Background Armed conflicts are known to have detrimental impact on availability and accessibility of health services. However, little is known on potential impact on utilisation of these services and health seeking behaviour. This study examines whether exposure to different types of war incidents affected utilisation of key health services—outpatient consultations, antenatal care, deliveries, and C-sections, in conflict affected areas of north west Syria between 1 October 2014 and 30 June 2017. Methods The study is an observational study using routinely collected data of 597,675 medical consultations and a database on conflict incidents that has 11,396 events. Longitudinal panel data analysis was used with fixed effect negative binomial regression for the monthly analysis and distributed lag model with a lag period of 30 days for the daily analysis. Results The study found strong evidence for a negative association between bombardments and both consultations and antenatal care visits. The monthly Risk Ratio was 0.95 (95% CI 0.94–0.97) and 0.95 (95% CI 0.93–0.98); and the cumulative daily RR at 30 days was 0.19 (95% CI 0.15–0.25) and 0.42 (95% CI 0.25–0.69) for consultations and antenatal care respectively. Explosions were found to be positively associated with deliveries and C-sections. Each one unit increase in explosions in a given month in a given village was associated with about 20% increase in deliveries and C-sections; RR was 1.22 (95% CI 1.05–1.42) and 1.96 (95% CI 1.03–3.74) respectively. Conclusion The study found that access to healthcare in affected areas in Syria during the study period has been limited. The study provides evidence that conflict incidents were associated negatively with the utilisation of routine health services, such as outpatient consultations and antenatal care. Whereas conflict incidents were found to be positively associated with emergency type maternity services—deliveries, and C-sections.

BackgroundArmed conflicts are known to have detrimental impact on availability and accessibility of health services. Consequently, utilisation of healthcare is usually affected. However, little is known on the extent of these effects largely due to challenges facing research in such settings. This study examines whether exposure to war incidents affected utilisation of key health services in conflict affected areas of north west Syria between 1 October 2014 and 30 June 2017.MethodsThe study is an observational study using routinely collected data in 8 health facilities in north west Syria and a database on conflict incidents. Longitudinal panel data analysis was used with fixed effect negative binomial regression for the monthly analysis and distributed lag model with a lag period of 30 days for the daily analysis.ResultsThe study found strong evidence for a negative association between bombardments and both consultations and antenatal care visits. The monthly Risk Ratio was 0.95 (95%CI: 0.94-0.97) and 0.95 (95%CI: 0.93-0.98) respectively; and the cumulative daily RR at 30 days was 0·19 (95%CI: 0·15 - 0·25) and 0·42 (95%CI: 0·25 - 0·69) for consultations and antenatal care respectively. Explosions were found to be associated with an increase in the number of deliveries and C-sections. The data provides evidence that each one unit increase in explosions in a given month in a given village was associated with about 20% increase in deliveries and C-sections; RR was 1·22 (95%CI: 1·05-1·42) and 1·96 (95%CI: 1·03-3·74) respectively.ConclusionThe study found that access to healthcare in affected areas in Syria has been limited. The study also provides evidence that conflict incidents were associated negatively with the utilisation of health services. Based on this evidence, health actors in conflict settings need to adopt strategies that ensure availability and accessibility of health services such as decentralisation and outreach health services.