The impact of armed conflict on utilisation of health services in north-west Syria: an observational study

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.