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Table 3 Identified Peer-Reviewed Articles and Reports

From: An overview of the sexual and reproductive health status and service delivery among Syrian refugees in Jordan, nine years since the crisis: a systematic literature review

Author(s)/ Year Title Type of Publication Journal or Agency Design/ Methods Major Findings Discussions, Implications, Recommendations
Gausman J et al., 2019 [25] How do Jordanian and Syrian youth living in Jordan envision their sexual and reproductive health needs? A concept mapping study protocol Peer-reviewed article BMJ Open Concept mapping Other studies indicate that Jordanian youth require reproductive health-related support, information and services; however, there remains very limited data as to how youth envision their SRH challenges and needs. Findings of this study will be released in future. Many of the SRH issues are inter-related and interact with each other. Recommendations will be released in future.
Al-Rousan T et al., 2018 [16] Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers Peer-reviewed article EMHJ Qualitative and quantitative methodologies. Many different problems were revealed such as cost, limited resources, changing policies, livelihoods and poor health literacy impeded delivery of public and clinical health services.
Of note is that, according to health care providers and key informants, Syrian refugees primarily seek health care for acute conditions, including respiratory illness, fever, diarrhea and injuries. Providers noted that the primary reason for reduced access to antenatal care was the lack of female physicians.
Syrian refugees identified cost as the main barrier to health care access. Both refugees and health care providers emphasized the importance of directing more resources to chronic diseases and mental health
One of the recommendations was to ensure availability of female physicians to provide these services in a culturally sensitive manner
UNHCR, 2018 [3] Health access and utilization survey: Access to healthcare services among Syrian refugees in Jordan Report UNHCR Cross-sectional Survey Women who needed antenatal care (ANC) were 17% of WRA or women of reproductive age (15–49 years), while 90% of the pregnant females received ANC during the last 2 years. Percentage of pregnant women who had difficulty accessing ANC was 16%. The highest number of pregnant females faced difficulties in user fees (55%) and transport cost (23%) in 2018, which were less in 2017 (46 and 19% respectively). An increase in child deliveries was witnessed among Syrian households in 2018, with 86% females delivering newborns compared to 74% in 2017.
Pregnant females with more than 4 ANC visits represent 67.9%. Deliveries location are divided among governmental hospitals (48%) and private clinics/hospitals (46%). Healthcare services were needed by 49% of household members in 2018 compared to 37% in 2017.
 
Asaf Y, 2017 [14] Syrian Women and the Refugee Crisis: Surviving the Conflict, Building Peace, and Taking New Gender Roles Peer-reviewed article Social Sciences Secondary research, review Refugees who are not registered or those living outside of camps have more difficulty to public services, They also have no right to work in Jordan, Turkey, and Lebanon. Gender is not mainstreamed in policies, affecting women and girls in particular. Women are targeted with various forms of gender-based violence, while the issues they raise are often marginalized or excluded.  
DeJong J et al., 2017 [19] Reproductive, maternal, neonatal and child health in conflict: a case study on Syria using countdown indicators Peer-reviewed article BMJ Global Health Systematic literature review Coverage rates of most key evidence-based interventions in reproductive, maternal, newborn and child health declined in Syria: among refugees in neighboring countries the picture was more mixed as compared with pre-conflict Syria. And in conflict settings such as that of Syria, coverage rates of such interventions are often unknown or difficult to ascertain. Research, 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.
Samari, G., 2017 [26] Syrian Refugees Women’s Health in Lebanon, Turkey, Jordan and Recommendations for Improved Practice Peer-reviewed article World Medical Health Policy Literature review Sexual and gender-based violence was associated with a reduced use of modern contraceptives. Menstrual irregularity, unplanned pregnancies, preterm birth, and infant morbidity are ongoing issues.
It was also noted that increased availability of female physicians will provide women’s health services in a culturally appropriate manner.
Taking a multilevel approach to eliminate social and service delivery barriers that prevent access to care, conducting thorough needs assessments, and creating policy and programmatic solutions that establish long term care for Syrian refugee women. One of the recommendations was also to ensure availability of female physicians to provide these services in a culturally sensitive manner
UNHCR, 2017 [27] Health access and utilization survey: Access to health services in Jordan among Syrian refugees Report UNHCR Cross-sectional Survey An increase in pregnant females who received antenatal care (88% vs. 85% in year 2016). A significant increase in difficulty accessing ANC, and an increase in those who can’t afford fees or transport compared to 2016. A decrease in the deliveries free of cost. Majority of deliveries took place mainly in governmental (53%) and private facilities (40%).  
Ay et al., 2016 [28] The perceived barriers of access to health care among a group of non-camp Syrian refugees in Jordan Peer-reviewed article International Journal of Health Services Cross-sectional, analytical, observational study using convenience and snowball sampling for data collection Preventive and primary health care were more accessible than advanced services. Structural and financial barriers hindered access. The capacities of health facilities at different levels should be increased. Enhanced information sharing among health providers can improve identification of needs and gaps.
Clark et al., 2016 [7] The influence of family violence and child marriage on unmet need for family planning in Jordan Peer-reviewed article Journal of Family Planning and Reproductive Health Care Logistic regression Experiencing family and intimate partner violence (IPV) has a compounding effect on unmet need for contraception among women who married as minors. Women married as minors who experienced IPV and FV had a four-fold higher likelihood of having an unmet need compared to those experiencing only IPV. No interaction between IPV and FV was detected for women married at or above majority. Screening for intimate partner violence (IPV) and family violence in health services may identify women who are especially vulnerable to having an unmet need for contraception. Laws that prohibit child marriage should be strengthened and health sector screening for violence experience could help identify women at risk of unmet need and improve their reproductive agency.
JCAP, 2016 [11] Family Planning Among Syrian Refugees in Jordan Report USAID/ JCAP Desk review Majority (85%) of Syrian refugees live outside camps, most of them ‘extremely vulnerable.’ Use of modern methods was lower among Syrians, at 22% vs. 29% of Jordanians. In 2015 only 64% of households of registered Syrian refugees knew that refugees had subsidized access to government primary health centers. While early marriage has long been an accepted practice in Syria, registered marriages among Syrian refugees including girls aged 15–17 increased almost threefold, from 12% in 2011 to nearly 32% in 2014. There is no reliable information on the number or proportion of Syrian refugees in Jordan who have experienced GBV Many Syrian refugees living outside of camps are unaware of health services available to them, especially women who have limited mobility. Support the national health system and services to strengthen the quality and accessibility of comprehensive RH/FP information and services for all residents in Jordan including Syrian refugees. Increase Syrian refugee access to accurate information about reproductive health and available services. Ensure broad awareness of the MOH policy issued in February 2016 regarding free maternal and health and family planning services in public health facilities for registered Syrian refugees.
Empower girls and educate parents and community members against child marriage. Prevent early pregnancy among young married girls through counseling. Increase access to accurate information about FV, IPV and GBV.
Juraibei, et al., 2016 [12] Reproductive Health Services for Syrians Living Outside Camps in Jordan Report The Higher Population Council Cross-sectional, descriptive study of SRH service recipients and providers The majority of organizations providing RH services to non-camp Syrians refugees reported financial challenges and high operational costs and costs incurred by Syrians reach centers, socially-sanctioned barriers to providing Syrians with RH services, a general lack of awareness, family intervention in personal healthcare choices, restrictive norms/ traditions, and early marriage. 68% receiving RH services were females aged 12–49 years and half of them receiving these services from NGOs. 41.4% used modern contraceptive methods. They had medium levels of satisfaction with the received RH services. Most of those not going to RH centers noted far location from their residence, overcrowded, lack of medical specializations, and poor treatment by center workers. Also, new security cards were one big public policy barriers to Syrians’ access to RH clinics. Raising awareness among Syrians residing outside of refugee camps on RH/FP services, early marriage, and pregnancy spacing. Provide financial support to MOH and technical/ logistical support to organizations providing RH services to non-camp Syrian refugees. Develop employee standards at RH clinics. Continuously monitor organizations providing RH services to non-camp Syrian refugees to ensure quality services and efficient operations. Activate legislation related to early marriage. Reassess ID card policies so as to allow cardholders to receive treatment at any health center outside of their residential areas.
Smith, H., 2016 [29] Syrian refugee women in Jordan: Family Planning Preferences and Barriers in a Host Community Peer-reviewed article SIT Digital Collection Cross-sectional study Although 71% of the women surveyed found their RH care provider to be extremely or somewhat trustworthy, nearly 86% of them said their health care provider did not initiate a conversation about birth control, causing a lack of awareness. Only 36% of women surveyed had attended an informal support group. Many women interviewed stated that birth control was harder to access in Jordan than in Syria due to lack of affordability and health insurance. This study recommends that birth control be more prevalent and discussed more in reproductive health clinics while being made more affordable.
West et al., 2017 [30] Factors in use of family planning services by Syrian women in a refugee camp in Jordan Peer-reviewed article Family Planning and Reproductive Health Care A small-scale qualitative study Family planning (FP) services were available; however, barriers to service uptake included poor awareness of FP services, overburdened health services, cultural pressures regarding fertility, and poorly trained service providers. International attempts to address refugees’ family planning needs remain inconsistent. Future research is needed into effective methods for international dissemination of evidence for established interventions in FP and how to adapt such interventions in different refugee settings.
Essaid M et al., 2015 [13] Gender Based Violence Against Women and Girls Displaced by the Syrian Conflict in South Lebanon and North Jordan: Scope of Violence and health correlates Research paper Spanish Agency for International Development Cooperation Mixed-methods design GBV is a significant problem in North Jordan and South Lebanon for Syrian refugee women and girls and frequently restrict their movement, causes them mental and physical distress, and occurs both inside and outside of the home. GBV is a contributor to poor RH outcomes among Syrian refugee women and highlights the risk to women’s reproductive and sexual health. Barriers to support seeking included shame because revealing family violence is perceived as a violation of social norms, fear of the consequences, lack of trust in service providers, and inability to leave the home due to lack of finances or childcare. Integrate the updated Inter-Agency Standing Committee (IASC) guidelines into GBV response in Lebanon and Jordan.
Higher Population Council King Hussein Foundation, 2015 [31] Jordan Agenda Setting for Sexual and Reproductive Health and Rights Knowledge Platform Report Higher Population Council King Hussein Foundation
Share-Net International
Agenda-setting discussion Improved SRHR can result from: better information and greater freedom of choice for young people about their sexuality; improved access to reproductive health commodities; better sexual and reproductive health care (during pregnancy and childbirth, including safe abortion); and, greater respect for the sexual and reproductive rights of groups who are currently denied these rights.  
Krause et al., 2015 [4] Reproductive health services for Syrian refugees in Zaatari Camp and Irbid city, Hashemite Kingdom of Jordan: An evaluation of the Minimum Initial Services Package. Peer-reviewed article Conflict and Health Formative evaluation approach Lead health agencies addressed the MISP by securing funding and supplies and establishing RH focal points, services and coordination mechanisms. However, Irbid City was less likely to be included in coordination activities and health facilities reported challenges in human resource capacity. Access to clinical management of rape survivors was limited, and both women and service provider’s knowledge about availability of these services was low. Activities to reduce the transmission of HIV and to prevent excess maternal and newborn morbidity and mortality were available, although some interventions needed strengthening. Some planning for comprehensive RH services, including health indicator collection, was delayed. Contraceptives were available to meet demand. Syndromic treatment of sexually transmitted infections and antiretrovirals for continuing users were not available. In general refugee women and adolescent girls perceived clinical services negatively and complained about the lack of necessities. MISP services and key elements to support implementation were largely in place. Pre-existing Jordanian health infrastructure, prior MISP trainings, dedicated leadership and available funding and supplies facilitated MISP implementation. The lack of a national protocol on clinical management of rape survivors hindered provision of these services, while communities’ lack of information about the health benefits of the services as well as perceived cultural repercussions likely contributed to no recent service uptake from survivors. This information can inform MISP programming in this setting.
Masterson A et al., 2014 [32] Assessment of reproductive health and violence against women among displaced Syrians in Lebanon Peer-reviewed article BMC Women’s Health Cross-sectional needs assessment, Survey, Bivariate and multivariate analyses We interviewed 452 Syrian refugee women ages 18–45 who had been in Lebanon for an average of 5.1 (± 3.7) months. Reported gynecologic conditions were common. Of women who experienced conflict-related violence (30.8%) and non-partner sexual violence (3.1%), the majority did not seek medical care (64.6%). Conflict violence and stress score was significantly associated with reported gynecologic conditions, and stress score was found to mediate the relationship between exposure to conflict violence and self-rated health. This study contributes to the understanding of experience of conflict violence among women, stress, and reproductive health needs. Findings demonstrate the need for better targeting of reproductive health services in refugee settings, as well as referral to psychosocial services for survivors of violence.
Although not a main recommendation, increased availability of female physicians will provide women’s health services in a culturally appropriate manner.
Doedens W et al., 2013 [33] Reproductive Health Services for Syrian Refugees in Zaatri Refugee Camp and Irbid City, Jordan. Report Washington, DC: US Department of State, Bureau of Population, Refugees and Migration Mixed quantitative and qualitative methods In spite of the steady influx of refugees into Jordan that has strained the resource capacity of this humanitarian emergency response, the agencies that provide RH services have been able to implement the MISP for the most part, although there is need for some key improvements. In this setting, the study team found some challenges, such as balancing the increasing demands for services while maintaining quality and managing information flow among multiple stakeholders. It is vital to stay informed and listen to the needs of Syrian refugees in Jordan to improve RH outcomes in the months to come.
Key informants were aware of the five MISP objectives. However, there was very limited understanding of the additional priorities of the MISP such as ensuring contraceptives are available to meet the demand; treatment for sexually transmitted infections (STIs) is available to people presenting with symptoms; antiretrovirals (ARV) are available to current users; and menstrual, hygiene supplies are available.
A number of key elements to support implementation of the MISP were in place, including a dedicated lead agency to support MISP implementation within the health sector, a focal point for RH coordination, regular RH coordination meetings, and RH kits and supplies, and funding for MISP implementation. However, key informants reported that RH coordination was insufficient for the urban areas; not all key stakeholders participated in coordination; protocols for care for survivors of sexual violence were incomplete or STIs did not exist; and that key informants would like UNFPA to share the information that it collects from stakeholders among stakeholders.
Syrian refugee women discussed security fears that they had in relation to using the latrines at night due to a lack of lighting. While services existed to manage sexual violence (SV), they were limited, and community and provider knowledge of the services was low.
In terms of additional priorities to the MISP, modern methods of family planning was available (although condom distribution limited), syndromic treatment for people presenting with symptoms of STIs was not available, the situation of continuing ARVs for refugees already on ARVs was unknown and menstrual hygiene supplies were insufficient.
MISP contingency plans were established but not activated. Jordan has undertaken some activities on disaster risk reduction although it was unclear if there have been initiatives to address health and RH.
Barriers to MISP implementation included a lack of adequate staffing in urban areas and of clear RH protocols, particularly on care for survivors of SV, and management of STIs); less focus by the RH working on urban populations compared with the camp population; and lack of capacity to implement the MISP contingency plan.
Strengthen coordination to address the RH needs of urban refugee populations; facilitate the participation of key stakeholders; address RH protocols, particularly, finalize the clinical care for SV survivors protocol; identify STIs management and protocols for referral of and caring for person living with HIV (PLHIV); improve data collection and use of data for action; and support information, education and communication (IEC) campaigns on the benefits to seeking care and the availability, location and hours of services in both urban areas and Zaatri refugee camp.
Improve free condom distribution with sensitivity to cultural norms.
Scale up the availability of clinical care for survivors of SV at service delivery sites and consider integrating the protocol into the Family Protection Department where forensic doctors are available and could be trained.
Strengthen community outreach, participation and services along with information and education, including for adolescents and people with disabilities, by utilizing existing IEC campaign resource materials on the MISP and family planning, and ensuring all service delivery is physically accessible and inclusive of people with disabilities.
Improve the health care environment with adequate staffing, particularly female doctors and by addressing the interactions between health care providers and Syrians so that Syrian women feel comfortable while seeking care. Advocate for Syrian health care providers to be involved in providing health care services to the refugees.
UN Women. (2013) Gender-based violence and child protection among Syrian refugees in Jordan, with a focus on early marriage: Inter-agency assessment Report United Nations Entity for Gender Equality and the Empowerment of Women (UN Women) Mixed method: Cross-sectional survey, FGDs, and KI interviews Women and children (80% of Jordan’s Syrian refugee population) are vulnerable to an increased risk of sexual, physical, and psychological abuse, yet have limited opportunities to access safe spaces or social services. Among those girls who were employed, 80% work in either domestic work or agriculture, both of which are known to be high-risk sectors for physical abuse and sexual exploitation.
Gender-based Violence (GBV) remains a private and sensitive issue that is largely addressed within the home setting. Specialized, confidential, and supportive services currently available to Syrian women and children survivors of GBV are not sufficient, and when such resources are available, Syrian refugees are very often (83%) unaware of them.
Early Marriage is a common experience for Syrian girls (51.3% married before the age of 18 and most prior to their arrival in Jordan), yet women of all ages knew someone who had experienced early marriage. With unemployment and dwindling family resources, more prolonged displacement will lead to greater likelihood of early marriage for girls, while many acknowledged heading households and rearing children at such a young age to be stressful and challenging.
Expand and improve services to respond to GBV including access to sexual and reproductive health information and programs.
Increase access to safe spaces in which trained professionals can provide psychosocial support for Syrian refugees who are experiencing violence, abuse, and exploitation. Increase availability of mobile clinics/units including GBV services to enable outreach in remote areas.
Donors should allocate predictable funding and sustain funding to support implementation of safe, non-stigmatizing, culturally relevant initiatives to prevent and respond to GBV strategies that will have longer-term impact on refugees, promoting durable solutions for “the day after” in Syria. GBV interventions should prioritize participation of men and boys as part of a comprehensive strategy to prevent, mitigate and respond to related risks.
Livelihood programs should be scaled up to support resilience and positive coping mechanisms of Syrian refugees to support broader prevention and reduction of GBV.