This comparative epidemiologic study looks at the effect of the Syrian war on neonatal morbidity and medical care in the Akkar region of North Lebanon in 2013, comparing data of the Lebanese neonatal population as gathered by the National Collaborative Perinatal Neonatal Network before 2013 with that of the Syrian refugees in the year 2013. The study was conducted from Jan. 1 through Dec. 31, 2013, at Hopital Notre Dame de la Paix, Kobayat, a major referral center for Syrian refugees. It revealed that Syrian refugee mothers were younger, less educated, and had higher rates of preterm births and infants with congenital malformations compared with Lebanese mothers both in Akkar and on a national scale.
There is a saying in Arabic that means, “When your neighbor is okay, then you’re okay.” The Syrian war started in 2011 and ravaged the whole country. As a result, more than 3 million people fled Syria, and more than 1 million of those people are now living indefinitely in Lebanon (Figure). We looked at the effect of the Syrian war on the morbidity and medical care of neonates in the Akkar region of North Lebanon during the year 2013. We looked at the differences and similarities between the Lebanese neonatal population before 2013 and the Syrian refugees in 2013 to better understand patient care needs and the specific characteristics of this population.
Material and Methods
This is an epidemiologic study that compares the data of the Lebanese neonatal population as gathered by the National Collaborative Perinatal Neonatal Network (NCPNN) (1) before 2013 with that of the Syrian refugees in the year 2013. We studied the activity of maternity and neonatal wards at Hopital Notre Dame de la Paix (HNDP) at Kobayyat Akkar, North Lebanon, from January 1 through December 31, 2013). The HNDP was chosen by the United Nations via the International Medical Corps to be the referral center for the Akkar region and therefore received most of the deliveries and neonatal admissions of Syrian refugees within and close to that area (Table 1). The data were gathered from the digital NCPNN archives for the HNDP and compared with the national mean for the year 2013 in Lebanon (Table 2).
This study found that the Syrian mothers were younger (the youngest being 12 years old) (Table 3), had a lower educational level (Table 4), and had higher rates of preterm births (Table 5) and infants with congenital malformations than Lebanese mothers (Table 6). There were no statistical differences between the 2 groups with regard to obstetric history, although Syrian refugees had a slightly higher percentage of primigravidity (Table 7). There were a few cases of eclampsia, bleeding, anemia, and hydronephrosis, but there were no statistical differences between the 2 groups (Table 8). We also looked at the Apgar scores at 1 and 5 minutes (Table 9), birth weight (Table 10), and need for resuscitation. The Syrian deliveries represented two-thirds of all deliveries in the HNDP for the year 2013, although the mode of delivery was similar between the 2 groups and close to the mean for Lebanon (Table 11). Pregnancies were multiple in a small percentage of Lebanese (1.62%) and a smaller percentage (0.88%) of Syrian mothers.
There were 374 admissions to the neonatology ward in 2013; 232 (62.0%) of them were children of Syrian refugees, whereas 142 (38.0%) were Lebanese children. Most of the infants admitted to the NICU were inborn, and part of the higher percentage of admission of Syrian refugees’ infants is due to the medical care coverage offered by Qatar in the year 2013 and that stopped after August 2014.
The Revised Graduated Prenatal Care Utilization Index is a measure of the adequacy of prenatal care provided to a woman by health care professionals during the prenatal period; it was developed by Alexander and Kotelchuck (2) in 1996 in Manitoba, Canada, and attempts to correlate the number of prenatal visits to pregnancy outcome. (3) In our study, 75 Lebanese mothers (8.7%) compared with 1,055 Syrian mothers (67.0%) had 0 to 1 prenatal visit, whereas 739 Lebanese mothers (85.9%) compared with 412 Syrian mothers (26.2%) had 2 to 3 prenatal visits.
Consanguineous marriages are custom in the Middle Eastern countries, although the Syrian refugee population had a slightly higher percentage of such marriages. Although there is no reason for discrepancies in the incidence of congenital malformations between the 2 groups, we found a slightly higher rate in the Syrian refugee group, which may be explained partially by the higher rate of consanguinity among this group (Table 12). We later discovered that the Syrian refugees considered consanguinity as familial relatedness from the side of the father only; maternal consanguinity did not count. Therefore, the rate of consanguinity must have been higher among this group.
The data concerning the characteristics of Syrian refugees’ neonates in the North Lebanon region of Akkar were compared with those of their Lebanese counterparts in a community hospital in Kobayyat-Akkar through the year 2013. We tried to identify the particularities of Syrian refugee mothers and infants and whether there were differences that could affect their medical care. We noticed that the Syrian refugee mothers were of a younger mean age, were less educated, and had higher rates of preterm births and infants with congenital malformations compared with Lebanese mothers both in Akkar and on a national Lebanese scale. This result can be interpreted in the context of a displaced, impoverished population who fled their country and whose normal life was interrupted. Many of the results of this study, such as the early age at marriage and conception (5 mothers aged <13 years and 28 between 13 and 15 years old) can be a direct consequence of the war because marriage would represent lessening the burden of a girl on her poor family, whereas increased reproduction could represent a survival tool.
Normally, this cannot have a powerful statistical significance because the 2 comparison groups have more similarities than differences. Therefore, birth weight, gestational age, Apgar score, and reason for admission to the NICU were not different between the 2 groups.
The presence of the refugees has stretched to the limits Lebanon’s medical facilities and has put a huge strain on the resources and capacity of the host government and communities. In fact, we had to recruit newly graduated nurses who did not have the necessary experience to deal, physically and psychologically, with the heavy load of patients. On some days, early discharge was so early that the same bed in the maternity ward was used 3 times during a 24-hour period. Of these infants, most were lost to follow-up because the free consultation clinic, allotted for them by the international aid agencies, was outside the area, and all we did was send a discharge summary with every patient.
There is no easy way to deal with such a huge number of displaced, fragile, and vulnerable people, and as usual the weakest chains, namely, the children, women, and elderly people, are those who suffer the most in areas of conflict around the world. Unfortunately, the international aid agencies have a lot of work to do.
Drs Makhoul, Falakha, Naufal Makhoul, and AbdelAhad have disclosed no financial relationships relevant to this article. This commentary does contain a discussion of an unapproved/investigative use of a commercial product/device.
- Copyright © 2015 by the American Academy of Pediatrics