By Bree Akesson, Dena Badawi, Karen Frensch
Introduction
Since the start of the conflict in March 2011, over half of Syria’s population has been forced to flee their homes. Most Syrian families have sought refuge in neighboring countries, including Lebanon, a small country that hosts approximately 1.5 million of the 6.6 million refugees who have fled Syria (United Nations High Commissioner for Refugees (UNHCR) et al., 2022). Lebanon hosts the greatest number of refugees per capita and per square kilometer in the world (UNHCR, 2023a). Lebanon is not economically prosperous, and it has been historically battered by religious divisions and political violence. The large number of Syrian refugees has further strained Lebanon’s already stressed infrastructure, increasing social tensions, while deepening the country’s socioeconomic disparities (Todman, 2021). Within this context, high rates of poverty, burdensome governmental policies and regulations, a lack of affordable housing, food insecurity, decreased school attendance, and family violence have all increased the vulnerability of Syrian families living in Lebanon. Exacerbated by the war and subsequent displacement, these vulnerabilities have a destabilizing effect on Syrian parents, as they struggle to meet their families’ needs in a low-resource and inhospitable environment (Akesson & Badawi, 2019, 2020). As the conflict enters its second decade, Syrian families in Lebanon face worsening humanitarian conditions and a lessening of public attention to address the crisis.
Among refugee populations, approximately 50% are women and girls, who often bear a heavy burden caring for their families and communities (UNHCR, 2023b). Fifty percent of these women and girls are of reproductive age, with one in five likely to become pregnant at any time during the course of war, flight, and displacement (World Health Organization (WHO), 2016). Refugees often have limited knowledge and therefore restricted access to healthcare systems in their host countries (Harakow et al., 2021), or the host country (like Lebanon) may not have an adequate healthcare system to begin with (Hanna-Amodio, 2020). For pregnant refugee women, this may lead to lack of access to adequate prenatal care and further increase the risk of complications during pregnancy (Asif et al., 2015; Heslehurst et al., 2018).
Though assessments of the physical health of pregnant women is critical, it is also important to expand our understanding of wellbeing beyond the biomedical model. Pregnant women are also impacted by their environments, their access to social relationships and supports, and their ability to care for their families. All these conditions impact health and wellbeing in ways that a biomedical framework cannot always capture. More research is therefore needed to assess the complexities of contexts within which pregnant women survive and how that impacts their wellbeing.
This paper is a means to address this gap in research by focusing on the psychosocial experiences of pregnant women in contexts of war and displacement. The following pages report findings from a study with Syrian refugee women who were currently pregnant or who had given birth within the last year and who were living in Lebanon after fleeing their home country due to war. The research focused on how mothers experienced pregnancy and motherhood—from the prenatal to postnatal period—in a context of extreme adversity.
Physical and Mental Health Challenges of Pregnant Women
Much of our understanding of women’s health has been confined within the parameters of physical health and a biomedical understanding of wellbeing. And it is not uncommon for women to experience pregnancy-related morbidity during pregnancy, which may be exacerbated by war and displacement. For example, there are high rates of maternal anemia among pregnant Syrian refugee women, as well as general malnutrition (Abou-Rizk et al., 2021). Maternal malnutrition can be harmful to both mothers and children by increasing the risk of maternal mortality, low birth weight, and poor cognitive development in children (Corley, 2021).
Pregnancy and childbirth are particularly dangerous for women and girls in the context of war, flight, and displacement, with approximately 500 dying each day from complications (Osotimehin, 2016). Despite improvements to global health over the past several decades (Jawad et al., 2021), war-affected pregnant women face unacceptably high levels of morbidity including increased risks of premature labor (Abu Hamad et al., 2007), low birthweight (Demirci et al., 2017), and fetal mortality (McGready et al., 2018; The Lancet, 2016; WHO, 2016).
Much of the literature on mental health among pregnant women in both war and peace has focused on perinatal depression (PND). Indeed, PND is one of the most commonly diagnosed mental health conditions in the general maternity population (Firth et al., 2022). The average diagnostic rate of PND among refugee women is 42% globally, which is double that of non-war-affected women (Firth et al., 2022). The cluster of symptoms related to PND include low mood, apathy, lethargy, change in appetite, social withdrawal, feelings of inadequacy, shame, guilt, and hopelessness. But each of these symptoms can be present among and impact women in the perinatal period without meaning there is a clinical diagnosis of PND.
In the case of Syrian refugees in Lebanon, a host of factors can contribute to negative physical and mental health. Nine out of 10 families live in extreme poverty line with food insecurity being highly prevalent (UNHCR et al., 2022). Women often report living in substandard housing with a lack of access to basic necessities such as water, sanitation, and food (UN-Habitat & UNHCR, 2018). In Usta and Masterson’s (2015) study, women reported that their living conditions led to feelings of mental stress and distress. These conditions included overcrowding, lack of access to water, lack of activities for children and food insecurity. Women also attributed their stress to fear over family left behind in Syria, boredom at repetitive routines, concerns of safety in Lebanon, and helplessness in supporting their children’s mental wellbeing (Usta & Masterson, 2015). In these contexts, it is not uncommon for women to put their families’ needs ahead of their own.
Limited Access to Health Services and Social Supports
Despite the conditions facing pregnant Syrian women in Lebanon, the contexts in which they live often leave them with limited access to health services and social supports. Much aid for pregnant women is funneled into the healthcare system with medical support taking prevalence. Despite subsidies, covering the costs of antenatal care in the context of poverty can be inhibiting for Syrian families (Benage et al., 2015). A UNHCR (2022) survey found that 70% of women accessed antenatal care at least once during their pregnancy and only 49% accessed this care the recommended four times; 30% received no antenatal care. Cost is the most highly reported barrier to seeking antenatal care (Abdin, 2018; Alnuaimi et al., 2017; Lyles & Doocy, 2015; Tappis et al., 2017).
Given the convoluted system of supports present in Lebanon, knowledge and awareness of services is often a reported barrier to seeking support (Abdin, 2018; El Arnaout et al., 2019). The decentralization of Syrian refugee households in Lebanon poses another significant barrier to accessing services. Syrian households are spread throughout Lebanon, with refugees living in shelters which range from rented apartments, tented settlements, and makeshift shelters (UNHCR et al., 2022). Families living in rural areas face increased challenges in accessing support due to not having information on services available as well as an inability to access reliable transportation to services (Lyles & Doocy, 2015). Lack of mobility and transportation to support services is another highly reported barrier to service access (El Arnaout et al., 2019; Lyles & Doocy, 2015; United Nations High Commissioner for Refugees (UNHCR) et al., 2022).
Culture and Social Supports
Conflict and its subsequent displacement rips apart the fabric of community and disrupts social support systems as families and communities may be subjected to violence and separated from their homes and networks (Slone & Peer, 2021). Social supports have been long understood as an important determinant of health (Tarlov, 1996). Social supports include the communities within which individuals live, particularly the friendships, families, neighbors, and social networks. The presence of social support through friendships, families, and community members has been shown to positively influence the health and wellbeing of refugee families through mediating the effects of stress (Simich et al., 2003). Social support can reduce feelings of isolation for refugee families as they are connected to others sharing similar experiences. These connections can positively influence psychosocial health for refugee families (Simich et al., 2003). Importantly, the unique connections and support that social systems provide cannot be easily replicated by formal support systems (e.g. health systems, economic systems) that constitute the majority of refugee support systems operationalized by governments, NGOs, and community groups working in the field. In the context of pregnancy, conflict and displacement can also impact the ability of communities to participate in cultural practices while preparing for the birth of a child and in the period afterwards (Akesson, 2017; Gottlieb, 2017; Shirdon, 2017). This is all compounded with the challenge of adjusting to a new environment when displaced. Despite the importance and relevance of social support to health during pregnancy, this area has not been investigated as widely as medical care for pregnant women.
Much of the literature investigating pregnancy in contexts of war and displacement is centered on biomedical models. There is less research on the experiences of pregnant women in these challenging settings. Our study refocuses the conversation on these experiences aiming to identify ways to better support pregnant women and their families.
Methodology
This paper reports on findings from a sub-sample of a 2016 research study aimed at generating knowledge regarding the experiences of Syrian refugee families. The research received human subjects’ approval through the Wilfrid Laurier University Research Ethics Board (REB #4661) and followed all REB guidelines. Initial recruitment of participants took place in partnership with various community and international organizations working in Lebanon. Aligned with cultural norms, families were subsequently recruited through word of mouth. Initiated by organizations and when relevant, we visited the community shawesh (leader), who introduced us to any available families who would be interested in participating. Families that included a woman who was or had been recently pregnant were specifically requested to participate.
For the larger study, we conducted collaborative family interviews (CFIs) with 268 individuals in 46 families who had fled Syria in the last five years and had resettled in three regions of Lebanon: northern Lebanon, Beirut, and Bekaa Valley. CFIs took place in the families’ homes. According to Merry and colleagues (2014), offering interviews in the home helps to facilitate participation of women, especially pregnant and new mothers, who may be less inclined to leave the home due to the physical demands of the perinatal period. CFIs included both nuclear family members (e.g., mother, father, children) and extended family members (e.g., aunts, grandmothers, cousins, etc.). CFIs consisted of discussions about parenting within the context of political violence, migration, and resettlement. If one of the participants was pregnant or had recently been pregnant, specific questions about the perinatal period were included.
In addition to CFIs, we conducted three focus group discussions with Lebanese community workers and Syrian refugee outreach volunteers, as well as three semi-structured interviews with individuals who were working directly with Syrian families in Lebanon. The research also included participant-observation of field agencies working with refugee families, attendance at meetings with aid organizations and local community-based organizations, and visits to informal settlements and other places refugee families were living.
With participants’ permission, interviews were audio-recorded, translated, and transcribed prior to data analysis. Data analysis was facilitated through Dedoose, an online research and evaluation data application. Data were analyzed through careful reading and collation of transcripts to ascertain meaning and significance that participants attributed to their experiences. Since the focus of this study is experiences of pregnancy, only data that discussed the perinatal period was included in this analysis.
Findings and discussion
Findings were categorized into four themes related to the perinatal period: (1) apathy, (2) stress, (3) barriers to accessing services, and (4) lack of social supports.
1. Feelings of Apathy Towards Pregnancy
Pregnancy is often a time of anticipation ultimately culminating in the joy of giving birth to a new life. However, for the mothers interviewed in this study, they often expressed apathy towards giving birth to a child in Lebanon, reflecting a lack of emotion. For example, when asked about how she felt about having another child in Lebanon, Umm-Fadel, a pregnant mother of two flatly responded: “Well, honestly, I don’t know. I don’t feel anything…. In the end, it is God’s will…. The life needs to go on. At the end life goes on.” Umm-Fadel’s words do not reflect a sense of anticipation or excitement at bringing a child into the world, but rather a passive sense of merely moving forward. In this case, apathy masks despair and disillusion. When things are so bad, when one suffers a lot, one may dissociate from events in order to survive (Borneman, 2023). After so many struggles—living through the violence of the Syrian conflict, leaving one’s home and country behind, and finding oneself displaced in a new and challenging context—the women in this study expressed sentiments akin to not caring and not showing interest in the future. The concept of apathy among refugee women populations has not been fully explored in the research. One exception is Kreitzer’s (2002) study of Liberian refugee women, which found that all participants mentioned apathy as an element of living in a refugee context. For these women, apathy may be a consequence of trauma and exacerbated by their living situation. Apathy may also be used as a way to cope with despair, disillusion, and disappointment (Jensen, 2021).
Umm-Fadel’s quote also reflects an external locus of control, relying on God and faith to make decisions for them. Reference to an external locus of control was also observed in other conversations with the participants. Participants would often express having a lack of control over their current situation, and a disregard to requiring an emotion around it, as it was a situation they perceived as being beyond their control. For example, mother of two and pregnant Umm-Bashir said: “I do not want to have children, but it is God’s will, and you cannot resist God’s will.” In difficult situations, individuals can sometimes release control to God, or an external higher power, as the magnitude and impossibility of the situation can be unfeasible to bear. An external locus of control describes where people tend to attribute cause for events in their environment (Rotter, 1966). Those with an internal locus of control attribute events to themselves, crediting their abilities, effort, or behaviors. In contrast, people with an external locus of control attribute events to things outside their control, including other powers. In the case of Umm-Bashir, her locus of control lied externally where she attributed events in her life to God’s will and the path He had written for her.
Prior research has investigated cognitions of a locus of control as a coping mechanism (Hahn et al., 2019; Schlechter et al., 2023). Possessing and fostering an internal locus of control is associated with better psychological health outcomes as it leads to preventative and action oriented behaviors in situations of adversity. As such, people with an internal locus of control tend to be resilient and suffer less from mental health issues. However, there continues to be limited research on the impacts of varying loci of control specifically in the context of war and displacement in refugee populations (Echterhoff et al., 2020), therefore further research is needed to investigate this relationship. As Umm-Fadel and others in this research show, this consideration for locus of control is at the forefront of their experience. Individuals interviewed dictated their stories and life experiences through the lens of God’s will and control.
2. Stress During Pregnancy
Mothers understood their experience in Lebanon to be captivated by the stress of survival. Having a child in Lebanon represented a situation of stress that mothers felt they needed to get through. Mothers often spoke about the stress of life in Lebanon, including a lack of access to food, services, and family support. Being pregnant in this context was an additional stress which they believed ended when the child was born. A pregnant mother of two, Umm-Hamed, expressed this sentiment when she responded to a question about how she felt about her new child being born in Lebanon and not Syria: “There is no difference at the end. He needs to be born, whether here or in Syria. The most important thing for me is for him to be born and to come and to end this stress.” In this statement, Umm-Hamed expressed the sentiment that pregnancy is an experience of stress and that particular stress ends in delivery. However, that point also marks the beginning of a host of other stressors, including ensuring the child’s survival and future livelihood. Mothers were very aware that stress during pregnancy is not good for their health or their baby, and of the need to minimize stress during pregnancy. This knowledge has both cultural and medical roots as it stemmed from a general knowledge of stress as being negative, as well as knowledge passed down through relationships. Most cultures advise women to avoid stress during pregnancy (Gottlieb & DeLoache, 2017). Echoing this near-universal belief, Umm-Khaled, the pregnant mother of two, emphasized: “A pregnant woman is not supposed to be upset or stressed, but now all that is present.” Syrian mothers in Lebanon—and more broadly within contexts of war and displacement—are locked in an impossible situation where they bear the knowledge of the need to minimize stress, but are also living in a context in which it is impossible to escape. Mothers often spoke about the vast stressors they face in Lebanon. Mothers are trapped in an inescapable cycle where they know they should not be stressed, and that knowledge, in a context where stress is ever-present, leads to more stress for mothers.
For parents, much of their stress is rooted in fear about their children’s survival. Everything that the parents do is for the wellbeing of their children, even those who aren’t born yet. Similarly, their hopes and dreams for the future are distinctly attached to their children’s wellbeing.
Families in Lebanon face a host of challenges which have been well documented. In this research, families often spoke of these challenges, including pregnant mother of two Umm-Rashid, who answered a question about what it was like to be pregnant during a crisis by describing her stress in pregnancy: “First of all, we lived in great fear, especially over my kids.” Umm-Amir, a mother of five, echoed the feeling that pregnancy is a source of stress, stating:
“Let me tell you something, financially if you have money and you are treating your son, you don’t feel it. [In Syria] we never felt the sickness in birth or anything. Here you feel it. For example, when a woman first gets pregnant, she stays worried until she gives birth and comes back from the hospital.”
In this context, mothers are caught in a dilemma where they are aware of the negative impacts of stress but are also unable to escape it given the context I’m which they live. They express frustration at knowing that stress is harmful but being absolutely unable to avoid it. The stress is so overwhelming that a common reaction is apathy and hopelessness (Yako & Biswas, 2014). However, maintaining hope is a strong indicator of resiliency and an ability to overcome adversity (Van Acker et al., 2022).
3. Barriers to Accessing Services
When discussing access to services in Lebanon, families often spoke retrospectively, looking back to their experiences in Syria. Comparison to their lives in Syria was a common theme, unsurprisingly identifying access to supports as easier in Syria prior to the war. This stemmed from a sense of familiarity and therefore comfort in the systems and structures in place in Syria such as a sense of knowing the physicians in the community and having trust in the care one receives during the perinatal period. For example, Umm-Mahmoud, mother of six, described her experience of care in Syria as the following:
“In Syria, I had a doctor who delivered all my children. Here I don’t. It was very different…. The doctors here aren’t so good. I have to change one every month. It wasn’t like this in Syria, where we just stuck to one doctor.”
Umm-Mahmoud also highlights a prominent issue of continuity of care within humanitarian settings. With multitudes of organizations and government bodies active in humanitarian settings, it becomes difficult for displaced persons to secure consistent, continuous care. A common critique of emergency healthcare systems is the lack of coordination, collaboration, and communication between organizations working in the field. For example, Noor, an NGO worker based in Lebanon, described the issue as follows:
“…you have regions where you do not have [clinics] – they are very far away – …you don’t necessarily have mobile clinics moving around… [and] some of the refugees cannot move freely because they do not have the proper registration and they can be stopped, so even if you want…to give birth, in which conditions are they giving birth? “
Another factor is the lack of sustainability in emergency settings, with organizations appearing and disappearing in response to funding changes. The continually changing nature of policies, government positions, and funding can result in support systems being volatile in emergency settings and affecting the ability of pregnant women to have continual access to health care throughout the perinatal period.
In addition, a prominent shift between the Syrian and Lebanese healthcare systems is the presence of a private healthcare system. Coming from a publicly funded system in Syria and adjusting to the pay-for-use system in Lebanon is a difficult transition for families facing severe poverty. Despite subsidization of certain services in Lebanon, covering the remainder of the cost in a context of poverty can be an impossible task. For example, mother Umm-Farid and father Abu-Farid, parents of four children, described their experience with childbirth in Lebanon:
Umm-Farid: “It was the most difficult birth, because I was sick when I was pregnant. I had diabetes when I was pregnant with them. Even when I was giving birth, the money was not enough.
Abu-Farid: “I started running around asking for money.”
Umm-Farid: “I suffered in the hospital and when I moved into the house. Back in Syria, I was comfortable. If something happens, I would go directly to the hospital.”
The financial fragility of parents in Lebanon produces more stress around seeking healthcare due to fears of rejection at healthcare facilities or incurring insurmountable debt. For mothers with pre-existing conditions, this complicates prenatal care and adds stress as the mother knows that she is at higher risk, but might not be able to get good care. Cost of treatment is reported as a major barrier for Syrian refugees to access primary health care in Lebanon (UNHCR, 2022).
Further contributing to negative experiences within Lebanon’s healthcare system is the evident racism and discrimination embedded both within the system and within healthcare workers’ attitudes and biases towards Syrian refugees. Families interviewed recounted stories in which they felt discrimination when accessing healthcare services. For example, Umm-Amir and her husband Abu-Amir described their experience below:
Umm-Amir: “Let me tell you something. I had a boy who passed away here, he was five-months-old. He had an allergy and they did not know how to treat him … so he passed away. After he passed away, they didn’t give him to us as they wanted a big amount of money.”
Umm-Amir: “To give us the [child’s] corpse. The amount was how much?“
Abu-Amir: “One million two hundred and fifty-five thousand Lebanese pounds. This is [above what] the UN cover[s].”
Umm-Amir: “Other than the UN, yes. The child passed away at 5:30 am and they didn’t give him to us until the evening prayer. And we didn’t have a pound to give them.”
Q: “And they gave you the child without you paying them?”
Umm-Amir: “They took our IDs.”
Abu-Amir: “They still have our [identity] papers ‘til this day.”
Umm-Amir: “In Syria, they don’t do this. Here, if one of my children get[s] sick, I don’t take him to treat him. I have a fear from this thing now.”
Q: “What do you do then?”
Umm-Amir: “I leave it to God.“
These negative encounters with the Lebanese system further deter families from accessing perinatal services. This leaves families in vulnerable positions where they are more hesitant to access health care and may turn towards an external locus of control rather than attempting to take control of their own health. In another example, Umm-Mahmoud shared her experiences:
“When it comes to health services, it is also very difficult. We had to have someone help us, a special favor, just for them to let me enter the hospital. The hospital also told us that I needed blood, and that I might have to pay [USD$66]. We suffered for three to four days until the paperwork was done.”
Her husband, Abu-Mahmoud, added:
“The situation here in Lebanon is very bad. I do not want to have a child, I do not want to go to a doctor or a hospital. There are no residency cards or birth certificates. Two years ago, this wasn’t the case. But nowadays, the Syrian person is going through a lot of difficulties. If you need to register the child’s name for a birth certificate, you need to pay…a lot of money, and we cannot really afford it. I started wanting to go back to Syria and risk my life, rather than just stay here.”
Legal limbo is a major barrier for pregnant women and their families. It has become increasingly challenging for Syrian families to gain legal residency permits to stay in Lebanon. Fear of checkpoints and deportation have restricted the mobility of families to seek services. This results in a cycle of uncertainty that can impact wellbeing.
4. Lack of Social Supports
Previous research has described how social supports can help mothers mediate the stress of pregnancy in the context of war and displacement (Akesson, 2008). But, paradoxically, war and displacement may also rupture these social supports. Traditionally, if the family has extended family members with them, they tend to be the father’s family not the mother’s family. For example, Umm-Wahed was separated from her family in the process of fleeing Syria. When asked what it was like to not have her mother and sisters with her during the perinatal period, she explained: “I was crying the whole time. I would not do it again…. I missed my sisters and mom. Here my cousins didn’t leave me [during pregnancy and delivery], but it is different having your mom and sisters with you.” Having the support of female family members has long been found to be vital for women in the perinatal period (Madi et al., 1999; Pascali-Bonaro & Kroeger, 2004; Rosen, 2004). These social supports provide both familiarity, wisdom, advice, and guidance. During pregnancy, labor, delivery, and the postpartum period, female relatives who are versed in the traditions of the culture can provide emotional support and wisdom as well as take care of other children while the mother delivers. When midwives are not available, female relatives can provide that kind of female wisdom and guidance during labor and delivery based on their knowledge and cultural wisdom. Women interviewed in this research often remarked that their lives were missing that piece of family, and female relatives, who can provide irreplaceable support during pregnancy. The absence of these social networks resulted in the experience of pregnancy being increasingly difficult. For example, when recounting her experience of pregnancy in Lebanon, pregnant Umm-Reza said: “…it is hard, especially because there is no one by my side, no mother, no sister. I don’t have relatives here at all, I’m finding everything hard….” This statement underscores how the support should not be limited to labor and delivery, but also the following days, weeks, and months when the mother is caring for a small child while also attending to her own physical and psychological needs. Families provide that network of care for both the child and the mother as the mother recovers and the child acclimates to life.
Absence of these social networks creates additional challenges in the pregnancy and can relate to feelings of apathy for mothers as they can no longer immerse themselves in the joy of bringing a new life in the world with the presence of their cultural traditions. Discussing her experience working with a pregnant woman, Maysa, a UN worker told the research team:
“…she told me she doesn’t feel happy anymore, like having children here, because back in Syria, her family was around her, they used to support her, and now having a newborn baby here, she only worries about what they need. So, it is also affecting the relationship between a mother and her baby.”
Maysa touches upon the fact that the experience of pregnancy and delivery has reverberations for parental mental health, long-term mother-child relationships, and ultimately child outcomes. Decades of research have demonstrated the impact of parental mental health and child-parent relationship on long term health and social outcomes for children (Ainsworth & Bell, 1970; Bowlby, 1969; Freud & Burlingham, 1943; Masten & Monn, 2015; Walsh, 2016; Winnicott, 1992). Therefore, the absence of supportive social networks to support parental wellbeing has the potential to have significant impacts on future generations.
Conclusions and recommendations
The biomedical model dominates humanitarian approaches to the perinatal period leaving little room to explore psychosocial experiences (Holst, 2020). By focusing on women’s psychosocial experiences, research has a greater potential to provide a more comprehensive picture of the everyday challenges that pregnant women are faced with and often overcome. In turn this will lead to more relevant and impactful practices and policies that can ameliorate the negative consequences of war and displacement among this population.
The findings provide insight into how Syrian refugee mothers experience pregnancy and motherhood—from the prenatal (pregnancy) to postnatal (early childhood) period—in a context of war and displacement. The analysis uncovered four themes identified by the mothers: (1) apathy, (2) stress, (3) barriers to accessing services, and (4) lack of social supports. First, while pregnancy is often a time of excited anticipation, the mothers in this study described their experiences of pregnancy with a sense of apathy and detachment. Secondly, mothers noted high levels of stress during pregnancy related to the highly volatile context within which they were living. Third, in contrast to their childbearing experiences in Syria, Syrian mothers in Lebanon noted extreme difficulties in accessing perinatal care and access to delivery services such as using a midwife or delivering in a hospital. Finally, mothers noted extreme anxiety due to not having their female relatives (e.g., mothers, sisters, etc.) available to support them during the perinatal period. These findings have implications for practice, policy, and future research, which we will discuss below.
Practice
The data points to the importance of continuous support for refuge women from pregnancy to the post-partum periods. Continuity and consistency of services and supports is critical, as it will provide these women with a sense of stability in an otherwise unstable context. Rather than providing standalone medical care for pregnant women, perinatal care should include psychosocial support that addresses the circumstances within which these women are living.
Previous research has emphasized the importance of emotional, cognitive, and material social supports to pregnant women (Akesson, 2008; Jacobson, 1986). This was especially highlighted by the women in this study, as they lamented the distance from their female relatives and friends during the perinatal period. In practice, emotional supports could be enhanced through the development of psychosocial groups for pregnant women. These peer groups can be informational by providing practical information about pregnancy and childbirth, with a mental health component. They could also provide a forum for pregnant women to give and receive support with the goal of improving mental health. Other supports could take the form of safe motherhood training programs that provide education, distribution of supplies, and access to resources. This form of support could be combined with traditional birth attendants and midwives who could provide critical advice on what to expect during pregnancy and beyond. This can be an empowering process for women. Plus being surrounded by peers can help to combat the apathy that was present among many of our pregnant research participants. Helping pregnant women to develop these supports also contributes to their social capital.
Though this research was focused on the experiences of pregnant women, the family-approach to the research offered unique insight into the role of fathers and extended family members. Like any member of a family, that individual does not exist in a vacuum. They influence and are influenced by other family members, their communities, and the context. It may be commonly assumed that a pregnancy is a very personal event for the woman, but the pregnancy impacts the whole family. In fact, the engagement of fathers in this research was a unique voice that should be valued and considered in practice, policy, and future research. Therefore, future practice should aim to engage fathers and other extended family members as a vital component of programs and supports for women.
Policy
The women in this study noted the importance of their social networks and the sadness they felt to be separated from beloved family members, especially their mothers, sisters, and other female relatives. Broad policies impacting refugee populations should encourage social connectedness in families and communities. For example, resettlement policies that only allow for the nuclear family (father, mother, and children) should reconsider the importance of including the resettlement of extended family members, especially when the mother is pregnant. Allowing for extended family members—such a grandparents, aunts, uncles, cousins—would help the family to recreate the social system that is so helpful to support the pregnant woman, her family, and the new child.
Future Research
Not only do the data point to ways to work with pregnant women in contexts of war and displacement, but they also point to several areas that researchers could investigate further. One area to expand would be the connection between challenging pregnancy experiences during war and displacement and child development outcomes. This would best be accomplished using a longitudinal design that could account for the complete perinatal period and beyond. Of course, determining cause-and-effect would be impossible. But creative methodological design may uncover the constellation of adverse experiences that potentially impact mother and child in both the short- and long-term, thereby illuminating ways that practice and policy can further ameliorate the negative effects. A second area is in line with the recommendations above to consider the family as more than the mother-child dyad, and rather including fathers, siblings, grandparents, and other extended family members. Though focusing research on the family unit is more complicated and messy than traditional individual research, it has the potential to tell researchers more about how social support systems function and how they can be mobilized to support pregnant women. Most importantly, this research combats the underrepresentation of pregnant women in research more generally. Continuing to conduct ethically responsible research with this population is critical to ensure that their experiences are known, their voices are heard, and the actions taken to address issues related to pregnant women’s lives are relevant and have the potential to make a difference in the lives of Syrian mothers and their families.
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