United Nations Population Fund; USAID, US Agency for International Development.

Figure 2

(A) This figure shows the total number of consultations (all presentations) per month between March 2017 and July 2020. (B) This figure shows the number of births per month delivered by caesarean sections or vaginal birth. In boxes are two time periods in which there are declines in the numbers of births. (C) This figure shows the caesarean section rates as a percentage of the total births across all SAMS’ health facilities per month between March 2017 and July 2020. SAMS, Syrian American Medical Society’s.

Figure 3

(A) This figure shows the number of facilities open each month from March 2017 to July 2020. (B) This figure shows the monthly caesarean section proportions as a percentage of total births, for each of the five facilities which remained open in March 2020 and were functioning between March 2017 and July 2020. (C) This figure shows the percentage of births by caesarean section on a monthly basis in referral and non-referral hospitals and in BemONC and CEmONC facilities. (D) This figure shows the number of vaginal and caesarean section births in referral and non-referral facilities divided by age group, under 18 and 18 years and over. BemONC, basic emergency obstetric care; CEmONC, comprehensive obstetric care; PHC, primary healthcare centre.

Figure 4

(A) This figure shows the number of births by caesarean section or vaginal birth divided into those aged under 18 years or 18 years and over. (B) This figure shows the percentage of caesarean section births each month in women under 18 compared with women aged 18 years of age or over.