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Impact of Syrian Refugees on NeonatalCare in Hopital Notre Dame de la Paix,Akkar, North LebanonGhaiss Makhoul,* Gaby Falakha,† Carole Naufal Makhoul,‡ Antoun AbdelAhad†

AbstractThis comparative epidemiologic study looks at the effect of the Syrian waron neonatal morbidity and medical care in the Akkar region of North Leb-anon in 2013, comparing data of the Lebanese neonatal population asgathered by the National Collaborative Perinatal Neonatal Network before2013 with that of the Syrian refugees in the year 2013. The study was con-ducted from Jan. 1 through Dec. 31, 2013, at Hopital Notre Dame de laPaix, Kobayat, a major referral center for Syrian refugees. It revealed thatSyrian refugee mothers were younger, less educated, and had higher ratesof preterm births and infants with congenital malformations compared withLebanese mothers both in Akkar and on a national scale.

IntroductionThere is a saying in Arabic that means,“When your neighbor is okay, thenyou’re okay.” The Syrian war startedin 2011 and ravaged the whole coun-try. As a result, more than 3 millionpeople fled Syria, andmore than 1mil-lion of those people are now living in-definitely in Lebanon (Figure). Welooked at the effect of the Syrian waron the morbidity and medical care ofneonates in the Akkar region of NorthLebanon during the year 2013. Welooked at the differences and similari-ties between the Lebanese neonatalpopulation before 2013 and the Syrianrefugees in 2013 to better understandpatient care needs and the specificcharacteristics of this population.

Material and MethodsThis is an epidemiologic study thatcompares the data of the Lebanese

Dr. Falakha

Dr. Makhoul

*Pediatric Department, Hopital Notre Dame de la Paix,

Kobayat, Lebanon.†Pediatric Department, Centre Hospitalier du Nord,

Zgharta, Lebanon.‡Pediatric private practice, Tripoli, Lebanon.

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neonatal population as gathered bythe National Collaborative PerinatalNeonatal Network (NCPNN) (1)before 2013 with that of the Syrianrefugees in the year 2013. We studiedthe activity of maternity and neonatalwards atHopital NotreDame de la Paix(HNDP) at Kobayyat Akkar, North

Lebanon, from January 1 through De-cember 31, 2013). The HNDP waschosen by the United Nations via theInternational Medical Corps to be thereferral center for the Akkar regionand therefore received most of the de-liveries and neonatal admissions ofSyrian refugees within and close to that

area (Table 1). The data were gatheredfrom the digital NCPNN archives forthe HNDP and compared with the na-tional mean for the year 2013 in Leba-non (Table 2).

ResultsThis study found that the Syrianmothers were younger (the youngestbeing 12 years old) (Table 3), hada lower educational level (Table 4),and had higher rates of preterm births(Table 5) and infants with congenitalmalformations than Lebanese mothers(Table 6). There were no statistical dif-ferences between the 2 groups with re-gard to obstetric history, althoughSyrian refugees had a slightly higherpercentage of primigravidity (Table 7).

Figure. Syrian Refugee Response.

Table 1. Patient Referral

Institution ThatReferred Patient

No. (%) of Patients

Lebanese Syrian Refugees HNDP, 2013 HNDP, 2010

NDPH 67 (46.4) 96 (41.5) 169 (45.2) 88 (48.1)Another hospital 24 (16.8) 77 (33.0) 99 (26.5) 48 (26.2)Home 51 (36.8) 59 (25.4) 106 (28.3) 47 (25.7)Total 142 232 374 183

HNDP¼Hopital Notre Dame de la Paix.

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There were a few cases of eclampsia,bleeding, anemia, and hydronephrosis,but there were no statistical differ-ences between the 2 groups (Table 8).We also looked at the Apgar scoresat 1 and 5 minutes (Table 9), birth

weight (Table 10), and need forresuscitation. The Syrian deliveriesrepresented two-thirds of all deliveriesin the HNDP for the year 2013,although the mode of delivery wassimilar between the 2 groups and close

to the mean for Lebanon (Table 11).Pregnancies were multiple in a smallpercentage of Lebanese (1.62%) anda smaller percentage (0.88%) of Syrianmothers.

There were 374 admissions to theneonatology ward in 2013; 232(62.0%) of them were children ofSyrian refugees, whereas 142 (38.0%)were Lebanese children. Most ofthe infants admitted to the NICUwere inborn, and part of the higherpercentage of admission of Syrian ref-ugees’ infants is due to the medicalcare coverage offered by Qatar inthe year 2013 and that stopped afterAugust 2014.

The Revised Graduated PrenatalCare Utilization Index is a measureof the adequacy of prenatal care pro-vided to a woman by health care pro-fessionals during the prenatal period;it was developed by Alexander andKotelchuck (2) in 1996 in Manitoba,Canada, and attempts to correlate thenumber of prenatal visits to preg-nancy outcome. (3) In our study,75 Lebanesemothers (8.7%) comparedwith 1,055 Syrianmothers (67.0%) had0 to 1 prenatal visit, whereas 739 Leb-anese mothers (85.9%) comparedwith 412 Syrian mothers (26.2%)had 2 to 3 prenatal visits.

Consanguineous marriages arecustom in the Middle Eastern coun-tries, although the Syrian refugeepopulation had a slightly higher per-centage of such marriages. Althoughthere is no reason for discrepancies inthe incidence of congenital malfor-mations between the 2 groups, wefound a slightly higher rate in theSyrian refugee group, which maybe explained partially by the higherrate of consanguinity among thisgroup (Table 12). We later discoveredthat the Syrian refugees consideredconsanguinity as familial relatednessfrom the side of the father only; ma-ternal consanguinity did not count.Therefore, the rate of consanguinity

Table 2. Admission Diagnosis and Age ofAdmission

Variable

No. (%) of Patients

LebaneseHNDP Akkar

SyrianRefugees

Mean LebaneseData, 2010

Admission diagnosisRespiratory distress 59 (41.5) 98 (44.5) (38.2)Rule out sepsis 31 (21.8) 39 (16.8) (15.3)Neonatal asphyxia 3 (2.1) 6 (2.6) (2.7)Jaundice 29 (20.4) 36 (15.5) (20.2)Congenital malformation 2 (1.4) 6 (2.6) (3.3)Surgical 3 (2.1) 8 (3.4) (2.7)Bronchiolitis 4 (2.8) 11 (4.7) (5.5)

Age on admission<24 h 77 (55.3) 130 (56.4)1-3 d 27 (19.8) 47 (19.8)3-7 d 15 (11.5) 29 (12.3)7-30 d 17 (8.3) 13 (5.7)>1 mo 6 (5.1) 13 (5.7)

Need for assisted ventilation 49 (34.5) 54 (23.3)Surfactant 23 (15.6) 30 (12.9) (10.0)Bronchopulmonary dysplasia 18 (12.2) 10 (4.4) (4.5)Surgery 3 (2.0) 8 (3.5)

HNDP¼Hopital Notre Dame de la Paix.

Table 3. Maternal Age

No. (%) of Patients

HNDP – Akkar

Maternal Age, y Lebanese Syrian National Mean, %

<13 0 5 (0.3) 013-15 0 28 (1.8) 016-19 74 (20.0) 400 (25.4) 3.620-24 296 (33.3) 514 (32.5) 19.725-29 286 (25.0) 323 (20.6) 29.230-34 135 (13.6) 196 (12.5) 21.935-39 57 (5.2) 70 (4.5) 16.740-44 10 (1.8) 3 (2.2)>45 2 (0.25) 4 (0.25)Total 860 1574

HNDP¼Hopital Notre Dame de la Paix.

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must have been higher among thisgroup.

DiscussionThe data concerning the characteris-tics of Syrian refugees’ neonates inthe North Lebanon region of Akkarwere compared with those of theirLebanese counterparts in a communityhospital in Kobayyat-Akkar throughthe year 2013. We tried to identifythe particularities of Syrian refugeemothers and infants and whether therewere differences that could affect theirmedical care. We noticed that theSyrian refugeemothers were of a youn-ger mean age, were less educated, andhad higher rates of preterm births andinfants with congenital malformationscompared with Lebanese mothersboth in Akkar and on a national Leb-anese scale. This result can be inter-preted in the context of a displaced,impoverished population who fledtheir country and whose normal lifewas interrupted. Many of the resultsof this study, such as the early age atmarriage and conception (5 mothersaged <13 years and 28 between 13and 15 years old) can be a direct con-sequence of the war because marriagewould represent lessening the burdenof a girl on her poor family, whereasincreased reproduction could repre-sent a survival tool.

Normally, this cannot have a pow-erful statistical significance becausethe 2 comparison groups have moresimilarities than differences. There-fore, birth weight, gestational age,Apgar score, and reason for admissionto the NICU were not different be-tween the 2 groups.

The presence of the refugees hasstretched to the limits Lebanon’s med-ical facilities and has put a huge strainon the resources and capacity of thehost government and communities.In fact, we had to recruit newly grad-uated nurses who did not have thenecessary experience to deal, physically

Table 4. Maternal Educational Level

Educational Level

No. (%) of PatientsLebaneseNationalMean, %Lebanese (HNDP) Syrian Refugees

Illiterate 45 (5.2) 98 (6.2) 1.8Primary 270 (31.4) 994 (63.1) 12.5Complementary 325 (37.8) 366 (23.3) 20.9Secondary 98 (11.4) 77 (4.9) NATechnical 48 (5.6) 24 (1.5) 25.5College 74 (8.6) 15 (0.95) 26.5

HNDP¼Hopital Notre Dame de la Paix; NA¼not applicable.

Table 5. Gestational Age of Neonates

GestationalAge

No. (%) of PatientsLebaneseNationalMean, %Lebanese

SyrianRefugees

HNDP,2013

HNDP,2010

£27 wk 7 (5.4) 4 (1.3) 11 (2.9) 4 (2.1) 1.628-30 wk 10 (7.5) 11 (4.4) 21 (5.6) 15 (8.1) 5.631-33 wk 9 (6.8) 22 (9.2) 31 (8.3) 20 (10.9) 6.434-37wk 13 (9.5) 28 (11.9) 41 (11.0) 24 (13.1) 18.4Term 95 (65.3) 156

(67.2)251(67.1)

110(60.1)

54.0

0-1 mo 8 (5.5) 11 (4.7) 19 (5.01) 10 (5.5)Total 142 232 374 183

HNDP¼Hopital Notre Dame de la Paix.

Table 6. Congenital Malformations

Type

No. (%) of Congenital Malformations

Lebanese Syrian Refugees

Multiple congenital anomalies 1 9Spina bifida 2 1Cleft palate 1 2Digestive tube anomalies 2 6Ichthyosis 2 1Polydactyly 1 1Hypospadias 3 0Anencephaly or anophthalmia 1 4Trisomy 21 0 2Osteogenesis imperfecta 0 2Cardiac malformation 0 4Total 13 (1.5) 32 (2.03)

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and psychologically, with the heavyload of patients. On some days,early discharge was so early thatthe same bed in the maternity wardwas used 3 times during a 24-hour

period. Of these infants, most werelost to follow-up because the freeconsultation clinic, allotted for themby the international aid agencies,was outside the area, and all we did

was send a discharge summary withevery patient.

There is no easy way to deal withsuch a huge number of displaced, frag-ile, and vulnerable people, and as usual

Table 7. Patient Gravidity

Gravidity

No. (%) of Patients

Lebanese (HNDP) Syrian Refugees

Primigravida 129 (15.0) 346 (22.0)Gravida 2 243 (28.3) 419 (26.6)Gravida 3 184 (21.4) 303 (19.2)Gravida 4 (7.0) 336 (1.3)Gravida 5 120 (14.0) 120 (7.6)Missing data 38 (4.0) 50 (3.12)

HNDP¼Hopital Notre Dame de la Paix.

Table 8. Patient Adverse Effects

Adverse Effect

No. (%) of Patients

Lebanese (HNDP) Syrian Refugees

Eclampsia 2 (0.23) 4 (0.25)Diabetes 1 (0.11) 1 (0.06)Anemia 3 (0.34) 27 (1.7)Bleeding 1 (0.11) 1 (0.06)Hydronephrosis 2 (0.23) 1 (0.06)Total 9 34

HNDP¼Hopital Notre Dame de la Paix.

Table 9. Apgar Scores

Apgar Score

No. (%) of PatientsLebanese National Mean

Lebanese Syrian Refugees

1 Minute 5 Minutes 1 Minute 5 Minute 1 Minute 5 Minutes

£3 16 (1.89) 14 (1.6) 22 (1.4) 20 (1.3)4-7 60 (7.0) 49 (5.7) 87 (5.5) 48 (3.0)8-10 784 (91.2) 797 (92.7) 1465 (93.1) 1506 (95.7)Total No. 860 860 1574 1574Mean 8.63/10 8.69/10 8.71/10 8.80/10 8.51 9.63

Table 10. Birth Weight

Weight, kgLebanesebabies

SyrianRefugees

1-1.5 9 (1.0) 15 (1.0)1.5-2 21 (2.4) 36 (2.3)2-2.5 72 (8.4) 167 (10.6)2.5-3 262 (30.5) 536 (34.0)3-3.5 345 (40.1) 584 (37.1%)3.5-4 130 (15.1) 191 (12.1)>4 16 (1.9) 38 (2.4)Mean 3.04 3.00

Table 11. Mode of Delivery

Mode ofDelivery

No. ofDeliveriesat theHNDP

No. (%) of DeliveriesNationalMean forLebanon, %Lebanese Syrian

Normalvaginal

1640 580(67.3)

1060(67.3)

68.9

Cesareansection

794 280(32.7)

514(32.6)

31.1

Totaldeliveries

2434 860(35.0)

1574(65.0)

HNDP¼Hopital Notre Dame de la Paix.

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the weakest chains, namely, the chil-dren, women, and elderly people,are those who suffer the most in

areas of conflict around the world.Unfortunately, the international aidagencies have a lot of work to do.

References1. National Collaborative Perinatal NeonatalNetwork (NCPNN). http://www.ncpnn.org/users/index.asp2. Alexander GR, Kotelchuck M. Quantify-ing the adequacy of prenatal care: a compar-ison of indices. Public Health Rep. 1996;111(5):408–4183. Tayebi T, Hamzehgardeshi Z, AhmadShirvani M, Dayhimi M, Danesh M. Re-lationship between Revised GraduatedIndex (R-GINDEX) of prenatal care uti-lization and preterm labor and low birthweight. Glob J Health Sci. 2014;6(3):131–137

Table 12. Consanguineous Births

Consanguineous

No. (%) of Consanguineous Births

Lebanese (HNDP) Syrian Refugees

Yes 205 (23.8) 534 (33.9)No 535 (62.2) 810 (51.5)Missing data 120 (14.0) 230 (14.6)

HNDP¼Hopital Notre Dame de la Paix.

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DOI: 10.1542/neo.16-8-e4562015;16;e456NeoReviews 

Ghaiss Makhoul, Gaby Falakha, Carole Naufal Makhoul and Antoun AbdelAhadHopital Notre Dame de la Paix, Akkar, North Lebanon

International Perspectives: Impact of Syrian Refugees on Neonatal Care in

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