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Seeking Maternal Care at Times ofConflict: The Case of LebanonTamar Kabakian-Khasholian a , Rawan Shayboub a & Faysal El-Kak aa Health Promotion and Community Health Department, Faculty ofHealth Sciences , American University of Beirut , Beirut , LebanonAccepted author version posted online: 08 Nov 2012.Publishedonline: 03 Apr 2013.

To cite this article: Tamar Kabakian-Khasholian , Rawan Shayboub & Faysal El-Kak (2013) SeekingMaternal Care at Times of Conflict: The Case of Lebanon, Health Care for Women International, 34:5,352-362, DOI: 10.1080/07399332.2012.736570

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Health Care for Women International, 34:352–362, 2013Copyright © Taylor & Francis Group, LLCISSN: 0739-9332 print / 1096-4665 onlineDOI: 10.1080/07399332.2012.736570

Seeking Maternal Care at Times of Conflict:The Case of Lebanon

TAMAR KABAKIAN-KHASHOLIAN, RAWAN SHAYBOUB,and FAYSAL EL-KAK

Health Promotion and Community Health Department, Faculty of Health Sciences,American University of Beirut, Beirut, Lebanon

Providing quality maternity care within the emergency care pack-ages for internally displaced populations in war-affected areas issomewhat challenging, although very essential. In this retrospec-tive study, we describe the experiences and health care seekingbehaviors of 1,015 pregnant and postpartum women during the2006 war in Lebanon. Women reported interruptions in regularmaternity care and experienced more complications during thisperiod. Availability of health services and experiences of complica-tions were the most important determinants of health care seekingbehaviors. Maternal health services should be a part of any compre-hensive emergency responsiveness plan, catering to women’s needsin war-affected areas.

A number of pregnancy outcomes are known to be largely affected whenwomen experience their childbirth in war-affected areas. Increased fetaldeath and low birth weight (Jamieson et al., 2000), higher rates of Hep-atitis B infections, premature labor, need for instrumental delivery, antena-tal complications, and increase in puerperal infections (Abu Hamad et al.,2007; King, Duthie, Li, & Ma, 1990; Ma & Bauman, 1996; Malamitsi-Puchner,Tzala, Minaretzis, Michalas, & Aravantinos, 1994; Zapata, Rebolledo, Ata-lah, Newman, & King, 1992) are among the important complications facingthese women, in addition to undernutrition, anemia, and psychological dis-turbances (Harris, Humphries, & Nabb, 2006; Jayatissa, Bekekle, Piyasena,

Received 25 July 2011; accepted 1 October 2012.We thank the United Nations Fund for Populations (UNFPA) for their funding, Maria Atoui

El-Hajj for supervising fieldwork, and Ziyad Mahfoud for statistical advice.Address correspondence to Tamar Kabakian-Khasholian, Health Promotion and Commu-

nity Health Department, Faculty of Health Sciences, American University of Beirut, P.O. Box11-0236, Riad El Solh 1107 2020, Beirut, Lebanon. E-mail: tk00@aub.edu.lb

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Maternal Care at Times of Conflict 353

& Mahamithawa, 2006). The detected health problems affecting pregnantrefugee women are associated with the interruption of the regular antena-tal care received before displacement, leading to several undetected healthproblems and delaying necessary interventions (Harris et al., 2006; Kahler,Sobota, Hines, & Griswold, 1996). The success of emergency reproductivehealth packages in reducing these undesired outcomes is highly dependenton the availability of various resources. In this study, we aim at identifyingthe needs and experiences, of internally displaced women in Lebanon withtheir pregnancy, birthing experience and their postpartum period in an at-tempt to understand factors affecting use of maternity care during conflictsituations.

Women affected by conflict need more focused reproductive health ser-vices than those not affected by war to avoid the need for more care thatmay not be readily available. It is well established that when a displacedpregnant population is provided with essential obstetric care and has accessto culturally relevant services in relation to psychosocial needs, obstetric out-comes will not vary from those of a nondisplaced population (Hynes, Sheik,Wilson, & Spiegel, 2002; McGinn, 2000; Spiegel, Sheik, Gotway-Crawford, &Salama, 2002; Yoong, Kolhe, Karoshi, Ullah, & Nauta, 2005).

Until the mid 1990’s reproductive health care was not included in thebasic health care service plans of emergency preparedness guides for conflictaffected areas. The collaborative efforts of governmental and nongovernmen-tal organizations as well as United Nations (UN) agencies have succeededin developing emergency reproductive health packages that were imple-mented successfully in many conflict areas of the world in the last decades(O’Heir, 2004). The success of these concerted efforts was largely dependenton availability of trained staff, funds, effective community participation, andcoordination among different relief agencies.

In Lebanon, more than 95% of pregnancies are followed up and deliv-ered by skilled personnel (Statistics Central Department, 2004). This practiceis believed to have been seriously interrupted during the war. The LebaneseHigher Relief Council estimated that nearly 975,000 people were internallydisplaced during the war on Lebanon in July–August 2006 (USAID, 2006).The vast majority of these internally displaced persons were women andchildren, with an estimated number of pregnant women to be approximately17,550, with a crude birth rate of 18 births/1000 population (United NationsChildren’s Fund [UNICEF], 2009). This situation has created a sudden needfor the organization of relief efforts in terms of providing health care servicesto the displaced population as well as in identifying and prioritizing needs.

Primary health care personnel and health care providers were alsoamong those who were displaced. Very few remained working on emer-gency surgeries and in deployed field hospitals. At the same time, mostof the antenatal care health services in both private and public sectors inconflict areas of the country were nonfunctional, a situation that deprived

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354 T. Kabakian-Khasholian et al.

the displaced pregnant from the desired continuity of care and made mon-itoring high-risk cases difficult. Although several medical relief teams wereorganized during the war by governmental and nongovernmental sectorstargeting emergency cases, basic obstetrical care was also provided focusingon the following: (a) basic antenatal care (blood pressure measurement, fetalheart documentation); (b) advice on adherence to basic essential diet andprovision of supplementation; (c) reporting of warning signs and contact incase of emergency through a hotline provided to those in charge of displace-ment sites; and (d) facilitating the place of delivery assigned in collaborationwith the Ministry of Public Health and Syndicate of Private Hospitals.

Despite these efforts that have made antenatal and birthing care avail-able to women who were internally displaced in Lebanon, little is knownabout the experience of women with the provided care and their specificneeds in relation to their pregnancy, birth, or the postpartum period whilebeing displaced. This study assesses the resettled women’s needs and ex-periences with their pregnancy, delivery, or postpartum period during theJuly–August 2006 war in Lebanon, as it relates to their access to antenatal,delivery, or postpartum services. It attempts to identify factors leading to useof maternity care services during displacement.

METHODS

In this study, we describe the needs and the health care seeking behavior ofthe displaced pregnant women, those who delivered while displaced, andthose who were in their early (3 months) postpartum period during the war.Our target population consisted of women who were displaced during July,August, or both months of 2006 and had resettled to their homes before thedata collection period.

The target population was accessible through the most affected com-munities in Lebanon, namely, the southern suburbs of the capital Beirut andthe South of Lebanon. We trained 12 interviewers who are outreach healthworkers in the health centers run by a local non governmental organiza-tion (NGO) in the targeted two regions of the country. This NGO had anextensive network in these regions.

In total, interviewers covered three health centers and three privateobstetrics’ clinics during peak visiting hours in the southern suburbs of Beirutand six health centers in the South, in addition to using the snowballingmethod within their own communities to identify and interview eligiblewomen. Two field supervisors were assigned to monitor the daily activitiesof the interviewers, edit the questionnaires, and act as the liaison betweenthe study team and the field activities in the communities.

The data collection instrument consisted of a structured questionnaire.The elements in the questionnaire measured the disruption in access to

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Maternal Care at Times of Conflict 355

antenatal and postpartum services, the perceived effect of the disrupted careon women’s well-being, provision and use of resources, women’s level ofsatisfaction with received services and available resources, and their unmetneeds with regards to obstetric care and maternal health.

The study protocol received ethical approval from the Institutional Re-view Board at the American University of Beirut. The field workers read aconsent form to each eligible woman, explaining the nature of the studyand ensuring confidentiality of the reported information. Verbal consent ofwomen was obtained before interviewing. Data collection was done duringApril and May of 2007.

Data was entered using CSPro 3.1 software, and analysis was done usingSPSS v. 16.0. The relationship between the selected determinants and useof maternal health care services (antenatal or postpartum services) duringdisplacement was assessed using the chi-square test. Statistically significantdeterminants were then entered into a logistic regression model. Odds ratiosand 95% confidence intervals were then calculated to measure the likelihoodof displaced women seeking maternal health care.

RESULTS

The attained sample size of the study is 1,015 women, with a 9.4% refusalrate. The profile of the resettled women is presented in Table 1. More thanhalf of the interviewed women were pregnant during the war, around 24%were in their postpartum period, and 19% of women delivered while beingdisplaced. Sixty-three percent of women in the sample were between theages of 20 and 30, and around 46% had two to three children. The vastmajority of women reported having had a live birth for their index pregnancy,with 7.7% having a miscarriage and around 3% reporting a stillbirth as anoutcome of their pregnancy.

In terms of disruption of maternity care during the war, 80.2% hadvisited a health care provider before being displaced, but only 34.5% reportedreceiving any type of care while being displaced. Women’s reported healthcomplications during displacement (35.5%) were significantly higher than thereported antenatal complications before displacement (13.5%). This is mostlyapparent for the group of women who delivered during displacement, where52.1% of them reported a certain health complication during displacement.

Table 2 presents the distribution of respondents by the type of warevents experienced, their displacement circumstances, the resources avail-able to them during displacement, and their specific needs. Almost half ofthe participants had a destroyed or damaged house, and a total of 28.2%of the women had experienced any casualty or injury in their immediateor extended family, their friends, or neighbors. Forty percent of respon-dents were displaced to rented houses or hotels, therefore lodging for a fee.

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356 T. Kabakian-Khasholian et al.

TABLE 1 Distribution of Respondents by Sociodemographic Indicators, Selected Birth Out-comes, and Utilization of Maternal Health Care Services (N = 1015)

Variable N a %

Pregnancy statusPregnant during the war 575 56.7Delivered during the war 194 19.1Postpartum within last 3 months 246 24.2

AgeBelow 20 years 24 2.420–29 years 625 62.730–39 years 324 32.540 and above 24 2.4

Number of live births1 327 32.32–3 470 46.44 or more 215 21.2

Pregnancy outcomeLive birth 903 89.4Still birth 29 2.9Miscarriage 78 7.7

Maternal care before vs. during displacementb

Received maternal care before displacement 812 80.2Received maternal care during displacement 349 34.5

Reported complicationsPrenatal complications before displacementc 137 13.5Among those pregnant 76 13.2Among those who delivered 27 13.9Among those who were postpartum 34 13.9

Health complications during displacementc 359 35.5Among those pregnant 226 39.4Among those who delivered 100 52.1Among those who were postpartum 33 13.5

aWhen totals do not add up to 1,015, it is due to missing values.bMaternal care is measured as antenatal or postpartum care. There is a significant difference (p < .001)between receiving maternal care before and during displacement.cThere is a significant difference (p < .001) between reporting having prenatal complications beforedisplacement and health complications during displacement.

An important 32% of the displaced women reported having lived in publicschools (open access granted by the government), underground shelters, oruninhabited houses provided to them by NGOs and the public in general.The rest of the women reported moving into houses of relatives, friends, oracquaintances in relatively safer areas. Around 30% of the respondents re-ported having moved from one residence to another more than once duringthe course of their displacement.

When asked about the daily difficulties they were faced with at thelocation of displacement, women stated that they lacked privacy (71.3%),physical comfort (59.7%), social support (58.9%), and health care services(58.1%). Few women (26.7%) pointed to the cleanliness of the premisesas being an issue. A scale for perceived daily difficulties representing the

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Maternal Care at Times of Conflict 357

TABLE 2 Distribution of the Respondents by War Events, Displacement Circumstances, andDifficulties Faced as Refugees (N = 1,015)

Variable N a %

Experienced war eventsDamaged or destroyed house 459 45.2Casualties and /or injuries in immediate family b 140 13.8Casualties and /or injuries in extended family,

friends, or neighborsb213 21.0

Any casualty or injury in immediate or extendedfamily, friends, or neighbors

286 28.2

Number of times displacedOnce 716 70.5Twice or more 299 29.5

Place displaced toHouse of relatives or friends 246 27.6Rented house or hotel 361 40.5School, uninhabited house, place for displaced,

shelter, etc.285 32.0

Availability of resources in displaced placeClean water 833 82.1Help with children 704 69.4Diversity of food 604 59.5Comfortable place to sleep 557 54.9Privacy 246 24.2Average score: X = 2.9; range 0–5

Perceived daily difficulties at place of displacementLack of privacy 724 71.3Lack of physical comfort 604 59.7Lack of social support 594 58.9Lack of health care 587 58.1Lack of cleanliness 270 26.7Average score: X = 2.75; range 0–5

Needed anything specific as pregnant or recentlydelivered during displacement

449 44.4

Psychological and physical support 196 43.8Food, milk, and medication for the children 41 9.2Medical care, medication, and food for the women 141 31.5Everything 31 6.9Other 39 8.6

Satisfied with social support as pregnant orpostpartum woman during war

444 44.0

aWhen totals do not add up to 1015, it is due to missing values.bCategories are not mutually exclusive.

number of difficulties faced by women at the place of displacement showsa mean score of 2.75 difficulties from a total of five.

During displacement, only 44% of the women reported being satisfiedwith the available social support, with those residing at their relatives’ housesbeing the most satisfied (51%) and those residing at schools being the leastsatisfied (41%). Eighty-two percent had access to clean water, 69.4% receivedhelp with childcare, almost 60% reported having access to diverse food

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358 T. Kabakian-Khasholian et al.

items, and another 55% had a comfortable place to sleep. Only 24.2% ofwomen, however, reported having privacy at the place of displacement. Thehighest proportion of women reporting lack of privacy was for those whohad been displaced to public schools or shelters (data not shown). A scalefor availability of resources measuring the number of resources available towomen at the place of displacement shows an average score of 2.9 out of 5.

Around 43% of women perceived having a specific need while beingdisplaced. The majority of their needs consisted around the lack of phys-ical and psychological support health care, medication, as well as propernutrition for them and their children.

Multiple logistic regression analysis was used to assess the independenteffect of age, health complications during displacement, satisfaction withsocial support, scale on availability of resources at the place of displacement,and availability of health care. The latter is presented as lack of health caremeasured as one of the perceived daily difficulties at place of displacementin Table 2. All the above-mentioned determinants were shown to have asignificant association with use of maternity services by the bivariate analysis(p value < .05). The scale on perceived daily difficulties was the only variablethat was significantly associated with use of services and not included in theregression analysis, as it was highly correlated with the variable measuringavailability of resources.

Table 3 presents the final model of the logistic regression analysis fordeterminants of use of maternity services during displacement. A fivefoldincrease in the use of maternal health care services is found among womenreporting availability of health care services during displacement (OR =

TABLE 3 Adjusted Odds Ratio and 95% Confidence Interval for Determinants of Using Ma-ternal Health Care Services During Displacement

Variable OR (95% CI) p value

Maternal age< 30 years 1≥ 30 years 1.261 (0.924–1.720) .144

Being satisfied with social supportNo 1Yes 0.894 (0.647–1.235) .497

Having health complication during displacementNo 1Yes 3.641 (2.667–4.969) <.000

Having available resources during displacementa

Having < 3 1Having ≥ 3 1.083 (0.784-1.496) .629

Availability of health careNo 1Yes 5.587 (3.953–7.874) <.000

aThe scale was dichotomized and the odds ratio compares women scoring above the median and belowthe median.

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Maternal Care at Times of Conflict 359

5.587; 95% CI 3.953–7.874; p value < .000) and a threefold increase in useof services among those reporting health complications during displacement(OR = 3.641; 95% CI 2.667–4.969; p value < .000), after adjustments weremade for age, satisfaction with social support, and availability of resourcesduring displacement.

DISCUSSION

The findings in this article point to the importance of availability of servicesprovided to displaced women in determining their use of maternal healthcare during displacement. In view of the fact that the use of antenatal andpostpartum services dropped dramatically during displacement, accessibilityand availability of services were the main factors determining use, togetherwith experiencing health problems.

Lebanon has high use of antenatal services, and maternal health careservices are widely available in all regions of the country through private andpublic sectors. Therefore, the drop in the use of maternity services duringdisplacement, as shown in our findings, is most probably attributable to thelack of provision of maternity care to displaced pregnant women, more thanto other factors related to the reality of being a displaced pregnant woman.Actually, there is some evidence to show that many pregnancy-related out-comes among refugee populations could be attributed to the availability anduse of maternal health services rather than to their refugee status (Bosmans,Nasser, Khammash, Claeys, & Temmerman, 2008; McGinn, 2000). Our datashow an increase in reported health complications during displacement,which could be attributed to the decrease in use of health services. In thecase of Lebanon during the war, regular antenatal care services were in-terrupted, where only 23.3% of primary health care services were still ableto provide antenatal care, 9.7% clean deliveries, and 11.4% emergency ob-stetric care (World Health Organization [WHO] & Ministry of Public Health[MOPH], 2006). Health services were mainly offered through emergency re-lief teams visiting internally displaced people’s locations and attending to sickadults and children, chronic conditions, and pregnancy. Due to shortage ofphysicians and midwives, fewer resources were available to obstetrical andgynecological conditions. It can be argued that although obstetrical serviceswere part of relief packages, they were not always available, responsive,and utilizable, despite the remarkable efforts of many agencies, mainly theUnited Nations Population Fund (UNFPA), to use the reproductive healthminimal invasive service package (MISP), which was deployed in the poste-mergency and stabilization phases. The traditionally recognized package forrefugees prioritizes the provision of food, shelter, clean water, sanitation,and basic health care (O’Heir, 2004). During the last decade, there has beenan increasing recognition of the importance of providing reproductive health

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360 T. Kabakian-Khasholian et al.

services to refugee and internally displaced populations (Austin, Guy, Lee-Jones, McGinn, & Schlecht, 2008; Krause, Jones, & Purdin, 2000; McGinn,2000; McGinn & Purdin, 2004), including the provision of quality reproduc-tive health care and care during pregnancy and childbirth (O’Heir, 2004). Ourfindings support that need among a group of internally displaced pregnantand postpartum women. Although we do not intend to undermine the impor-tance of providing basic health care services in situations of scarce resources,as it is in many areas affected by war, maternal health services should beconsidered an important component of the basic health care services andresources should be organized and managed accordingly, as women duringwar time and displacement situations have the same maternity and childbirthneeds as women in the normal population (O’Heir, 2004)

Actually, the challenge remains in the organization of maternity servicesfor displaced women during war, when considering the fact that only abouta third of them were residing in identifiable places assigned for the displacedand the remaining sought shelter in nonspecified places (private houses, rela-tives’ houses, etc.). This in fact raises the importance of organizing maternityservices in a way to reach all segments of the displaced population dur-ing emergencies, and specifically targeting women living away from centersand shelters. Alternative approaches could be considered, such as assigningspecific clinics as maternity care centers in all regions of the country andadvertising for them in media. Efforts should also be made to make theseservices culturally sensitive to minimize barriers for use. This should be partof an overall emergency responsiveness plan, which includes, in addition tothe abovementioned, training and mobilization of personnel, referral centersand hospitals, and postpartum recovery places.

Finally, health care providers are not routinely trained about healthneeds of displaced populations or in general about providing care in emer-gencies. In regions with high potential for armed conflict, there is an obliga-tion for such a preparation, taking into account lessons learned from similarsituations in the past. Some specifically organized training activities may takeplace; however, it should be a requirement to include these as an ongoingprofessional training embedded within the system.

The main limitation of this study is in the nature of the sample. Althoughthe snowballing technique was used, returnee women were recruited mostlyfrom health centers, therefore probably under-representing women who donot use these services or seek care from different health care providers. Onanother hand, the success of data collection and the fact of accessing a largenumber of returnee women in a relatively short period of time was mainlydue to the collaboration with the main gatekeepers in those communitiesand the recruitment of field workers from within the community. In terms ofthe study design, it was difficult to capture women’s feelings about theirpregnancy and birth during wartime with a closed-ended questionnaire.For that purpose, a qualitative study design would be more useful for an

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Maternal Care at Times of Conflict 361

in-depth understanding of women’s experiences in more details and beyondthe findings of this study.

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