While postpartum home visits significantly increased exclusive breastfeeding, other outcomes did not change. Further studies framed in a nonbiomedical context are needed. Other innovative approaches to improve postnatal care in Syria are needed.

Implementing labor companionship can improve women's childbirth experiences and outcomes. Organizational structural barriers and non-supportive providers' attitudes need to be addressed to influence hospital practices.

IntroductionWomen and children account for a disproportionate morbidity burden among conflict-affected populations, and yet they are not included in global accountability frameworks for women’s and children’s health. We use Countdown to 2015 (Millennium Development Goals) health indicators to provide an up-to-date review and analysis of the best available data on Syrian refugees in Jordan, Lebanon and Turkey and internally displaced within Syria and explore data challenges in this conflict setting.MethodsWe searched Medline, PubMed, Scopus, Popline and Index Medicus for WHO Eastern Mediterranean Region Office and relevant development/humanitarian databases in all languages from January 2011 until December 2015. We met in person or emailed relevant key stakeholders in Lebanon, Jordan, Syria and Turkey to obtain any unpublished or missing data. We convened a meeting of experts working with these populations to discuss the results.ResultsThe following trends were found based on available data for these populations as compared with preconflict Syria. Birth registration in Syria and in host neighbouring countries decreased and was very low in Lebanon. In Syria, the infant mortality rate and under-five mortality rate increased, and coverage of antenatal care (one visit with a skilled attendant), skilled birth attendance and vaccination (except for DTP3 vaccine) declined. The number of Syrian refugee women attending more than four antenatal care visits was low in Lebanon and in non-camp settings in Jordan. Few data were available on these indicators among the internally displaced. In conflict settings such as that of Syria, coverage rates of interventions are often unknown or difficult to ascertain because of measurement challenges in accessing conflict-affected populations or to the inability to determine relevant denominators in this dynamic setting.ConclusionResearch, monitoring and evaluation in humanitarian settings could better inform public health interventions if findings were more widely shared, methodologies were more explicit and globally agreed definitions and indicators were used consistently.

Ultrasound scanning is firmly embedded in antenatal maternity care around the world. This paper reports on a qualitative study carried out in 2003 of 30 Syrian women's perceptions and experiences of routine ultrasound in pregnancy. It was part of a larger study of the experiences of pregnancy and childbirth of 500 women from Damascus and its suburbs who had recently given birth to healthy newborns. The women had had multiple scans during pregnancy and accepted its use uncritically nearly all the time. The scans gave them reassurance that the baby was healthy, the pregnancy was progressing well and allowed them to learn the sex of the baby. The women also reacted positively to the antenatal educational messages that were conveyed using scans. However, we found the excessive use of this technology worrying. We believe private doctors, who attend 80% of pregnant women, use ultrasound primarily to attract women to their clinics and increase their income. We recommend that maternity care in Syria should be better regulated; that women and their doctors should be made aware of the essential components of antenatal care; that notional guidelines for antenatol care should be developed and that Syrian women should be empowered to ask questions about pregnancy and childbirth and the care they receive.

ObjectivesTo determine the effect of training residents in interpersonal and communication skills on women’s satisfaction with doctor–woman relationship in labour and delivery rooms.DesignA stepped wedge cluster randomised trial.Setting4 tertiary care teaching maternity hospitals in Damascus, Syria.Participants2000 women who gave birth to a living baby in the four study hospitals and consented to participate in the intervention took part in the study. Women with difficult labour and high-risk pregnancies were excluded. All were interviewed at home after discharge.InterventionsA specially designed training package in communication skills was delivered to all resident doctors at the four hospitals.Primary outcome measuresThe main outcome measure was women’s satisfaction with interpersonal relationships in labour and delivery rooms measured via a series of questions on a Likert scale modified from the Medical Interview Satisfaction Scale.ResultsAt the individual level, the mean for the average satisfaction score was 3.23 (SD 0.72) of a possible score of 5 in the control group and 3.42 (SD 0.73) in the intervention group. Using generalised linear mixed models, we were unable to detect a difference between the mean for the average satisfaction score of women in the intervention arm and that of women in the control arm; the 95% CI associated with the effect of the intervention ranged from –0.08 to 0.15.ConclusionsDespite slight changes in the observed residents’ communication skills, the training package in communication skills does not seem to be associated with higher satisfaction scores of women. This raises the question of whether training individuals without further structural changes in the delivery of care and without further reinforcement of the training can have an impact on improving the quality of doctor–patient communication.Trial Registration NumberISRCTN80243969

To the Editor-Children are the invisible victims of the COVID-19 pandemic. Although they have a low risk of severe COVID-19 disease and death, they are suffering disproportionate harm from non-pharmaceutical public-health measures, including deleterious educational effects of school closures, and decreased social care,

Prior to the conflict, Syria had relatively high fertility rates. In 2010, it had the sixth highest total fertility rate in the Arab World, but it witnessed a fertility decline before the conflict in 2011. Displacement during conflict influences fertility behaviour, and meeting the contraceptive needs of displaced populations is complex. This study explored the perspectives of women and service providers about fertility behaviour of and service provision to Syrian refugee women in Bekaa, Lebanon. We used qualitative methodology to conduct 12 focus group discussions with Syrian refugee women grouped in different age categories and 13 in-depth interviews with care providers from the same region. Our findings indicate that the displacement of Syrians to Lebanon had implications on the fertility behaviour of the participants. Women brought their beliefs about preferred family size and norms about decision-making into an environment where they were exposed to both aid and hardship. The unaffordability of contraceptives in the Lebanese privatised health system compared to their free provision in Syria limited access to family planning services. Efforts are needed to maintain health resources and monitor health needs of the refugee population in order to improve access and use of services.

BackgroundThe cooperation of patients and their consent to involve medical students in their care is vital to clinical education, but large numbers of students and lack of experience as well as loss of privacy may evoke negative attitudes of patients, which may sometimes adversely affect the clinical teaching environment. This study aimed to explore the attitudes of patients towards medical students at Damascus University hospitals, and to explore the determinants of those attitudes thus discussing possible implications applicable to clinical teaching.MethodsThis cross-sectional study was conducted at three teaching hospitals affiliated to the Faculty of Medicine at Damascus University. Four hundred patients were interviewed between March and April 2011 by a trained sociologist using a structured questionnaire.ResultsOf the patients interviewed, 67.8% approved the presence of medical students during the medical consultation and 58.2% of them felt comfortable with the presence of students, especially among patients with better socio-economic characteristics. 81.5% of the patients agreed to be examined by students in the presence of the supervisor, while 40.2% gave agreement even in the absence of the supervisor. Privacy was the most important factor in the patients' reticence towards examination by the students, whilst the relative safety and comfort if a supervisor was available determined patients' agreement.ConclusionsThe study concluded overall positive attitudes to the medical students' involvement in medical education. However, it is essential that students and clinical supervisors understand and adhere to professional and ethical conduct when involving patients in medical education.