Forced migration occurs globally for various reasons, including wars and political conflicts, economic circumstances, or environmental crises [1]. Women refugees of all nationalities are a particularly vulnerable group of displaced people. Having a higher reported prevalence of adverse maternal-neonatal outcomes than native women [2, 3] makes them a unique population in host communities in terms of needed humanitarian and healthcare services. Stillbirths, delayed arrival at the hospital for birth [4, 5], inappropriate weight for gestational age [2], low birthweight infants [6], and higher rates of neonatal intensive treatments for neonatal comorbidities [2] are a few adverse pregnancy outcomes that are commonly reported among women refugees. However, contemporary research and knowledge on women refugees’ health during pregnancy and pregnancy outcomes is limited in the international literature. Therefore, further understanding of how their health is compared to non-refugee counterparts is needed [3].

Since March 2011, Syria has been in a state of political instability that has resulted in about 13.5 million Syrians being forcibly displaced to escape the war, out of which 6.8 million sought refuge in their country [7]. The neighbouring country of Jordan has been the host of more than one million Syrian refugees [8], of which only 673,957 have registered with the United Nations High Commissioner for Refugees (UNHCR) as of February 2022 [9]. Women and girls constitute 49.6% of all registered refugees in Jordan, and 30% of them are above the age of 12 years [9]. Further, reports indicate that the majority (>85%) of registered Syrian refugees live outside camps, in urban, peri-urban, or rural regions of Jordan [9]. According to recent assessments of the needs of refugees for financial and non-financial services [10, 11], more than 86% of Syrian refugees live under the Jordanian poverty line [11] despite the substantial response by government and humanitarian partners.

In Jordan, healthcare services, including pregnancy and delivery services, are available to all registered refugees from all nationalities at the non-insured Jordanian rate at public health centres and governmental hospitals [12]. However, because most Syrian refugees are not insured and must pay health-related fees for hospitals and clinics, Syrian refugees identified cost as the main barrier to healthcare access [13]. The UNHCR supports healthcare services for all refugees. However, research has shown that Syrian women refugees in Jordan continue to have significant unmet needs and barriers to access, utilisation, and implementation of sexual and reproductive health (SRH) in comparison to their host community counterparts [14, 15].

There is limited research assessing the reproductive health status and service delivery among Syrian refugees in Jordan [14]. Currently, there is little understanding of the risks of adverse pregnancy outcomes among Syrian women refugees in Jordan and the extent to which disparities exist regarding pregnancy outcomes. The adverse maternal and neonatal pregnancy outcomes and disparities need to be addressed first, and their contributing factors should be systematically investigated to improve the maternal healthcare utilisation and health services provided to Syrian women refugees.

The Jordan Stillbirths and Neonatal Deaths Surveillance System (JSANDS) is an electronically secure surveillance system to register and disseminate reliable, comprehensive, individual-level data on stillbirths and neonatal deaths, the causes and the risk factors most commonly associated with perinatal mortality in Jordan [16–18]. The system record events for women prospectively after giving their births. The surveillance system automatically and accurately transfers the data on births, stillbirths, and neonatal deaths from five maternity hospitals to the Ministry of Health [16]. These hospitals are among the most significant and primary referral hospitals in Jordan that cover most births and deaths in all regions in the north, east, and south of Jordan. Khader, Alyahya [16] examined the JSANDS attributes, including its data quality and sensitivity. The system users rated the usefulness of JSANDS as excellent (percentage score = 85.6%). The overall acceptability (percentage score = 82.3%), flexibility (percentage score = 80.2%), stability (percentage score = 80.0%), and representativeness (percentage score = 86.6%) were also rated excellent. All variables in JSANDS had complete data with no missing values for clinical variables because these data are entered by nurses who were trained to enter data completely and because the system has automated quality checks. The overall simplicity was scored well (percentage score = 75.4%) [16].

The purpose of this study is to explore the adverse birth outcomes among Syrian women refugees and Jordanian women using data from the JSANDS. Specifically, in this study we identified disparities of the obstetric and neonatal characteristics and birth outcomes between Syrian and Jordanian women, and explored the factors determining adverse neonatal birth outcomes among Syrian women in Jordan.

This study is the first to systematically assess and compare wide-ranging birth outcomes and disparities among Syrian women in the host community of Jordan. Using comprehensive multicentre data, our analysis specifically provided information about the discrepancies in LBW (<2,500 g), SGA, preterm delivery, birthweight, stillbirth, and perinatal death rate among Syrian and Jordanian women’s births.

Our findings indicate remarkable disparities in pregnancy outcomes among the Syrian women refugees in the host communities of Jordan. Compared to the Jordanian women, the adverse pregnancy outcomes were remarkably higher among the Syrian women refugees, a gravely concerning finding that resonated with a previous retrospective study conducted at two governmental hospitals in northern Jordan [24]. The previous study documented a significant inequality in terms of the rate of caesarean section, anaemia, and lower neonates’ APGAR scores and birthweight among Syrian women deliveries compared to those from Jordan [24]. When summed together, these findings indicate a priority for more effective and tailored maternal-newborns healthcare services directed toward the refugee mothers in Jordan. Transformation is required in the current healthcare policies and interventions implemented in Jordan to improve women refugee’s access to and quality of antenatal, birth, and postnatal healthcare services.

Neonatal health outcomes, in general, have improved considerably in Jordan, as indicated by a slow but progressive decline in neonatal death rates over the past 20 years [25]. According to international reports, Jordan’s overall neonatal mortality rate is recorded at 9 per 1,000 LB [25], and above 14 per 1,000 LB, according to research-based information conducted nationally [19, 26]. Comparing our findings to these national reports, the neonatal and perinatal death rates recorded among Syrian births are remarkably higher than those reported nationally and internationally [19, 25, 26]. Adverse pregnancy outcomes are significantly high among Syrian women refugees on all measured parameters in this study. Our analysis showed that the overall birth outcomes among the Syrian women refugees in Jordan are poor and create a threat to achieving Jordan’s national and international development sustainability goals [27, 28].

Our findings regarding certain birth outcomes (e.g., weight at birth, SGA, low birthweight) were in agreement with those that have been reported among displaced Syrian women in a few comparable studies from Lebanon [6, 29] and Turkey [2, 5, 30]. However, in opposition to our findings, numerous studies from Turkey demonstrated no disparities affecting Syrian women concerning caesarean birth rates [2, 30–33], preterm delivery [30, 32, 33], stillbirth [5, 34], abortion [32, 33], LBW (<2,500 g) [33, 35], and small for gestational birthweight [5]. These discrepancies could suggest that health policies and interventions that facilitate women refugees’ access to and the provision of quality maternal and neonatal services could positively reduce the prevalence and disparities of adverse pregnancy outcomes among women refugees. An international conclusion should be drawn with caution and should be interpreted within its terrestrial context, considering the variations in the quality of healthcare services across countries.

Our findings also showed that other disparities also existed in the sociodemographic characteristics that are related to birth outcomes of the mothers from Syria compared to those from Jordan, specifically in terms of younger age, income, unemployment, and educational attainment. The results showed that the difference can be attributed to the background variables among the Jordanian and Syrian women. After controlling for these factors, the difference between the two groups of women seems to become not significant. These sociodemographic discrepancies could have contributed to worsening pregnancy outcomes and widening the healthcare disparity gap among the Syrian women refugees in Jordan. Low socioeconomic state [6], early-age/adolescent pregnancy [35], infrequent antenatal visits [6, 32, 34, 35], and the late arrival to skilled maternal care at birth [5, 24, 35] are contributing factors to adverse pregnancy outcomes that were prevailing among women refugees from Syria in other countries. The adverse birth outcomes are multifactorial, and this should be considered when designing and delivering care services to women refugees in the host countries.

Adolescent pregnancy, in particular, has been consistently observed to be prevalent among Syrian displaced women compared to native women in host countries [2, 35–38], which is in accordance with our comparison in Jordan. Adolescent pregnancy is one crucial factor associated with adverse birth outcomes worldwide [39, 40], which is similar to the case of Jordan [41]. The socioeconomic and healthcare needs, risks and pregnancy outcomes of Syrian adolescents and young women should receive further attention through humanitarian field assessments and research work. Our findings sheds light on the importance of designing healthcare policies and services to provide additional support for the vulnerable groups of women refugees.