Caesarean section rates among the Syrian refugee population in Lebanon: possible causes, implications and recommendations going forward

Abstract

As of September, 2013, the conflict in the Syrian Arab Republic is far from abating, and this country of over 22 million citizens has now over 2 million of its people (three quarters of them women and children) have sought refuge in neighboring countries. With a surface area of 10,452 km2, Lebanon is by far the smallest of all hosting countries, yet it is hosting the highest number of refugees. Today, over 769,000 refugees are living in Lebanon (registered and awaiting registration) - over 1 million according to government sources--mostly concentrated in the Bekaa and the North of the country, settling in mainly economically stressed areas where services were severely strained to begin with. With a 2012 population of 4.425 million, Syrian refugees now account for about a quarter of Lebanon's total population, undoubtedly placing a very heavy strain on this small country's resources. In response to this refugee crisis, UNHCR has been assuming the role of leading and coordinating agency. On the health front of the response, the demand from refugees has been great. Hospitalizations have accounted for a proportionally large part of UNHCR's health budget expenses, with 14,546 hospital admissions from Jan-June 2013 alone. But it has especially been so in the request for maternal health services (deliveries), with 6,375 births recorded in that 2013 timeframe, and accounting for over 47% of our largest implementing partner's (IP) recorded requests for hospital admissions in 2013 (up from 23% in 2012). Of note, 5.6% of the overall hospital admissions requests were for "neonatal conditions". Combined, this constitutes over 53% of all hospital admissions. Overall, deliveries account for almost 50% of hospitalizations in our contracted hospitals, and are an important part of UNHCR's health expenses. From those hospital admissions for deliveries, the data collected for 2013 indicated an overall c-section (CS) rate of 35% in the Syrian refugee population , much higher than the recommended threshold of 15% given by the WHO, and also more elevated than Syria's reported CS rates of 12-23%. Since CS cost on average two times more than a natural delivery, it was important for UNHCR to try and understand what impetus was behind the CS rates that were being observed. Indeed, from Jan-June 2013, out of 6,375 births covered by UNHCR, an estimated minimum of $1.4 million would have been spent on CS (2,244 CS between Jan-June 2013) and $1.4 million for Natural Vaginal Deliveries (NVDs) (4,131 NVDs between Jan-June 2013). Taking into account that many of those CS actually cost much more because they are often linked to birth complications and neonatal ICU admissions, the total bill is most likely much higher than the simple delivery act. From this limited mixed methods study which looked at our IPs' 2013 hospital admissions data, as well as from our limited interviews with hospital administrators, medical providers and women having undergone c-sections, we tried to better understand the factors driving the CS rate among the Syrian refugee population.