Abstract
Introduction
Adolescent pregnancy and forced migration intersect to create unique challenges for reproductive health equity, particularly in obstetric care. This study examined disparities in delivery mode, anesthesia practices, and neonatal outcomes between Turkish citizen and Syrian refugee adolescent mothers in Türkiye.
Materials and methods
We conducted a retrospective cohort analysis of 4,170 adolescent deliveries (ages 15–19) at a tertiary hospital in Türkiye between January 2017 and December 2024. Variables included delivery mode (vaginal vs. cesarean), anesthesia type (spinal vs. general), and 1- and 5-minute APGAR scores. Comparative analyses used chi-square and Mann–Whitney U tests, with Bonferroni correction applied for multiple comparisons.
Results
Spinal anesthesia was significantly more common among Turkish citizens, while general anesthesia was more frequent in the refugee group (p < 0.001). Refugees had a higher cesarean section rate (48.8% vs. 45.4%; p = 0.0445). Neonates born under spinal anesthesia had higher APGAR scores at both 1 and 5 min (p < 0.001). These disparities persisted across the study years.
Conclusions
Observed differences in anesthesia type and neonatal outcomes between Turkish and Syrian adolescent mothers may reflect underlying differences in healthcare experiences. While the data do not directly measure factors such as informed consent, language access, or antenatal care quality, these variables warrant consideration in future studies. Targeted, culturally informed policies may help promote more equitable maternal and neonatal care for migrant populations.
Keywords: Adolescent pregnancy, Reproductive health equity, Refugee health, Health disparities
Introduction
Adolescent pregnancy remains a critical global public health concern, with profound implications for both maternal and neonatal outcomes across low-, middle-, and high-income settings. According to the World Health Organization, approximately 21 million girls aged 15–19 become pregnant each year, the majority of whom live in developing countries [1]. Pregnancy during adolescence has been strongly associated with adverse perinatal outcomes, including low birth weight, preterm delivery, and increased neonatal mortality.
Türkiye has experienced a significant demographic shift following the onset of the Syrian civil war in 2011, resulting in the arrival of over 3.5 million registered Syrian refugees, a considerable proportion of whom are women of reproductive age [2]. Emerging evidence indicates that pregnancy rates among Syrian refugee women—particularly within the adolescent subgroup—are markedly higher than those of their Turkish counterparts [3].
Previous studies have documented higher cesarean section rates among refugee women compared to native populations [4, 5]. This disparity is influenced by a complex interplay of factors, including obstetric complications, prior cesarean history, limited access to healthcare services, and sociocultural determinants. Among adolescent Syrian women, cesarean deliveries appear to follow a distinct pattern, with higher rates of primary cesarean sections and differing clinical indications compared to Turkish peers [6].
Anesthesia practices during childbirth also demonstrate notable variation between refugee and citizen populations. Refugee women have been reported to have lower access to regional anesthesia techniques such as spinal anesthesia, while general anesthesia is more frequently used—a practice associated with increased perioperative risks [7]. Contributing factors may include language barriers, limited health literacy, variations in clinical decision-making, and infrastructural constraints.
This study aims to provide a comparative analysis of delivery modes, anesthesia preferences, and neonatal outcomes between adolescent Syrian refugee and Turkish citizen mothers in Türkiye. By examining these differences, the study seeks to highlight potential inequities in obstetric care, identify structural and cultural barriers to optimal outcomes, and inform policies that promote reproductive health equity for migrant populations.
Methods
Study design and setting
This retrospective cohort study was conducted at a tertiary referral hospital in Türkiye, which serves both Turkish citizens and a substantial population of Syrian refugees. The study period covered deliveries between January 1, 2017, and December 31, 2024.
Participants
The study population included all adolescent mothers aged 15–19 years who delivered at the hospital during the study period. Eligible participants were identified through the hospital’s electronic medical record system. Exclusion criteria included multiple gestations, deliveries with missing anesthesia or neonatal outcome data, and cases with incomplete demographic information. The flow of participant selection, including the application of exclusion criteria, is illustrated in Fig. 1. This diagram depicts the initial number of deliveries identified, the reasons for exclusion, and the final sample size included in the analysis.
Fig. 1.
Flow diagram of inclusion and exclusion criteria for adolescent pregnancies
Statistical analysis
Analyses were performed using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA). Categorical variables were expressed as frequencies and percentages, and continuous variables as medians with interquartile ranges (IQR). The chi-square test was used for categorical variables and the Mann–Whitney U test for non-normally distributed continuous variables. Bonferroni correction was applied for multiple comparisons. A p value < 0.05 was considered statistically significant. Odds ratios and 95% confidence intervals were calculated for binary outcomes using contingency tables and log-transformed standard errors. Cases with missing data were excluded from analysis; no imputation was performed.
Results
Participant characteristics
A total of 4,170 adolescent deliveries were recorded between January 2017 and December 2024. After applying the exclusion criteria, the final analytic sample is presented in Fig. 1.
Maternal age ranged from 12 to 19 years, with a median of 19 years in Turkish citizens and 18 years in Syrian refugees (p < 0.001). The majority were primigravidas, with a median gravidity of 1 in both groups. Most deliveries occurred at 38 weeks of gestation. Birth weights were comparable between the two groups (p = 0.910). Minor but statistically significant differences were observed in gestational age and length of hospital stay (Table 1).
Table 1.
Clinical characteristics
| Variable | Turkish Citizens (mean ± SD/median) | Refugees (mean ± SD/median) | p |
|---|---|---|---|
| Age | 19.0 (12–19) | 18.0 (13–19) | < 0.001 |
| Gravidity | 1.0 (1–4) | 1.0 (1–4) | < 0.001 |
| Gestational Age | 38.0 (25–42) | 38.0 (22–41) | 0.0016 |
| Birth Weight (g) | 3040.0 ± 465.2 | 3036.7 ± 468.5 | 0.9099 |
| Length of Hospital Stay (days) | 2.0 (2–15) | 2.0 (2–21) | 0.0010 |
Mode of delivery
Overall, 53.4% (n = 2,228) of deliveries were vaginal and 46.6% (n = 1,942) were cesarean sections. Cesarean rates were higher among Syrian refugees compared with Turkish citizens (48.8% vs. 45.4%, p = 0.0445). Year-by-year analysis showed statistical significance only in 2021 (p = 0.004) (Table 2).
Table 2.
Yearly Distribution of Delivery Modes in Adolescent Pregnancies
| Year | Turkish citizen | Refugee | |||
|---|---|---|---|---|---|
| Vaginal birth n(%) | Cesarean birth n(%) | Vaginal birth n(%) | Cesarean birth n(%) | p | |
| 2017 | 134.0 (53.4%) | 117 (46.6%) | 202 (57.4%) | 150 (42.6%) | 0.37261 |
| 2018 | 122.0 (46.7%) | 139 (53.3%) | 207 (49.6%) | 210 (50.4%) | 0.51218 |
| 2019 | 111.0 (51.2%) | 106 (48.8%) | 214 (53.5%) | 186 (46.5%) | 0.63597 |
| 2020 | 55.0 (45.1%) | 67 (54.9%) | 136 (46.7%) | 155 (53.3%) | 0.84203 |
| 2021 | 64.0 (41.8%) | 89 (58.2%) | 191 (56.2%) | 149 (43.8%) | 0.00435 |
| 2022 | 95.0 (55.6%) | 76 (44.4%) | 196 (54.3%) | 165 (45.7%) | 0.85728 |
| 2023 | 75.0 (56.0%) | 59 (44.0%) | 181 (55.9%) | 143 (44.1%) | 1.0 |
| 2024 | 64.0 (55.2%) | 52 (44.8%) | 153 (57.5%) | 113 (42.5%) | 0.75397 |
| 2017-2024 | 727 (51.2%) | 692 (48.8%) | 1501 (54.6%) | 1250 (45.4%) | 0.0445 |
| Total | 1419 (100.0%) | 2751 (100.0%) | |||
A statistically significant difference in cesarean section rates was observed between Turkish and Syrian adolescent mothers (p < 0.05). Refugees had higher odds of cesarean delivery compared to Turkish citizens (OR: 1.14, 95% CI: 1.01–1.30, p = 0.042). Although the rate of vaginal deliveries was slightly higher among refugees, the magnitude of the difference is clinically noteworthy. The distribution of delivery modes by nationality across the study years is illustrated in Figure 2. This figure offers a comparative view of trends in vaginal versus cesarean deliveries among Turkish and refugee adolescents. Notably, the marked increase in vaginal deliveries among the refugee group in 2021 aligns with the statistical findings.
Fig. 2.
Annual trends in delivery modes among adolescent pregnancies
Anesthesia practices
Spinal anesthesia was used in 85.9% of cesarean deliveries, while general anesthesia accounted for the remaining cases. The use of general anesthesia was significantly higher among Syrian refugees compared to Turkish citizens (17.1% vs. 8.8%, p < 0.001). These differences persisted across study years (Table 3). The odds of receiving general anesthesia were significantly higher among refugees compared to Turkish citizens (OR: 0.47, 95% CI: 0.35–0.63, p < 0.001).
Table 3.
Association between nationality and type of anesthesia in Cesarean deliveries
| Nationality | Spinal Anesthesia n (%) | General Anesthesia n (%) | p |
|---|---|---|---|
| Turkish | 631 (91.2%) | 61 (8.8%) | < 0.001 |
| Refugee | 1,036 (82.9%) | 214 (17.1%) |
Neonatal outcomes
Neonates delivered under spinal anesthesia had significantly higher median APGAR scores at both 1 min (9 vs. 8) and 5 min (10 vs. 9) compared to those delivered under general anesthesia (p < 0.001 for both). The mean neonatal birth weight was 2,961.3 ± 534.5 g. No statistically significant differences were found in birth weight between groups (Table 4).
Table 4.
Comparison of 1- and 5-minute APGAR scores according to anesthesia type
| Parameter | Spinal (Median, IQR) | General (Median, IQR) | p |
|---|---|---|---|
| APGAR 1. minute | 9.0 (9.0–9.0) | 8.0 (6.0–8.0) | < 0.001 |
| APGAR 5. minute | 10.0 (10.0–10.0) | 9.0 (8.0–9.0) | < 0.001 |
The majority of deliveries occurred at 38 weeks of gestation. The mean neonatal birth weight was calculated as 2,961.3 g (SD ± 534.5). The median APGAR scores were 9 at the first minute and 10 at the fifth minute. Of all cases, 53.4% (n = 2,228) resulted in vaginal delivery, while 46.6% (n = 1,942) were cesarean sections. Although cesarean section rates varied across the study period, notable increases were observed in 2018 and 2020. The most frequent indications for cesarean delivery were fetal distress, failure to progress during labor, and a history of prior cesarean section.
Spinal anesthesia was the most commonly administered technique among cesarean cases (85.9%). In contrast, cases conducted under general anesthesia were associated with significantly lower first- and fifth-minute APGAR scores compared to those performed under spinal anesthesia (p < 0.001 for both measures).
Furthermore, when anesthesia type was analyzed by nationality, the rate of general anesthesia was found to be significantly higher among refugee patients (17.1%) compared to Turkish citizens (8.8%) (p < 0.001).
Discussion
This study identified significant differences in mode of delivery, anesthesia preference, and neonatal APGAR scores among adolescent mothers based on nationality. The rate of general anesthesia (GA) was notably higher in the refugee group, and both first- and fifth-minute APGAR scores were lower compared to those of Turkish citizens. These findings suggest that obstetric outcomes among migrant populations may vary due to a combination of individual-level and systemic factors, although the study did not directly measure these factors [8].
Evaluation of the entire eight-year dataset revealed a statistically significant difference in cesarean section rates between Turkish and Syrian adolescent mothers. However, year-specific analyses showed significance only in 2021, indicating that while annual cesarean rates may appear relatively stable, cumulative disparities over time render the long-term difference statistically meaningful. These trends may be influenced by fluctuations in healthcare accessibility and differences in clinical practice. Changes in hospital protocols during the COVID-19 pandemic (2020–2021) may also have contributed to this divergence.
Accordingly, assessments of cesarean delivery trends should go beyond single-year comparisons and incorporate longitudinal patterns. In Türkiye, the adolescent fertility rate has steadily declined in recent years. According to the Turkish Statistical Institute, the fertility rate among women aged 15–19 fell from 49 per thousand in 2001 to 10 per thousand in 2024 [9]. This decline may reflect delayed childbearing and improved health literacy among Turkish citizens. By contrast, elevated fertility patterns persist among groups such as Syrian refugees—highlighting a structural factor underlying the disproportionately high rate of adolescent births in this population. These differences should be interpreted in light of healthcare accessibility and the influence of culturally embedded reproductive norms [10].
A study conducted in Istanbul demonstrated that the GA rate among refugee women was significantly higher compared to native women, and this discrepancy was also reflected in neonatal APGAR scores [8]. Our findings are consistent with these results and may reflect differences in interaction with the healthcare system, although causality cannot be assumed.
Furthermore, expectations and perceptions of care among migrant women may differ from those of the host population. For example, high satisfaction levels may be rooted not in the objective quality of care but in lower baseline expectations. Similarly, distrust or difficulty navigating healthcare systems, as documented in other refugee populations, may affect clinical decisions around childbirth and anesthesia [11]. These contextual interpretations remain speculative in our study due to lack of direct data.
In addition, migrant women may develop a sense of distrust toward the healthcare system. A study involving Ukrainian refugees resettled in the United States found that the healthcare system was often perceived as complex and unreliable, prompting many to seek support through informal or non-institutional channels [12]. Such perceptions of distrust and communication barriers may significantly influence decision-making around childbirth and anesthesia preferences.
Similar concerns have been raised in Denmark, where studies have shown that health screening guidelines for refugee women are largely under-implemented [13]. While formal recommendations exist at the policy level, their translation into routine clinical practice appears to be limited. The disparities in anesthesia type and the lower APGAR scores observed in our study may be interpreted as downstream consequences of these implementation gaps.
Psychosocial factors may also contribute to the underutilization of healthcare services among adolescent migrants. A study conducted among Afghan refugees in Iran found that more than one-third of adolescents exhibited psychotic-like symptoms, and that these individuals were significantly less likely to seek medical care [14]. Such psychological burdens may indirectly undermine the effective management of the childbirth process and erode trust in healthcare systems.
Access to healthcare may be constrained not only by individual-level barriers but also by structural determinants. A study conducted among elderly migrants in China demonstrated that factors such as migration type, income level, and educational attainment significantly influenced healthcare utilization, with migrants from rural backgrounds facing substantial disadvantages [15]. By analogy, adolescent refugees may similarly experience systemic exclusion and limited integration, resulting in diminished engagement with formal healthcare systems.
Within this context, the concept of Cultural Health Capital (CHC) provides a possible framework for understanding disparities in healthcare engagement. Individuals with limited CHC may have difficulty navigating formal care systems [16]. While our data do not directly assess CHC, the higher general anesthesia rate and lower APGAR scores among refugee adolescents may be indirectly influenced by such factors.
Although interpreter services are formally available at our institution, they are primarily assigned to outpatient or inpatient areas during daytime hours. In contrast, interpreter access is often limited or unavailable in acute care settings such as operating rooms or delivery wards, especially during emergencies or night shifts. This constraint may further compound communication barriers in critical situations, potentially influencing anesthesia decisions and neonatal outcomes.
Taken together with the language barrier, these findings highlight possible barriers to equitable care. It has been reported that a substantial proportion of refugee women living in Türkiye for many years remain unable to speak Turkish, significantly limiting their participation in healthcare services [17]. Among adolescents, underdeveloped cognitive capacity and social inhibition may further hinder engagement, particularly in areas such as antenatal monitoring and the informed consent process. The elevated rates of general anesthesia and lower APGAR scores observed in our study may well be interpreted as downstream effects of this communication deficit.
Strengths & limitations
Although this study has certain limitations, its strengths are also noteworthy. First, it is among the few investigations to comparatively assess delivery and anesthesia preferences between migrant and citizen adolescent mothers, using a large sample size. Second, it provides a detailed and systematic analysis of both delivery modes and anesthesia types, as well as their associations with neonatal outcomes. Third, the single-center design contributes to methodological consistency, thereby enhancing internal validity by minimizing protocol variability.
The study assumes equal access to the healthcare system for both Turkish citizens and Syrian refugees; however, in practice, this equality may be influenced by factors such as timing of hospital presentation, referral pathways, health literacy, and access to interpreter services. Moreover, attributing differences in neonatal outcomes solely to the type of anesthesia constitutes a methodological limitation, as other clinical and social determinants—such as frequency of prenatal care, nutritional status, and individual medical history—may also contribute to these differences. While the data were assumed to be complete and accurate, variations in record-keeping quality across years and units in public hospitals may have introduced inconsistencies. Given the retrospective design, causal relationships cannot be established. Additionally, the single-center setting limits the generalizability of the findings. These factors should be carefully considered when interpreting the results.
Conclusion
This study revealed significant differences in delivery modes and anesthesia preferences between Turkish citizens and Syrian refugee adolescent mothers. The refugee group demonstrated a higher rate of general anesthesia use, which was associated with less favorable neonatal outcomes. While clinical decision-making plays a role, these differences may also be influenced by broader structural and communicative challenges—including language barriers, health literacy, and healthcare navigation difficulties. However, as these elements were not directly assessed, conclusions about systemic inequities should remain interpretive and cautious.
In the context of Türkiye, these findings provide important insights into adolescent pregnancy and migrant maternal health. They suggest the need for more inclusive clinical protocols and culturally sensitive healthcare delivery. Future research should incorporate not only clinical outcomes but also mixed-method approaches to explore underlying social and structural determinants of health among adolescent migrant populations.
Acknowledgements
We would like to thank Dr. Fatma Gürlek for her profound insights on migrant populations.
Abbreviations
- APGAR
Appearance, Pulse, Grimace, Activity, Respiration
- CHC
Cultural Health Capital
- COVID
Coronavirus Disease
- GA
General Anesthesia
- IQR
Interquartile Range
- SD
Standard Deviation
- SPSS
Statistical Package for the Social Sciences
Authors’ contributions
SK (Sabri Kurtay) contributed to conceptualization, methodology, formal analysis, investigation, data curation, resource acquisition, and drafting the original manuscript.MKK (Mehlika Kuşvuran Kurtay) contributed to conceptualization, methodology, formal analysis, resource acquisition, original draft writing, review and editing, supervision, and project administration.CT (Cuma Taşın) contributed to methodology, resource acquisition, manuscript review and editing, and data visualization.All authors read and approved the final version of the manuscript.
Funding
This study was not supported by any sponsor or funder.
Data availability
The datasets generated and analyzed during the current study are not publicly available due to ethical restrictions and patient confidentiality. However, they are available from the corresponding author on reasonable request and with permission from the institutional ethics committee.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Clinical Research Ethics Committee of Toros University on December 24, 2024 (Decision No: 203).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed during the current study are not publicly available due to ethical restrictions and patient confidentiality. However, they are available from the corresponding author on reasonable request and with permission from the institutional ethics committee.