Investigating the impact of armed conflict, cultural factors, and demographic characteristics on access to family planning services in Northwest Syria: a cross-sectional study

Abstract

Against the backdrop of a protracted conflict, northwest Syria faces significant challenges in delivering sexual and reproductive health and rights (SRHR) services. The conflict, which began in 2011, has severely impacted maternal and child health, women’s wellbeing, and agency. This disruption has been exacerbated by widespread displacement, infrastructure damage, and interruptions in reproductive healthcare provision. Addressing these challenges is crucial for advancing family planning and empowering women in the region. This study investigates the factors influencing family planning service accessibility in northwest Syria, considering the intricate interplay of cultural norms, beliefs, and the backdrop of armed conflict. The study employed a cross sectional-methods approach incorporating structured surveys with a sample size of 2175 women, representing diverse demographics across the region.

38% of the 2175 participants were in early marriages, defined as any formal marriage or informal union between a child under the age of 18 and an adult or another child (UNICEF India, Child marriage, 2017). Among them, 58% reported current contraceptive use. Analysis by age groups revealed that individuals aged 26–35 exhibited the highest proportion of contraceptive usage at 41.5%, while the under-18 age group showed the lowest at 7.7%. Predominantly, oral contraceptive pills were the most used contraceptive method (40%), followed by intrauterine devices (IUDs) (31%), condoms (7%), and injectables (5%). Of contraceptive users, 29% reported experiencing side effects, with bleeding between periods or spotting being the most prevalent (26%), followed by irregular periods (21%). Despite 75.5% of participants being internally displaced persons (IDPs), there was no significant difference in usage between IDPs and residents (p = 0.337), although IDPs residing in camps showed the highest usage at 67%. Attending awareness sessions on family planning was associated with increased contraceptive usage, with 67% of attendees reporting usage compared to 44% of non-attendees. Education level and family monthly income strongly influenced usage, with higher education and income correlating with increased usage (p < 0.001 for both). Moreover, the number of children significantly impacted usage, with higher rates observed among women with more children (p < 0.001). Logistic regression analysis further demonstrated that awareness of family planning methods significantly influenced usage (OR: 2.39, p < 0.001).

Our findings underscore the pronounced influence of cultural beliefs on individuals’ attitudes towards family planning. Displacement, infrastructure damage, and interruptions in healthcare delivery pose formidable barriers, further marginalising vulnerable populations. Community engagement and resilient healthcare infrastructure emerge as critical facilitators, fostering trust and service utilisation. Conversely, stigma, misinformation, and resource constraints hinder access, underscoring the need for targeted interventions.

This research illuminates the complex dynamics surrounding family planning practices in northwest Syria. Holistic strategies are needed to ensure equitable access to family planning services in northwest Syria and similar contexts globally. By addressing the intersecting challenges of culture and conflict, efforts can be directed towards meeting the reproductive health needs of populations enduring humanitarian crises.

Introduction

Ensuring robust sexual and reproductive health and rights (SRHR), including access to comprehensive family planning services, is crucial for reducing maternal mortality and morbidity, safeguarding the health of newborns, infants, and children, and securing a better future for generations [1]. Armed conflict, forced displacement, and natural disasters account for 60% of unnecessary maternal mortality, 53% of deaths in children under five, and 45% of newborn deaths [2, 3].

Family planning is significant in alleviating poverty and reducing maternal mortality. Yet, in low and middle-income countries, approximately 218 million women and girls of reproductive age who desire to prevent pregnancy do not utilize safe and effective family planning strategies for a range of reasons, including difficulty finding information or services and insufficient support from their families or societies [4]. Furthermore, the approximate 3 to 6 months interruption of the availability of family planning supplies and services during the first year of the COVID-19 pandemic may have contributed to more than 1.4 million unplanned pregnancies [4].

Due to the breakdown or disruption of vital sexual and reproductive health infrastructure and services in conflict settings, displaced women and girls are particularly susceptible to high-risk and unintended pregnancies, miscarriages, perinatal complications, unsafe abortions, and unsafe deliveries and subsequent deaths [5]. Even in areas where these services exist, women may have trouble gaining access to them due to inadequate coordination, lack of information, or insecurity, and numerous pregnant women and girls give birth without the intervention of a trained medical professional [6].

The impact of culture, beliefs, and conflict on access and provision of effective family planning services is significant. Cultural factors, such as kinship and reproductive decision-making, vary across regions, communities, religions, influencing program design and organization [7]. Gender and socio-cultural factors can create obstacles to informed discussions about sexual and reproductive health issues, including contraception, with women often requiring permission or consent from spouses to access contraceptive services [8]. In conflict and humanitarian settings, misconceptions, religious objections, and larger family size as a perceived advantage, can hinder the acceptability and uptake of family planning services [9]. Sociocultural hindrances, discriminatory gender norms, and limited autonomy for women, combined with facility-level barriers and supply-side challenges, further impede access to modern contraception [10, 11].

Syria confronts multiple obstacles, making it among the world’s most complex humanitarian crises [12]. After more than 13 years of armed conflict, northwest Syria (Idleb and Aleppo governorates) remains the only part of Syria partially controlled by non-state actors. The health system in northwest Syria is heavily disrupted due to systematic attacks on healthcare facilities, a shortage of resources, and loss of medical expertise, resulting in an inadequate health system supporting more than 4 million people [13].

In northwest Syria, approximately 5.1 million people are living, including 3.4 million people who are internally displaced and 3.97 million in need of health assistance. Notably, 1.15 million women of reproductive age urgently require lifesaving, high-quality, and dignified sexual and reproductive health (SRH) services. Of these women, over 150,000 are expected to give birth in 2024. Additionally, more than 600,000 women and girls will need comprehensive and tailored family planning services, with a high risk that their needs may go unmet [14].

The situation in northwest Syria is particularly dire, with SRH needs increasing due to a lack of funding and the forced closure of health facilities providing these essential services. Less than 45% of functional health facilities in northwest Syria offer any form of SRH services, including those that provide basic or comprehensive emergency obstetric and newborn care (EmONC). 232 facilities provide RH services among them 60 are EmONC facilities (SRH TWG data) [15].

Attacks on health facilities, the distance to health facilities, and the risk of captivity prevent women in northwest Syria from receiving adequate access to reproductive health services [16]. Furthermore, the earthquake that hit southern Turkey and northern Syria in February 2023 completely damaged 15 facilities, resulting in their closure, and partially damaged a further 55, resulting in their closure [17].

The aim of this study is to investigate how the predominant culture and belief system in northwest Syria impact women’s access to sexual and reproductive healthcare services, focusing on family planning. Family planning is part of the concept of SRH, which encompasses a state of physical, emotional, mental, and social well-being in relation to all aspects of sexuality and reproduction. It moreover involves the ability to have a safe and satisfying sexual life, the capacity to reproduce, and the freedom to make informed decisions about reproduction, including family planning [18]. Understanding community perceptions, sociocultural norms, and barriers to utilizing services is crucial for identifying family planning needs, in addition to developing key strategies to provide reproductive and family planning services that respect beliefs and cultural norms. To enable this comprehension of community perception, the survey included sixteen tailored statements in which participants had five options to rank their views on each statement (see Additional file 1). This study is the first to investigate multiple barriers and beliefs to accessing family planning services in northwest Syria. The research examines the intersecting difficulties faced in accessing essential services in northwest Syria, where the ongoing conflict, the threat of earthquakes, and potential limitations on cross-border assistance compound the challenges.

Methods

Study design

The study relied on a quantitative survey approach (cross-sectional study) through secondary data collected by Syria Relief and Development (SRD), a leading non-governmental organization in northwest Syria. The data collection strategy involved surveying all women and girls who met the inclusion criteria. This included those who visited the health facilities for any reason as well as those reached through Community Health Workers (CHWs). Trained data collectors conducted the surveys using the KoBo Toolbox platform, ensuring systematic and standardized data gathering. The data was used only for program planning. The data is publicly accessible with the aim of enhancing the response of family planning programs in northwest Syria.

Study setting and population

The targeted population was women between the reproductive ages of 15–45 years old, who were either residents or IDPs in northwest Syria.

Study sample

The available data was collected by SRD in 2022 through conducting a survey in six health facilities. The supported facilities are Emergency Obstetric and Newborn Care (EmONC) centers, including one Comprehensive Emergency Obstetric and Newborn Care (CEmONC) facility and several Basic Emergency Obstetric and Newborn Care (BEmONC) facilities. These facilities are located across multiple districts in Idleb and Aleppo. They provide a range of reproductive health (RH) services as well as general healthcare, delivered by doctors, midwives, and nurses. SRD supports and directly operates these facilities in the main subdistricts with the largest population.

A total of 2250 participants were surveyed based on a systematic sampling technique, and a sample of 2175 records was included in the data analysis of our study that applies the agreed criteria. Systematic sampling at health facilities involved selecting participants at regular intervals from those visiting the facilities or those accessed through CHWs or outreach teams. In this study, participants were women aged 15–49 years, whether pregnant or not, and included those seeking antenatal or postnatal care, family planning services, child vaccinations, or other health services. The survey was supported by various health facilities, including reproductive health units, outpatient departments, and vaccination clinics, ensuring a comprehensive representation of service utilization.

Inclusion and exclusion criteria

The study’s inclusion criteria comprised married women aged 15–45 residing in northwest Syria for at least one year. This selection was made because unmarried women were interviewed in limited numbers, and considering the context of northwest Syria, unmarried women may not disclose accurate information on family planning usage due to societal norms, which can introduce a measurement bias. Conversely, exclusion criteria encompassed women whose health beliefs or access to health services differed significantly, despite meeting residency requirements in northwest Syria. For instance, women with religious or cultural beliefs that strongly opposed modern contraceptive methods, or those with access to specialized healthcare services beyond what is typically available in the region, were excluded. Additionally, women who do not believe in healthcare services at all and resort to traditional medicine, such as traditional treatment, or natural remedies, were also excluded, as they do not answer health-related questions and are attended to by traditional midwives during childbirth. These factors could potentially bias the results and limit the study’s applicability to the broader population. This exclusion was made by the Syria Relief and Development Team, as the information was gathered from health center teams, and therefore only women with access to these services at the facilities were included.

Data sources and management

This study employed a systematic analysis of primary data available on the NGO’s website for data collection. After securing permission, the information was downloaded in excel format. Following data extraction, cleaning procedures were undertaken to enhance data quality, including eliminating duplicates and addressing outliers. Criteria set for the study purpose, such as excluding responses from males or unmarried women, were applied. The data, collected between July and October 2022, utilised a Kobo questionnaire prepared by a reproductive health consultant and underwent rigorous training of data collectors to ensure quality and minimise bias. Ethical principles were emphasised, with verbal consent obtained from female participants before data collection and conducted by female interviewers recruited from local communities or health facilities staff. The female interviewers were working as CHWs. All data collectors were trained on data ethics and data collection. All data collectors used the same questionnaire. The Kobo questionnaire accommodated various response formats, with responses quantified using a scoring system ranging from 0 to 3. Finally, demographic and clinical data were extracted, checked, and cleaned before analysis in STATA version 18.

Data analysis

The primary clinical and demographic features of the patients in the research were analysed using descriptive statistics. This was accomplished by using cross-tabulations and univariable analysis for the various variables:

• Describe the number of observations and type of study variables (binary or ordered categorical).

• Describe the community’s beliefs and barriers to utilizing family planning services.

• Describe the percentage of early marriage among women in northwest Syria.

• Investigate the possible association between barriers and beliefs with women’s socio-demographic characteristics.

We examined the possible association between barriers and beliefs with women’s socio-demographic characteristics utilizing a multivariable logistic regression framework with a random effect, the forward technique used to predict the odds ratio for exposure (with P value and 95% confidence intervals). This is presented in Table 3.

Organization of variables

Participants were grouped into categories based on key demographic and socioeconomic variables:

• Family Monthly Income: Participants were categorized into three income groups: less than $100, $100-$500, and more than $500.

• Number of Children: Participants were grouped based on the number of children they had: none, 1–3, 4–5, and 6 or more.

These groupings allowed for detailed analysis of trends and patterns in the data, facilitating a comprehensive understanding of the factors influencing family planning utilization and access to health services.

Ethical approval

The data is publicly available, and an MOU agreement with the country director of SRD of Turkey has been signed to use the data. Also, the Syria Interim Government approved the research proposal. Lastly, ethical approval was received from the University of South Wales’ Faculty of Education and Life Sciences.

Results

Descriptive analysis

The baseline characteristics of the study population and the distribution of family planning methods usage among the various groups is shown in Table 1. The study population consisted of a total of 2,175 female participants. The participants were categorized into different age groups, based on the categories provided by the SRD data. The largest age group was 26–35 years, comprising 852 individuals (39.17%), followed by the 18–25 years group with 625 participants (28.7%). Of the total participants, 1,642 individuals (75.5%) were IDPs, and 533 individuals (24.5%) were residents. There were two further categories among IDPs, those in camps (920 individuals, 42.3%) and outside of camps (722 individuals, 33.2%). The remaining participants were residents. Participants were categorized based on their education level, including illiteracy, primary school, secondary school, and higher education. Forty percent of participants had primary school education, 30.9% had secondary school education, 17.8% were illiterate, and 11.4% were university graduates. Participants were further grouped based on their family monthly income, including less than $100, $100-$500, and more than $500. 79.8% of participants had a family monthly income of less than $100 per month. Lastly, participants were categorized based on the number of children they had, including none, 1–3, 4–5, and 6 or more. Most participants had 1–3 (39%), closely followed by 4–5 (35.5%) and 23% with 6 or more.

Table 1 Baseline characteristics of study population and the distribution of family planning methods usage among the various groups

Among the participants, 912 individuals (43.5%) reported no use of family planning methods, while 1,263 participants (58.1%) reported usage. The lowest proportion of family planning method usage was observed in the under-18 age group, with 97 individuals (7.7%) reporting usage. A statistically significant difference was found among the age groups (p < 0.001). Among those who received awareness about family planning, 1,319 individuals (60.6%) reported using family planning methods, whereas, among those who did not receive awareness regarding family planning, only 378 individuals (29.9%) reported usage. The difference in family planning method used between the two groups was statistically significant (p < 0.001). There was no significant difference in family planning method usage between IDPs and residents (p = 0.337). Around half of the participants using family planning methods were IDPs in camps (617 individuals, 48.9%), while IDPs outside of camps had the lowest proportion (346 individuals, 27.4%). A statistically significant difference was found in family planning method usage based on residency type (p < 0.001). Individuals with no children had the lowest family planning method usage (3 individuals, 0.2%), while those with 4–5 children had the highest proportion (489 individuals, 38.7%). There was a statistically significant difference in family planning method usage based on the number of children (p < 0.001).

Family planning methods overview

The study found that 58% of female respondents were using some form of family planning method. The age group with the highest usage was women aged 35 to 45 years, with approximately 62% using contraceptives, followed closely by those aged 25 to 35 years, at around 61.5%. Among girls under 18, who are often subject to early marriage, the usage rate was notably lower at 51%. This lower usage in younger women may reflect cultural expectations for early childbearing, particularly in conflict settings where there is a heightened desire to secure lineage [19, 20].

Pills were the most commonly used contraceptive method, accounting for 40% of usage among respondents. Intrauterine devices (IUDs) were the second most used method at 31%, which can be attributed to their long-term effectiveness and the reduced need for frequent medical visits, a significant advantage in conflict-affected areas where health facility access is limited. Injectables, used by 5% of respondents (with 90% of these using depot-medroxyprogesterone acetate “DMPA”), and condoms, used by 7%, were less popular. The high prevalence of pills usage is likely due to their ease of use and relative availability, even in the context of ongoing conflict. Furthermore, the limited use of injectables may be linked to supply chain disruptions caused by the conflict, making them less consistently available. All supplies were procured internationally through UNFPA based on requests submitted by health facilities. Each contraceptive method was procured individually, but pills were generally preferred by both providers and users due to their ease of use, user control, and the ability for women to quickly regain fertility upon discontinuation. Moreover, the lower utilization of condoms, particularly female condoms, reflects both cultural preferences and potential misconceptions about their effectiveness, as well as limited promotion and availability in the region. In Syria there is an aversion to condom use, partly attributed to a lack of condom awareness as well as socio-cultural stigma associated with their use and the promotion of illicit sex [21, 22].

Implants were the least utilized method at just 1%. This extremely low uptake may be due to the scarcity of implants in the region, compounded by a lack of information among the population about this method. Indeed, 37% of respondents indicated that they did not have enough information about implants to consider using them, and 17% expressed interest in using implants if they were available. This highlights the significant impact of both availability and awareness on contraceptive choice.

The unusual distribution of contraceptive methods can be largely attributed to the ongoing conflict in northwest Syria. Disruptions in supply chains, damage to health infrastructure, and the closure of many health facilities have all influenced the availability and choice of contraceptive methods [5, 6, 16]. Based on the lead author’s observations, health facilities that remain operational may prioritize certain methods over others based on what is more readily available, leading to an over-reliance on methods like pills and IUDs that can be stockpiled or used over extended periods without frequent medical intervention [23]. In addition, the conflict has intensified the challenges in accessing healthcare, leading to a preference for long-acting reversible contraceptives (LARCs) like IUDs, which do not require frequent resupply or repeated visits to healthcare providers. This strategic prioritization by health facilities and NGOs working in the region ensures that women continue to have access to reliable contraception, even in the face of ongoing instability. Before the conflict, reports stated that the IUD was the most widely used method (19%), followed by oral contraceptives (8.6%), and the rhythm method (3.5%) [24, 25]. Figure 1 details the current methods of family planning reportedly utilised, with pills and IUDs being the most frequently used.

Fig. 1

Methods of family planning that females are using currently

According to the questionnaire responses, most users of family planning methods require a joint decision between the spouses (66% of cases). In 19% of cases, the husband is responsible for making this decision, whereas, in only 13%, the woman decides. On the other hand, 68% of females said that their husbands were not allowed to accompany them to the RH’s clinic to obtain family planning services. While 29% of women reported that they were not permitted to take contraceptives in health facilities without the consent of their husbands, 29% also reported that men allowed them to use family planning methods. In contrast, 14% of respondents said joint consent was only when they were under 18 years old.

On the awareness level, 63% have received awareness sessions regarding family planning. Awareness sessions were conducted at the health facility, during home visits, or community group sessions led by midwives and CHWs. 67% of those who received educational information use a method of family planning, compared to 44% of those who did not receive this information, indicating that access to family planning services is related to adequate awareness and the elimination of misinformation. In addition, 58% of those who participated in awareness sessions believed that there should be at least 2–3 years space between births, whereas only 47% of those who did not participate in these sessions held this view. There was also a correlation between the percentage of contraceptive use and the level of education. The percentage of women who used contraception reached a high of 66% for those who had a university education, while it was only 44% for those in the Illiterate group.

Sources of family planning methods

Fifty-nine percent of people obtain family planning methods primarily from primary health care centres, followed by hospitals at 23% and mobile clinics at 8%, as outlined in Fig. 2. Only 11% of women and girls obtain family planning methods from the private sector or directly from pharmacies, where they pay for them.

Fig. 2

Source of family planning methods

Reported side effects of family planning methods

Sixty-eight percent of respondents reported that they have been using their chosen method for less than two years (35% less than one year). Ten percent between 2–3 years and only 7% for more than 2 years. Only 29% reported side effects from using family planning methods. The most common side effect reported was bleeding between periods or spotting at 26%, followed by irregular periods at 21%, mood change at 15%, and headaches at 13%. This is outlined in Fig. 3.

Fig. 3

Reported side effects of family planning methods

The most common symptoms associated with the use of IUDs, both hormonal and regular, are menstrual cycle related. About 17.2% of respondents reported intermenstrual bleeding or spotting, and 12.6% reported menstrual irregularities. At the same time, amenorrhea occurred in less than 1% of cases. On the other hand, 8.8% of women using different types of contraceptive pills reported experiencing mood changes, followed by weight gain at 4.9%, menstrual problems such as bleeding and spotting at 4.1%, and irregular periods at 3.5%. When it came to contraceptive injection, it was discovered that the menstrual cycle did not occur in 17% of cases. This was the result of changes in the menstrual cycle and weight gain, both of which were reported in 20% of cases, respectively. In addition, it was observed that 17% of cases described a decline or complete absence of sexual desire. This is depicted below in Table 2. Each percentage listed in Table 2 reflects the percentage of respondents who reported the side effects for each of the chosen methods. Respondents were able to report multiple symptoms. This aids in distinguishing between the prevalence of each symptom when using different methods.

Table 2 Reported side effects and associated family planning method

Barriers to access family planning methods

Thirty-one percent of women who did not want contraception confirmed that the desire for more children is the most important reason for rejecting family planning, while refusal by the husband or parents accounted for approximately 13%. Possible side effects of using various family planning methods are a potential barrier to utilising family planning services. In approximately 27.5% of cases, fear of adverse effects was one of the barriers to using contraceptives. 56% of those who used family planning methods had to stop due to side effects. Similarly, 11% of women who used these methods for a period refused to continue because they feared infertility. On the other hand, only 6% of women refused to use contraceptives for religious reasons. Following this were reasons related to the availability and provision of services, such as the distance from health facilities, the inability to provide the service for free, and the lack of access to family planning information, each of which was reported in approximately 2–3% of cases.

Beliefs and attitudes on family planning

In northwest Syria, negative beliefs and attitudes regarding family planning and the use of contraceptives are prevalent, with an average of 45% of respondents expressing opposition to various aspects of family planning. This is depicted in Fig. 4. This opposition is particularly strong concerning the use of contraceptives by adolescents, with approximately 55% of respondents opposing the provision of contraceptives to girls under the age of 18, regardless of the method used. These attitudes are deeply rooted in cultural norms that emphasize early marriage and large family sizes as markers of social status and security [26, 27].

Fig. 4

Beliefs and attitudes concerning family planning

A significant cultural factor influencing family planning decisions is the preference for male children. Approximately 50% of respondents believe that a mother who has only female children should continue to have more children until a male is born, as the male child is traditionally seen as the bearer of the family name and a source of future financial support, particularly in agrarian societies [28]. This cultural preference not only drives higher fertility rates but also delays the adoption of family planning methods until a male child is born. Furthermore, 52% of respondents perceive a woman’s fertility—and by extension, her value—through the number of children she bears, which perpetuates the expectation of large families. This belief is reinforced by the idea that having more children can serve as a form of social security, particularly in the aftermath of conflict, where there is a perceived need to ‘replace’ lost male members of the family. In fact, 47% of women believe that having more children after the conflict compensates for the loss of boys and young men, which reflects the cultural resilience strategy in response to high male mortality during conflict.

Religious beliefs also play a crucial role in shaping attitudes towards family planning. Although only 6% of women explicitly cited religious reasons for refusing contraceptives, religious teachings are often interpreted in ways that encourage large families. Approximately 45% of respondents believe that it is a religious obligation to have as many children as possible, which aligns with interpretations of religious texts that promote procreation.

In terms of beliefs about specific family planning methods, 41% of respondents believe that contraceptive injections cause infertility, while a similar percentage believe that the insertion of an intrauterine device (IUD) leads to infections. These misconceptions are compounded by limited access to accurate information, particularly in conflict-affected areas where health education is disrupted. Additionally, 39% of respondents believe that IUDs interfere with sexual intercourse, reflecting a broader discomfort with methods perceived to affect marital relations.

Despite these challenges, there are positive attitudes towards certain aspects of family planning. For instance, 64% of respondents agree that a mother should wait at least six months after an abortion and two years after the birth of a child before becoming pregnant again. Additionally, 58% believe that family planning reduces maternal and child diseases and mortality. These positive perceptions provide a foundation for expanding family planning programs that are culturally sensitive and address both misconceptions and the genuine needs of the population.

Factors associated with using family planning methods in Northwest Syria

Data from univariant logistic regression analysis are presented in Table 3, revealing that the women who reported receiving awareness of family planning methods had a higher usage rate than those who were unaware (67.1% vs. 44.2%). The odds ratio (OR) for usage among those who were aware was 2.6 (95% CI: 2.16–3.08), indicating a significant association (p < 0.001). There was no significant association between age group and family planning method usage. The usage rates were similar across different age groups, ranging from 51.6% among those under 18 to 62.4% among those aged 36–45. IDP women had a higher usage rate than residents (58.7% vs. 56.3%). However, the difference was not statistically significant (p = 0.337).

Table 3 Factors associated with using family planning methods among women in Northwest Syria 2023

Among the IDPs, those living in camps had a significantly higher usage rate than those living outside camps (67.1% vs. 47.9%). The OR for family planning methods usage among IDPs in camps compared to residents was 1.58 (95% CI: 1.27–1.97), indicating a significant association (p < 0.001).

There was a clear association between education level and family planning method usage. As the education level increased, the usage rates also increased. Illiterate women had the lowest usage rate (44.8%), while those with higher education had the highest usage rate (66.8%). The association was statistically significant, with increasing ORs for higher education levels (p < 0.001). Women with higher family monthly incomes had higher usage rates. The usage rate was 55.5% among those with a monthly income of less than $100, while it increased to 68.5% among those with an income of $100-$500. However, the difference in usage rates among income groups was only statistically significant for the $100-$500 income category (p < 0.001). The number of children showed a strong association with family planning method usage. Women with more children had higher usage rates. For example, the usage rate of women with six or more children was 69.9%, while it was only 5.6% among women with no children. The ORs for usage significantly increased with the number of children (p < 0.001).

Factors such as awareness, residency type (explicitly living in camps), education level, family monthly income, and the number of children were significantly associated with family planning methods among women in northwest Syria in 2023. These findings highlight the importance of targeted interventions and programs to improve awareness, education, and access to family planning methods in specific demographic groups to promote reproductive health and family planning in the region.

The association of family planning awareness with the usage of family planning methods

The multivariable analysis to estimate the odds ratio for the awareness of family planning is presented in Table 4. Age was considered a forced confounder and adjusted for in the first model. The second model was adjusted for age group, education level, monthly income, residency type, and the number of children. Education status, residency type, and the number of children produced the most significant change in the primary exposure effect, while monthly income change was slight, so we did not include it in the final model. After adjusting for participants’ age, education status, residency type, and the number of children, the adjusted OR for family planning awareness was 2.39 (1.96–2.91) and p-value (< 0.001 LRT).

Table 4 Association between family planning awareness and the use of family planning methods

Discussion

This study provides vital information about female respondents’ current usage patterns and attitudes toward contraceptive methods and how conflict and other factors have affected the provision and access to family planning. Furthermore, the study’s key findings provide crucial insights and recommendations for improving uptake of family planning services.

The high overall percentage of contraceptive use among female respondents is notable, with 58% reporting that they currently use a family planning method. This is a promising finding, indicating that a sizable proportion of women are actively choosing to avoid unexpected births and gain control over their reproductive health. This corresponds to the 58.3% contraceptive prevalence rate announced by WHO in their last report on Syria in 2008 [29]. This percentage, however, is higher than what has been reported on Syrian refugees in neighbouring countries such as Lebanon, which was around 50% [30] and around 47% in Turkey [31]. However, the percentage of the use of contraception among married women of reproductive age in conflict settings was around 40% in Afghanistan [32] and 38% in Yemen [33].

The age distribution of contraceptive usage reflects some interesting patterns. The 36 to 45 age group had the greatest rate of contraceptive usage, closely followed by the 26 to 35 age group. This suggests that younger age groups seek to have more children and then stop or begin spacing when they reach their mid-thirties. Families with female children are more likely to have more children until male children arrive. Furthermore, women over the age of 35 are more likely to want to stop having children to avoid birth defects, which become more common after this age. At the same time, it is alarming that the lowest percentage of usage, around 51%, is reported by girls under the age of 18. With the high rate of early marriage in northwest Syria, this is considered a dangerous indicator, as pregnancies under the age of 18 are considered risky, and the death rate among mothers rises [20, 34]. Our findings suggest this appears to be related to a lack of awareness and level of education. One of the reasons for delaying marriage in Syria found in the wider literature, is parents’ desire for a girl’s educational attainment, an educated girl has a greater ability to persuade her family to understand the dangers of early marriage and pregnancy and delay marriage [1, 20, 34, 35]. Therefore, increasing family planning awareness and advancing educational opportunities for girls is critical for reducing early marriage and complicated pregnancies.

The finding that camp-dwelling women have the highest contraceptive use rate (67%) indicates good access to family planning methods among camp residents. However, it may also raise concerns about the specific circumstances and factors that influence this population – desiring no children. The link between difficult situations and the lack of desire in having children was reported in a study conducted with Syrian refugees in Jordan [36]. This high utilisation of contraceptives among women residing in camps is different to other camp settings in Africa. A systematic review in 2018 reported limited access to reproductive health services and family planning methods in camps in Africa [37]. Similarly, a study in Jordan reported very limited use (8.7%) of family planning by rural women in south Jordan [32]. These findings underscore the relevance of tailoring family planning services to the unique requirements and contexts of displaced populations.

Pills were the most used contraceptive method, followed by IUDs, injectables, and condoms. The low utilisation of implants and female condoms among the surveyed population suggests a potential disparity in availability, awareness, or preference for these methods. This finding also supported by the study of Bardaweel et al. [14], which reported that pills where the most used by Syrian refugees in Jordan with around 45%. Also, it seems the most common method in different contexts and countries, like the UK, but it was followed by male condoms [38]. The lack of condom use may be attributed to the fact that there are very few documented cases of AIDS, a lack of information regarding sexually transmitted infections, and the fact that relationships in a conservative Islamic environment are mostly limited to marriage [21, 22].

The study findings also provide insight on the dynamics of family planning decision-making within households. In most cases, it was reported that a joint decision between spouses was required for family planning, highlighting the significance of involving males in discussions about reproductive health. Some women reported that their spouses were not permitted to accompany them to health clinics and others were required to obtain their husband’s permission to access contraceptives. The same finding reported by Almualm [39] in Yemen, found that the percentage of contraceptive use with the consent of the husband is higher, and that approximately 20% of women were denied the use of family planning because they did not obtain that consent. Decision-making autonomy for women is determined as an important part of sexual and reproductive health, yet studies across contexts find this can be undermined by household and gender dynamics and can negatively impact health outcomes [40,41,42,43,44]. It is therefore important to understand these dynamics to implement appropriate initiatives that increase awareness and education for both men and women.

A positive correlation was found between receiving family planning education and actual contraceptive use. Education and awareness campaigns can positively influence behavior and increase the use of family planning methods. This is supported by findings from healthcare workers and administrators in northwest Syria who expressed concern that their patients lacked sufficient awareness about family planning services, noting cultural and social norms that value fertility and having many children [45]. Expanding awareness programs, particularly among women with lower levels of education, can help resolve information disparities and empower individuals to make informed reproductive health decisions.

The survey results highlighted the barriers to accessing family planning services. The most prevalent reason for rejecting family planning was the desire for more children, followed by concerns about adverse effects and the fear of infertility. It is essential to address these concerns through comprehensive education and counselling services to dispel myths and provide accurate information regarding the safety and efficacy of family planning methods. This too is reflected in the few studies that consider sexual and reproductive health and family planning in northwest Syria. Improving access to family planning services can be achieved through several strategic measures, including increased funding for mobile teams and community health workers is essential, as these professionals can lead awareness sessions and provide essential services in underserved areas. Initiatives that implement tailored education and awareness training programs are also critical. Engaging communities and families, particularly those in at-risk groups, is crucial for fostering support and understanding of family planning. Additionally, addressing the availability and provision of family planning services—ensuring proximity to health facilities and affordability—is vital for ensuring that all women have equitable access to these services [20, 45].

Negative beliefs and attitudes regarding family planning and contraceptive use were prevalent in the population surveyed. To assess these specific questions were asked in the survey, which are available in Additional file 2. Deep-rooted societal norms and gender expectations are reflected in opposition to providing contraceptives to females under the age of 18 and beliefs about the role of women in bearing more children until a male child is delivered. These attitudes highlight the need for comprehensive social and behavioural change interventions that challenge detrimental gender norms, promote gender equality, and highlight the health and well-being benefits of family planning for women. These results are consistent with findings from other studies [16, 20]. A study in northwest Syria also found across all participants surveyed a decrease in support for family planning for girls (under 18) with fewer than three children [20]. One study in Uganda found that cultural and societal norms influence the use of contraceptives when few or no male children are born into a family and that sociocultural expectations and values attached to marriage, women and children are an impediment to using modern contraception methods [41]. On the other hand, many respondents acknowledged the significance of birth spacing, the appropriate age for becoming parents, and the prospective benefits of family planning in reducing the mortality of mothers and babies. These positive perceptions provide a foundation for expanding existing knowledge and promoting further acceptance of family planning as a tool for promoting individual and community health. Building on this, findings in the same study in northwest Syria above, demonstrated an overall increase in community acceptance of family planning post-marriage [20]. In a study conducted among Syrian refugees in Turkey [46], the majority of females believed that having a male child raised the father’s power, that having many children brought social respect, and that having female children did not count as having children. Moreover, many women believe that having male children will help the family work, especially in an environment that relies on agriculture. Therefore, having more male children means more workers and a higher financial return in the future.

These findings provide important insights into the current landscape of family planning practices, decision-making dynamics, and awareness levels among the population surveyed. These findings can help decision-makers, healthcare providers, and organizations working in reproductive health better tailor their interventions to meet the needs of women and couples seeking family planning services. In addition, it emphasizes the significance of removing barriers to accessing family planning services, disseminating accurate information about adverse effects, and confronting profoundly held beliefs and attitudes. To address these issues while improving uptake of family planning services, it is critical to promote the benefits of family planning for individuals, families, and communities. As identified in the findings, positive perceptions of family planning are held by some individuals and therefore building on this through targeted interventions that include comprehensive education, advocacy and awareness campaigns, counselling, and community engagement, are necessary. Additionally, it is vital that all health staff are trained to deliver quality family planning services. Well trained staff will not only deliver accurate information about available methods, but they will also ensure individual needs are tailored to, and health facilities have adequate supplies to meet individual needs.

Strengths and limitations of the current study

This study is one of the few focused on family planning methods in conflict-affected northwest Syria, shedding light on community perceptions and barriers in a region lacking such data. These findings offer crucial insights to refine medical practices in similar contexts, prioritizing respect for cultural norms. Employing a quantitative survey with thousands of diverse participants, including IDPs and host communities, strengthens the study’s generalizability. Design-based models bolster accuracy, while utilizing 2022 data ensures relevance to contemporary decision-making amid enduring socio-economic and health system challenges.

Some limitations to consider include the design being cross-sectional, which might affect the possibility of establishing causal relationships between variables, limiting findings to associations rather than definitive cause-and-effect links. Potential reporting bias among women responding to contraceptive use queries may skew results, influenced by social desirability or other factors. Additionally, reliance on secondary data restricted variable selection, potentially overlooking key factors influencing contraceptive usage, necessitating further exploration for a comprehensive understanding. Further variables may have included existing health conditions and past experiences with contraceptive use, the ability to make independent decisions regarding reproductive health, marriage status, accessibility, affordability, crisis level (front line areas versus more stable areas).

Conclusion

The study findings highlight the importance of improving family planning services in northwest Syria. Such improvements should include expanding educational campaigns targeting women with lower education levels to address information disparities and empower informed decision-making. Promoting joint decision-making between spouses and tailoring family planning services to meet the needs of displaced populations are also crucial. Additionally, improving availability, awareness, and counselling on different family planning methods, addressing misconceptions, and promoting the health benefits of family planning are essential. Tackling child marriage and developing comprehensive programs combining education, counselling, affordability, and community engagement are key strategies. Ensuring availability of implants and involving men in family planning discussions are also vital. Implementing these recommendations can enhance access, awareness, and informed decision-making, ultimately improving reproductive health outcomes for individuals, families, and communities.

The study highlights the desire for family planning services among Syrian women in northwest Syria, despite hindrances such as conflict effects, lack of knowledge, misconceptions, and cultural beliefs. Factors like fear of side effects and the need for spousal approval further challenge access. Sustaining reproductive health kits, integrating family planning into sexual and reproductive health services, and educating people about service availability and risks are crucial. Further research on the long-term social impact of armed conflicts is recommended to deepen understanding of war’s dynamics on individuals and communities.