Keywords
Syrian Refugees - immigrants - obstetric outcomes - neonatal outcomes - antenatal
care
Introduction
People moving out of their country due to restriction or danger to their lives are
vulnerable. Syrian refugees are citizens of Syria who have fled their country since
the onset of the Syrian civil war, in 2011. Because of its geographical location and
politics, Turkey has been the first choice of Syrian asylum seekers.[1] International temporary protection was an urgently granted temporary status decided
on by the Council of Turkish Ministers when this massive migratory movement occurred.
Temporary protection regulations were enacted on October 22, 2014. According to these
regulations, healthcare must be given to Syrian asylum seekers in their province of
residence in Turkey.[2]
There are currently 2,973,980 registered Syrian refugees in Turkey; 23.6% of them
are females over 18 years of age.[3] The proportion of Syrian refugees among the population in Ankara is 1.32%.[2] One objective of the Healthy People 2020 Project is to increase the proportion of
pregnant women who receive early and adequate prenatal care.[4] Pregnant refugee women face multiple and complex systematic obstacles to perinatal
care, such as language and cultural barriers, lack of resources, difficulty navigating
a complex system and diverse migratory experience and legal status.[5] Timely care of pregnant refugees can decrease their vulnerability. The goal of prenatal
care for all pregnant refugees is the provision of qualified obstetrical care, which
contributes to a safe birth and favorable outcomes for both the mother and child.
Without this, obstetric complications may occur, which require lengthy recovery times,
such that female refugees may face lasting physical, psychological, and economic consequences.
In Turkey, Syrian refugees have free access to primary and secondary healthcare facilities
in public hospitals. Of all women giving birth at our Tertiary Care Maternity Hospital
in 2015, 3.2% were refugees; they were at higher risk for certain adverse obstetric
outcomes.
The aim of this study was to analyze and compare obstetric and neonatal outcomes between
Syrian refugees and ethnic Turkish women giving birth at a maternity clinic in Ankara,
Turkey.
Methods
This was a retrospective cohort study performed between January 2015 and December
2015 at Zekai Tahir Burak Woman's Health, Education and Research Hospital, a tertiary
government maternity training hospital located in Ankara, the capital city of Turkey.
The study protocol was approved by the institutional review board of the hospital
(No. 30/2015, December 2015). During this study period, the first ethnic Turkish women
to give birth after each Syrian refugee woman (using the protocol number) who delivered
at our hospital were enrolled in this study. The primary outcomes were pregnancy outcomes
and cesarean rates between the groups. Maternal age, body mass index (BMI), obstetric
history, education level, number of antenatal follow-ups, hemoglobin and hematocrit
levels, clinical findings, and obstetric and neonatal outcomes were obtained from
medical records. Data on maternal age, rate of adolescent pregnancy, weight gain during
pregnancy (WGPD), weight gain per week, educational level, number of antenatal follow-ups,
route of delivery, primary Cesarean section (C-section) rate, induction of labor,
meconium-stained amniotic fluid, amount of red cell transfusion, and obstetric complications
(including preterm delivery, postterm pregnancy (> 41 weeks gestational age), preeclampsia,
stillbirth, macrosomia (birth weight > 4,000 g), premature rupture of membranes (PROM),
preterm premature rupture of membranes (PPROM), and postpartum hemorrhage were obtained
through medical chart review. Hematocrit and hemoglobin levels were evaluated at admission
for delivery. Education level was classified according to the number of years spent
at primary and secondary school, high school and university (1: uneducated, 2: 0 to
8 years, 3: > 8 years). Neonatal outcomes, including birth weight, small for gestational
age (SGA), low birth weight (< 2,500 g) and height, head circumference, fetal gender,
first and fifth minute Apgar scores, and neonatal intensive care unit (NICU) admission
were also obtained from medical records. Type of delivery was noted as vaginal or
Cesarean. Indications for Cesarean delivery included previous history of C-section,
fetal distress, cephalopelvic disproportion, breech presentation, and others.
The estimation of gestational age was based on the last menstrual period and fetal
crown-rump-length on the basis of ultrasound performed between 11 and 14 weeks of
gestation. BMI was defined as pre-pregnancy weight in kilograms divided by height
in meters squared and categorized three group as BMI < 19, 19 to 25, and > 25. Weight
gain during pregnancy is defined as the amount of weight gained between before conception
and just before the birth of the infant. Weight gain per week calculated as WGDP divided
(g) gestational week at birth. Preterm delivery was defined as delivery before 37
completed gestational weeks,[6] and PROM referred to rupture of membranes before the onset of uterine contractions;
PPROM referred to PROM before 37 weeks of gestation.[7] Preeclampsia was described as new-onset hypertension (> 140/90 mm Hg) after 20 weeks
of gestation in a previously normotensive woman, accompanied by proteinuria (> 300
mg/24 hour).[8] Small for gestational age was defined as infants with a birth weight below the 10th percentile for gestational age.[9] Stillbirth was described as a baby born with no sign of life at or after 28 weeks'
gestation, according to the World Health Organization (WHO) criteria.[10] All of the subjects underwent a two-step gestational diabetes mellitus (GDM) screening
between 24 and 28 weeks of gestation. A positive 50-g glucose challenge test (GCT)
is defined as a glucose level one hour after glucose challenge of at least 140 mg/dl.
Women who had a positive 50-g GCT were advised to follow a normal diet 3 days before
the 100-g oral glucose tolerance test (OGTT). Gestational diabetes mellitus was diagnosed
if there were two or more abnormal values with a 100 g OGTT performed according to
the criteria identified by Carpenter and Coustan.[11] The double test at first trimester (using ultrasound measurement of nuchal translucency,
pregnancy-associated plasma protein A, and human chorionic gonadotrophin [hCG]) and
triple test at second trimester (using α-fetoprotein, hCG, and uE3) were conducted
to identify whether their fetus has an aneuploidy.[12] Emergency birth was defined as a birth that occurs accidentally or precipitously
in the hospital without standard obstetric preparation and procedures. Neonatal death
was defined as death occurring within the first 27 completed days of life.
Statistical analyses were performed using the SPSS software ver. 17.0 (SPSS Inc.,
Chicago, IL, USA). Means and standard deviations (SDs) were calculated for continuous
variables. Subject characteristics and demographics were analyzed descriptively. The
normality of the distribution of the variables was analyzed by the Kolmogorov-Smirnov
test. The Student t-test, the Mann-Whitney U test, and the χ2 test or Fisher exact test were used to evaluate associations between categorical
and continuous variables. Odds ratios and 95% confidence intervals (CIs) for preterm
birth, PPROM, and low birthweight were calculated by a logistic regression model.
Two-sided p-values were considered statistically significant at p < 0.05.
Primary outcome of this study is to compare the obstetric outcomes of two groups.
The assumption to estimate the sample size was based on Preterm delivery (< 37 weeks).
After sorting through the patient files the primary data was yielded and power analysis
conducted for the calculation of the sample size. Sample sizes of 576 and 576 for
each group were detected, with a 98.6% power at a significance level (α) of 0.05.
Results
There were 17,704 births at Zekai Tahir Burak Woman's Health, Education and Research
Hospital during the study period. Of these, 3.2% of the mothers were Syrian refugees.
In total, 576 Syrian refugees and 576 pregnant ethnic Turkish women were included
in this study. Thus, in total, the births of 1,152 women were analyzed. Demographic
and medical characteristics of the patients are shown in [Table 1]. Mean age, gestational age at delivery, WGPD, and weight gain per week were all
significantly lower in the refugee group (p < 0.001). Body mass index > 25 kg/m2 was more common in the refugee group than in the control group (412 (82%) versus
436 (75%); p = 0.006). The proportions of adolescent pregnancies aged 12 to 19 years, and pregnancies < 18
years were significantly higher among the Syrian refugees (p < 0.001). The mean gravidity of the Syrian refugees was significantly higher than
that of the Turkish women (p < 0.001). Parity > 3 in the refugee group was more common than in the control group
(130 [22%] versus 48 [8%]; p < 0.001). Hemoglobin and hematocrit levels were significantly lower in the Syrian
refugees than in the Turkish women (p < 0.001). The proportion of uneducated women was significantly higher in the refugee
group (p < 0.001). There were no statistically significant differences between groups in terms
of the rates of abortion or dilatation and curettage (D&C) (p > 0.05).
Table 1
Demographics and medical history
|
Variables
|
Refugee Group
|
Control groups
|
p-value
|
|
(n = 576)
|
(n = 576)
|
|
|
Age (years) median (min–max)
|
23 (14–44)
|
27 (16–44)
|
< 0.001[*]
|
|
Adolescent pregnancy (< 21 years) (n/%)
|
183 (31%)
|
54 (10%)
|
< 0.001[*]
|
|
Pregnancy with < 19 years (n/%)
|
57 (%10)
|
5 (1%)
|
< 0.001[*]
|
|
Gravida (mean ± SD)
|
2.92 ± 2(1–15)
|
2.27 ± 1.3 (1–9)
|
< 0.001[*]
|
|
Parity (n/%)
|
|
|
< 0.001[*]
|
|
Nullipara
|
200 (34%)
|
233 (40%)
|
|
|
1
|
246 (42%)
|
295 (51%)
|
|
|
≥ 2
|
130 (22%)[*]
|
48 (8%)[*]
|
|
|
Previous abortion median (min–max)
|
0 (0–5)
|
0 (0–7)
|
0.288
|
|
Previous D&C median (min–max)
|
0 (0–4)
|
0 (0–5)
|
0.114
|
|
Maternal BMI n (%)
|
|
|
0.006[*]
|
|
< 19
|
8 (1.4%)
|
4 (0.8%)
|
|
|
19–25
|
132 (23%)[*]
|
83 (16%)
|
|
|
> 25
|
436 (75%)
|
412 (82%)[*]
|
|
|
Gestational age(weeks) (mean ± SD)
|
37.49 ± 2.05
|
38.14 ± 1.78
|
< 0.001[*]
|
|
WGDP (kg) (mean ± SD)
|
9.33 ± 4.28
|
11.87 ± 4.59
|
< 0.001[*]
|
|
Weight gain per week (g)
|
25.29 ± 11.6
|
31.06 ± 11.7
|
< 0.001[*]
|
|
Education level (n/%)
|
|
|
< 0.001[*]
|
|
1
|
308 (53%)[*]
|
11 (1.9%)[*]
|
|
|
2
|
133 (23%)[*]
|
432 (75%)[*]
|
|
|
3
|
51 (8.9%)[*]
|
20 (3.5%)[*]
|
|
|
Maternal systemic disease (n/%)
|
17 (3%)
|
17 (3)
|
1
|
|
Hb levels (mg/dl) median (min–max)
|
11.7 (6.1–15)
|
12 (7.7–14.7)
|
< 0.001[*]
|
|
Anemia (Hb < 12 mg/dl) (n/%)
|
332 (57%)
|
197 (39%)
|
< 0.001[*]
|
|
Hematocrit median (min–max)
|
35 (22–45)
|
36 (24–45)
|
< 0.001[*]
|
Abbreviations: BMI, body mass index; D&C, dilatation and curettage; Hb, hemoglobin;
SD, standard deviation; WDGP, weight gain during pregnancy.
Education level = 1: uneducated, 2: 0–12 years, 3: >12 years; Maternal systemic disease
included diabetes and hypertension.
*
p < 0.05, significant.
A comparison of antenatal parameters is shown in [Table 2]. The rates of antenatal follow-up, double test, triple test, gestational diabetes
mellitus screening test and iron replacement therapy were significantly lower in the
refugee group (p < 0.001).
Table 2
Antenatal parameters
|
Variable n (%)
|
Refugee group
|
Control groups
|
p-value
|
|
(n = 576)
|
(n = 576)
|
|
|
Antenatal follow-up
|
137 (23%)
|
497 (86%)
|
< 0.001[*]
|
|
Double test
|
92 (16)
|
465 (80%)
|
< 0.001[*]
|
|
Triple test
|
92 (16)
|
470 (81%)
|
< 0.001[*]
|
|
GDM screening test
|
88 (15%)
|
464 (80%)
|
< 0.001[*]
|
|
Antenatal iron supplementation
|
301 (52%)
|
450 (78%)
|
< 0.001 [*]
|
Abbreviation: GDM, Gestational diabetes mellitus.
*
p < 0.05, significant.
[Tables 3] and [4] summarize the obstetric and neonatal outcomes of the Syrian women. There was no
statistically significant difference between the groups in terms of delivery type,
indications for C-section, amount of red cell transfusion, number of congenital abnormalities,
postterm pregnancy, stillbirth, preeclampsia, PROM, SGA, NICU admission, neonatal
death, or fetal gender (p > 0.05). Emergency births, the requirement for labor induction using oxytocin, and
meconium-stained amnions were more common in the refugee group (p < 0.001). The primary C-section rate was significantly lower in the refugee group
(p = 0.034). Pregnancies in the refugee group were more complicated, with higher rates
of preterm delivery (< 37 weeks), PPROM, and low birth weight (< 2,500 g) versus the
control group (p < 0.001, p = 0.011, and p < 0.001, respectively). Macrosomia (birth weight > 4,000 g) was more common in the
control group (p = 0.03). Birth weight, height, and head circumference were lower in the refugee group
(p < 0.001). Rate of newborn Apgar scores < 7 at 1 and 5 minutes were significantly
higher in the refugee group (p < 0.001).
Table 3
Obstetric outcomes
|
Variable n (%)
|
Refugee group
|
Control groups
|
p-value
|
|
(n = 576)
|
(n = 576)
|
|
|
Emergency birth
|
121 (21%)
|
23 (4%)
|
< 0.001[*]
|
|
Mode of delivery
|
|
|
0.084
|
|
Vaginal birth
|
391 (67%)
|
355 (51%)
|
|
|
C-Section
|
185 (32%)
|
221 (38%)
|
|
|
Primary C-section rate
|
94 (16%)
|
107 (21%)
|
0.034[*]
|
|
Indications of C-section
|
|
|
0.068
|
|
Previous C-section
|
91 (15%)
|
95 (16%)
|
|
|
Fetal distress
|
39 (6%)
|
51 (9%)
|
|
|
Cephalopelvic disproportion
|
13 (2)
|
30 9(5%)
|
|
|
Breech presentation
|
9 (1%)
|
14 (2%)
|
|
|
Others
|
33 (5%)
|
31 (5%)
|
|
|
Requirement induction of labor
|
107 (18%)
|
217 (37%)
|
< 0.001[*]
|
|
Type of induction
|
|
|
< 0.001[*]
|
|
Oxytocin
|
104 (18%)[*]
|
170 (29%)
|
|
|
Dinoprostone vaginally
|
4 (0.7%)
|
8 (1.4%)
|
|
|
Meconium stained amnions
|
46 (8%)
|
13 (2.3%)
|
< 0.001[*]
|
|
Amount of red cell transfusion
|
2 (1–5)
|
2 (1–2)
|
1
|
|
Congenital abnormality
|
3 (0.5%)
|
1 (0.2%)
|
0.135
|
|
Preterm delivery (< 37 weeks)
|
24 (4.2%)
|
4 (0.7%)
|
< 0.001[*]
|
|
Postterm pregnancy (> 41 weeks)
|
17 (3%)
|
15 (2.6%)
|
0.720
|
|
Stillbirth
|
12 (2%)
|
5 (1%)
|
0,220
|
|
Macrosomia (birthweight > 4,000 g)
|
9 (1.6%)
|
26 (4.5%)
|
0.03[*]
|
|
Preeclampsia
|
11 (1.9%)
|
5 (0.9%)
|
0.131
|
|
PPROM
|
9 (1.6%)
|
1 (0.2%)
|
0.011[*]
|
|
PROM
|
69 (12%)
|
68 (11%)
|
0.927
|
|
SGA (< 10th percentile)
|
10 (1.7%)
|
21(3.6%)
|
0.312
|
|
Low birthweight (< 2,500 g)
|
74 (12%)
|
29 (5.8%)
|
< 0.001[*]
|
|
Postpartum hemorrhage
|
15 (2.6%)
|
10 (2%)
|
0.546
|
Abbreviations: PROM, premature rupture of membrane; PPROM, preterm premature rupture
of membrane; SGA, small for gestational age.
*
p < 0.05, significant.
Table 4
Neonatal characteristics
|
Refugee group
|
Control group
|
p-value
|
|
(n = 576)
|
(n = 576)
|
|
|
Birthweight (g) (mean ± SD)
|
3,013 ± 520
|
3,199 ± 500
|
< 0.001[*]
|
|
Height (cm) (mean ± SD)
|
49.1 ± 3.2
|
50.5 ± 19.3
|
0.092
|
|
Head circumference (cm) (mean ± SD)
|
34.3 ± 1.7
|
34.5 ± 1.4
|
< 0.001[*]
|
|
Apgar score n (%)
|
|
|
|
|
< 7 at 1th minute
|
39 (6.8%)
|
21 (4.2%)
|
0.044[*]
|
|
< 7 at 5th minute
|
12 (2%)
|
2 (0.4%)
|
0.015[*]
|
|
NICU admission (n/ %)
|
54 (5.9%)
|
35 (6.1%)
|
0.115
|
|
Fetal sex (n/ %)
|
|
|
0.135
|
|
Female
|
278 (48%)
|
283 (49%)
|
|
|
Male
|
298 (51%)
|
293 (51%)
|
|
Abbreviation: NICU, requirement of neonatal intensive care unit.
*
p < 0.05, significant.
A binary logistic regression was performed to test the main effects of nationality,
adolescent pregnancy, parity, low education level, WGDP, and anemia on the likelihood
that women have preterm birth, PPROM, and low birthweight. As shown in [Table 5], low education level (OR = 1.7, 95% CI = 0.5–0.1), and WGDP (OR = 1.7, 95% CI = 0.5–0.1)
in pregnancy were significant indicators for preterm birth/PPROM, and low birthweight
adjusted for age, parity, nationality, and anemia.
Table 5
Logistic regression analysis of independent risk factors for preterm birth/PPROM,
and Low birth weight
|
Wald
|
OR (95% CI)
|
p-value
|
|
Adolescent pregnancy (age < 21)
|
0.92
|
1.1 (0.16–0.17)
|
0.226
|
|
Parity
|
0.2
|
0.9 (0.07–0,1)
|
0.478
|
|
Low education level (uneducated)
|
12.49
|
1.7 (0.5–0.1)
|
< 0.001[*]
|
|
WDPG
|
13.89
|
1.7 (0.5–0.1)
|
< 0.001[*]
|
|
Nationality (Syrian)
|
2.19
|
1.3 (0.2–0.1)
|
0.138
|
|
Anemia
|
0.16
|
1 (0.06–0.1)
|
0.547
|
Abbreviations: CI, confidence interval; OR, odds ratio; WGDP, weight gain during pregnancy.
*
p < 0.05 is considered statistically significant.
Discussion
In the present study, we analyzed and compared the obstetric and neonatal outcomes
of Syrian refugees and ethnic Turkish women. First, the proportions of adolescent
pregnancies—pregnancies at < 18 years—and mean gravidity were significantly higher
among the Syrian refugees. Additionally, mean age, gestational age at delivery, WGPD,
the proportion of uneducated women, and rate of antenatal follow-up were significantly
lower in the refugee group. Secondly, our study showed that Syrian refugees were at
increased risk of certain adverse obstetric outcomes, including preterm delivery,
PPROM, and lower birth weight.
Previous refugee studies done in Turkey showed that Syrian pregnant women were younger
than Turkish patients, and their mean age ranged from 23 to 25 years. Similarly, we
found that mean age in our refugee group was 23 years.[13]
[14] Also, adolescent pregnancies have been reported to occur at a high rate among Syrian
refugees. One third of the Syrian patients in this study were adolescents, and 10%
of all pregnancies were in women under the age of 18 years. The proportion of adolescent
pregnancies under 19 years of age was significantly higher among the Syrian patients
(10% versus 1%, p < 0.001). A study by Cetorelli et al[15] showed that adolescent fertility increased by over 30% soon after the onset of the
Iraq war, while total fertility remained stable. They posited that adolescent girls
may have been forced into marriage due to the lack of alternatives and a belief of
their families that early marriage was the best way to protect the girls during this
turbulent period.[15]
Adolescent pregnancies are riskier for both the mothers and their newborns, in terms
of the rates of preterm delivery, PPROM, low birth weight (< 2,500 g), and anemia.[16]
[17] Similarly, we found that our Syrian refugees had higher rates of preterm delivery
rates, PPROM, low birth weight, and anemia. Additionally, according to our data, the
birth weight, head circumference, and rate of Apgar score < 7 at the 1th and 5th minutes
of the neonates born to Syrian refugees were lower than those of neonates born to
Turkish women. The difference of birth weight between the two groups cannot be statistically
significant for term fetuses with birth weights between 10 and 90 percentile. Nevertheless,
the number of infants with birth weights under 2,500 g was significantly higher in
the refugee group. Low birth weight is correlated with high mortality and morbidity
in the neonatal period.
In a systematic review, Villalonga-Olives et al[18] evaluated pregnancy and birth outcomes among immigrant women in the US and Europe
and demonstrated that the prevalence of low birth weight among migrants varied by
host country, as well as the composition of migrants to different regions. This can
be explained by the reduced WGDP, lack of routine antenatal follow-up, nutritional
deficiencies, and insufficient iron supplementation among Syrian refugees. In logistic
regression analysis, we found that only low education level and lower WGDP were more
likely to be at risk of preterm birth/PPROM and low birthweight. For pregnant refugee
women, malnutrition may pose a challenge due to insufficient access to food in war-torn
environments and refugee camps. Ongoing nutritional support, counseling, and early
intervention are important to promote healthy nutrition choices during pregnancy.
The health of pregnant refugees and their forthcoming babies is mostly associated
with the same factors as in native populations, but there are some additional factors
that apply specifically to pregnant refugees: income level in the country of origin,
fear of persecution, exposure to trauma, the asylum process, social background, employment
status, living conditions, acculturation, and language-related factors.[19] Posttraumatic stress disorder (PTSD) has been shown to be more frequent among asylum
seekers and refugees,[20]
[21] and this can lead to adverse pregnancy outcomes, such as preterm birth and low birth
weight,[22]
[23] due to changes in stress hormones.
Prenatal care is an important component of basic maternal healthcare; mothers should
receive at least four antenatal visits.[24] Of the Syrian refugees in our study, 67% did not receive antenatal care; this percentage
was only 14% among the Turkish women. Furthermore, only 15% of the Syrian refugees
underwent double/triple prenatal tests and a GDM screening test. Erenel et al[14] studied antenatal care among Syrian refugees in Turkey and found this rate to be
41.3%. Many factors may be associated with decreased antenatal care. Although the
“open-gate” policy of Turkey has saved the lives of many people fleeing persecution,
the cost of health services has reached a high level. According to data from the Turkish
Ministry of Health in 2015, 35,000 Syrians gave birth in Turkey.[25] Reproductive health counseling and contraceptive materials are supplied by family
planning services free of charge. Illiteracy can be an obstacle to antenatal care
services among Syrian refugees. In agreement with this information, we demonstrated
that half of our Syrian refugees were uneducated. Demirci et al[13] showed that the percentage of women reporting illiteracy was higher among Syrian
refugees, at 67.2%.[10] Communication between healthcare professionals and pregnant Syrian women is a major
problem.[26] Although the Turkish government allocates translators to health services, their
number is insufficient. Therefore, leaflets on safe motherhood and pre and postpartum
care practices are written in Arabic and disseminated to refugees. Linguistic diversity
and cultural barriers can negatively affect treatments and use of an interpreter may
decrease the probability of poor obstetric outcomes. Several studies have been done
on maternal outcomes among refugees of different ethnicities. However, there have
been few reports on maternal outcomes among the Syrian refugee population of Turkey.
In terms of birth outcomes, we found that the primary C-section rate was higher among
Turkish women than among Syrian refugees (21% versus 16%, p = 0.034). This may be related to differences between the nations. In another study
done by Alnuaimi et al,[27] they found that Syrian refugee mothers had a significant increase in the rate of
overall C-section when compared with their Jordanian counterparts (36% versus 21%,
p < 0.001). They explained that the most common reason for the high cesarean rates
may be related to the high reported rate of previous C-section in Syria (20%). But
in our study, this rate was found to be as low as 15%, and there was no statistical
difference between the groups. Similarly, two previous studies done in Turkey demonstrated
lower C-section rates among nulliparous Syrian patients;[13]
[14] they reported that their control groups were more likely to show the complications
of GDM and preeclampsia. Our hospital is a reference hospital for high-risk pregnancies
and older maternal age. The rate of fetal macrosomia was significantly higher among
the pregnant Turkish women. However, we could not calculate the prevalence of GDM
in the refugee group because few of the Syrian patients underwent a GDM screening
test; thus, this parameter could not be compared between the groups. Also, the need
for labor induction was significantly lower among the Syrian women (p < 0.001). The proportion of emergency births was higher among Syrian refugees than
the Turkish control group (20% versus 4%, p < 0.001). One reason for this could be the preference for oxytocin, instead of dinoprostone,
seen among the Syrian women for the purpose of labor induction. It is probable that
they had greater cervical dilatation and higher Bishop scores at the time of hospital
admission.
Conclusion
In conclusion, obstetric outcomes among the Syrian refugees differed significantly
from those of the Turkish women. Several different factors may influence these findings;
thus, refugee women would benefit from more targeted care during pregnancy and childbirth.
