Exploring stressors impacting the mental health of refugee mothers in Lebanon during COVID-19 pandemic: A qualitative study

Abstract

This study analyzes stressors experienced by Syrian mothers in Lebanon in 2020 and emphasizes the necessity of addressing their distinct needs. Through in-depth interviews, it identifies stressors linked to living conditions in Lebanon, the economic crisis, health care access, and the impact of the pandemic. The study recommends that social workers should utilize and enhance existing support systems. It also recommends social policies facilitating mobility for Syrians to reunite with their families and livelihood programs enabling families to prioritize their own financial stability. This comprehensive approach has the potential to alleviate the challenges faced by Syrian mothers in Lebanon.

Keywords

Health disparities mothers pandemic postpartum refugees social isolation social support stress

Background

The armed conflict in Syria, which began in 2011, resulted in one of the largest displacements of refugees ever (Almoshmosh et al., 2019). Syrians faced major stressors, including witnessing mass casualties, losing loved ones, and sexual and physical violence (Almoshmosh et al., 2019). In countries of displacement, refugees have faced additional challenges, including poverty, lack of access to essential services, social isolation, marginalization, and limited mobility (Darawsheh et al., 2021; Silove et al., 2017). All of these challenges can be significant determinants of refugee mental health and wellbeing (Wessells, 2009).

Refugee women, who constitute more than half of the refugee population, face unique challenges and protection risks. In Syrian culture, women are usually the primary caregivers responsible for family affairs (Doocy and Lyles, 2017). The arrest or death of men during the war increased the number of female-headed households among Syrians (Reese Masterson et al., 2014). A study of Syrian refugees in Lebanon revealed that female-headed households were the most vulnerable in terms of food security, shelter, access to water, and sanitation (Doocy and Lyles, 2017). Furthermore, mothers in the postpartum period (within one year of giving birth) may also experience additional stressors related to recovering from childbirth, sleep deprivation, and caring for an infant with limited access to social support (O’Mahony et al., 2012; O’Mahony and Donnelly, 2013). One additional layer of stress for postpartum mothers was the COVID-19 pandemic, which negatively affected the mental health of everyone around the globe (Wu et al., 2021).

In Lebanon, Syrian women who gave birth during the COVID-19 pandemic faced the common challenges faced by refugees while struggling to cope with a severe economic crisis complicated by a pandemic. In fact, the COVID-19 pandemic revealed many of Lebanon’s health infrastructure shortcomings (Koweyes et al., 2021). Since 2019, Lebanon had been experiencing a severe political and economic crisis with the Lebanese currency losing nearly 80 percent of its value (World Food Program [WFP] 2020). The resulting inflation, estimated at 174 percent, significantly impacted food security. Almost 50 percent of Syrians in Lebanon, including breastfeeding mothers and babies, were food insecure in 2020 (WFP, 2020). The economic crisis was further exacerbated by a huge explosion in the main port in Beirut that damaged three main hospitals and displaced thousands of people. At the same time, the number of COVID-19 positive cases increased to over 1000 per day leading to an intensive care unit (ICU) bed crisis (Koweyes et al., 2021). While there is research that has examined each of these nodes of stressors, none has examined the impacts of the constellation of stressors on postpartum Syrian mothers in Lebanon.

In this study, we focus on a group of postpartum mothers who were living in Lebanon’s Bekaa Valley, where approximately 40 percent of Syrian refugees live (UNHCR Lebanon, 2021). Using qualitative in-depth interviews, we aim to answer the following research question: What are the perceived stressors impacting the mental wellbeing of postpartum Syrian women who lived in Bekaa Valley region during the first year of the COVID-19 pandemic?

Theoretical framework

This research was inspired by the ecological model of refugee distress developed by Miller and Rasmussen (2017), which demonstrates that mental health among refugees stems not only from exposure to war trauma but from multiple levels of post-migration stressors, such as poverty, discrimination, and separation from family. In our research, we modified this framework to be specific to postpartum mothers which guided a larger mixed-methods study that aimed at understanding Syrian mothers’ mental health experiences in the postpartum period (Figure 1). Following the completion of the research, we revised the framework to incorporate our results (Figure 2). The developed framework considers a balance between risk factors and protective factors, which both determine refugee mothers’ mental wellbeing. On one hand, personal resilience, which stems from personal traits, culture, and the person’s own beliefs, is a major determinant of mental wellbeing and the ability to cope with adversities (Hutchinson and Dorsett, 2012). Similarly, having a strong family and community support systems and access to mental health resources are key to mental wellbeing (Donnelly et al., 2011). On the other hand, the balance could be impaired by the overwhelming stressors of daily life and the memories experienced during displacement. The daily stressors of life as a refugee are often overlooked but are often the most detrimental factor affecting their wellbeing (Wessells, 2009). A study done by the World Health Organization assessing the most distressing aspects of Syrian refugee lives found that ‘worry and concern over the situation, relatives, and the future’ were foremost (Alfadhli and Drury, 2018). In the context of the pandemic, a global study that assessed the effect of daily stressors on the mental health of refugees during the COVID-19 pandemic (n = 20,742) showed that daily stressors of the pandemic were negatively associated with mental wellbeing, especially for women (Spiritus-Beerden et al., 2021).

Figure 1.

Conceptual framework depicting refugee mothers’ balancing biopsychosocial challenges.

Figure 2.

Revised conceptual framework depicting refugee mothers’ balancing biopsychosocial challenges.

Using this conceptual framework, we anticipate that the mental wellbeing of Syrian mothers was impaired due to the daily stressors faced during the first year of the pandemic. For this article, we aim to shed light on those stressors. We begin by describing the methodology of this study. As this article is part of a larger mixed-methods study, we will only address the aspect of perceived stressors; details of other aspects of the framework are documented elsewhere (Alnaji, 2021). We will then describe the findings organized by four themes: (1) challenges of living in Lebanon, (2) financial situation and the economic crisis, (3) health and access to health care, and (4) the pandemic and social isolation. We end the article by proposing practical steps for social workers to support refugee mothers during the postpartum period.

Methods

Study design

The research presented in this article was conducted as part of a doctoral thesis in Health Practice & Medical Education Research at the University of Nebraska Medical Center, with the first author as the thesis candidate and the second and third authors serving as academic supervisors. The primary research focus of the first author lies in the field of refugee health, encompassing prior research experiences with refugee populations in various countries, including Lebanon, Jordan, Iraq, and the United States. Both the first and second authors are part of the Global Adversity and Wellbeing Research Group.

The larger mixed methods study included validation of a mental health tool among postpartum mothers and qualitative interviews exploring stressors faced by mothers in Lebanon, cultural traditions around childbirth, sources of social support, and attributions of postpartum depression among Syrian mothers (Alnaji, 2021). In this article, we aim to answer the following research question: What are the perceived stressors impacting the mental wellbeing of postpartum Syrian women who lived in Bekaa Valley region during the first year of the COVID-19 pandemic? The research uses a phenomenological approach, which produces data that will offer insight into the meanings that informants give to a major life event, such as giving birth (Larkin et al., 2022 [2021]). This approach is particularly useful for understanding under-examined or novel phenomena. It is, therefore, well-suited for research on refugee mothers’ postpartum experiences. A phenomenological approach has been used in research with postpartum mothers (Abdollahpour and Motaghi, 2019; Abota et al., 2021; Benuyenah and Tran, 2021; Ladd, 2021).

This qualitative study is focused on Syrian mothers who gave birth in Lebanon in 2020. We selected this sample because we anticipate that these mothers would have faced unique challenges during their postpartum period due to the pandemic and economic crisis in Lebanon. The study was approved by the Institutional Review Board (IRB) at the University of Nebraska Medical Center (IRB #787-20-EP) and followed all ethical guidelines.

Data collection

The first author collected data from April to May 2021, while the COVID-19 lockdown was in effect in the Bekaa Valley. Syrian women were recruited through a partner organization; Mutli-Aid Programs (MAPS) beneficiary list and through purposive snowball sampling of previous clients of social workers. Initial communication with mothers was made by phone by a social worker who was familiar to each mother through working together at (MAPS). However, aligned with ethical norms and using the IRB-approved informed consent process, informants were assured that their participation (or non-participation) in the research would not impact the services they received through the organization. This step eased the recruitment process and ensured all informants were relaxed during the interview. After the initial approval to participate in the study, the first author communicated with each informant through the WhatsApp mobile application and made an appointment for the interview. The data were collected through remote phone and virtual communication due to the COVID-19 lockdown. Although the lockdown was eased during data collection, the researchers consulted with the partners in MAPS and decided to continue the interviews virtually as many families were afraid to meet or host strangers.

A total of eight women – five postpartum mothers and three social work practitioners – participated in the study, aligned with sample size norms for phenomenological research (Korstjens and Moser, 2017; Larkin et al., 2022 [2021]). The inclusion of three social work practitioners in the study was important to gather specialized and practical knowledge and to better inform practice and systems-related recommendations. Furthermore, the social workers were Syrian mothers themselves (though not in the postpartum period), which added another rich and culturally relevant perspective that was both personal and professional.

The five postpartum mothers lived in informal settlements in the Bekaa Valley region, while all three social workers worked part-time with refugee women in that area. Postpartum Syrian refugee mothers were between the ages of 19-27 with an average of three children and a period between 20 days and 7 months postpartum. The social workers were between the ages of 26-37. The postpartum group was generally younger than the social workers’ group because of the average younger age of motherhood in this population, while the social workers were not in the postpartum period and had at least 5 years of experience in the profession.

Interviews were conducted by the first author, who is a native Arabic speaker, using either a Zoom call or a phone call. The informed consent form for the study was read to each informant prior to the interview and verbal approval was attained before proceeding with the interview. Each interview lasted between 30 and 40 minutes, and interviews were audio-recorded with informants’ permission. The interviews were later translated and transcribed by the first author.

Data analysis and quality assessment

To ensure the credibility of the data, the authors engaged in regular analytical sessions with members of the Global Adversity and Wellbeing Research Group (led by the second author) to read and discuss the transcripts and emerging themes for this study (Korstjens and Moser, 2017). Since qualitative research depends on the subjectivity of the researchers and their own analysis and interpretation of data, which cannot be detached from their own experiences and values (Groenewald, 2004), these sessions were also opportunities to engage in reflexive analysis whereby potential biases were discussed. Using preliminary themes derived from the regular analytical sessions, the first author analyzed the data using Colaizzi’s (1978) steps for descriptive phenomenological analysis. The first step was data immersion, where the first author read the transcript multiple times and wrote initial ideas that came to mind. In the second step of coding, the first author read each line of text, documenting similar themes. Each code was given a description to ensure the standardization of coding. The third step was creating categories. Later, the first author organized the codes into larger categories. Finally, the fourth step was the identification of themes, where the main themes were identified. To code and organize the data into themes, the mixed methods web application Dedoose was used.

Results

Four themes emerged from the data: (1) challenges of living in Lebanon, (2) financial situation and the economic crisis, (3) health and access to health care, and (4) the pandemic and social isolation. Table 1 shows the four major themes and sub-themes. Each of the themes is discussed in detail in the sections below. Informants were given pseudonyms to protect their privacy. Table 2 summarizes the names and demographics of study informants.

Table 1.

Major themes and sub-themes.

Themes	Sub-themes
1. Challenges of living in Lebanon	Residency and mobility
1. Challenges of living in Lebanon	Poor living conditions
2. Financial situation and the economic crisis	Inability to meet family’s basic needs
	Taking loans
	Loss of jobs
	Insufficient aid money
3. Health and access to health care	Delay in access to health care
	Inability to afford medications
	Postpartum health conditions
	Sleep deprivation
	Having multiple young children
4. The pandemic and social isolation	Social isolation
	Older children staying home all dayFamily violence

Table 2.

Demographics of the study informants.

Name	Category	Age	Origin in Syria	Number of children	Postpartum period
Hadeel	Social worker	29	Dara’a	2	NA
Norah	Social worker	35	Damascus	2	NA
Ameerah	Social worker	37	Homs	4	NA
Rana	Mother	20	Aleppo	3	7 months
Nadia	Mother	27	Homs	5	6 months
Afnan	Mother	20	Homs	3	2 months
Manar	Mother	19	Aleppo	2	20 days
Sara	Mother	24	Damascus	3	3 months

Challenges of living in Lebanon

All postpartum mothers interviewed were living in tents in informal settlements of the Bekaa Valley in Lebanon. These tents were often shared with other members of the extended family. In addition to being crowded, during the winter months, tents became very cold which made mothers worry about the health of their children. Nadia, a 27-year-old mother of five who was six months postpartum, described the situation:

The winter was cold. Even if the kids stay in bed covered with blankets, at some point, they will get up and we need the tent to be warm so they don’t get sick.

Due to the residency issues in Lebanon, Nadia described mobility as the main stressor in her life, and that she was afraid to move around Lebanon for fear of being stopped at checkpoints.

Sometimes they just ask questions about why you don’t have official papers, but sometimes they may place people in prison. It depends on the mood of the official at that checkpoint. We heard of people who were sent to Syria and were arrested by the Syrian regime when they were returned to Damascus.

Sara, a 24-year-old mother of three who was in her third month postpartum, also indicated that restriction on mobility affected her ability to seek support from her family after giving birth.

My extended family lives far away from me. In Lebanon, our mobility is restricted to the area we are living in. We cannot move to other areas of Lebanon because we are afraid we might be stopped at a checkpoint on the way and be asked about our documentation, which we don’t have.

Even for those living within the same region as their families, paying for transportation was often a restricting factor to visiting families. Manar, a 19-year-old mother of two who was 20 days postpartum on the day of the interview, told us:

My family lives at a distance of an hour driving, but I can’t visit them whenever I want because transportation is very expensive. It was bearable before, but now with the price inflation, it has become too expensive.

The residency issue for Syrian refugees in Lebanon, not only affected their ability to move but also influenced their ability to access education, job opportunities, and contributed to their sense of security and stability. Nadia explained:

If you get a job in another region, you cannot go to get the job, or even if you are able to go, you feel you are taking a risk. Either you will reach there, or you will be returned.

Nadia and Manar agreed that the lack of documentation made them feel that they are living in limbo and constant fear for their family members.

Ameerah, a 37-year-old social worker and mother of four also shared her personal experience of being overwhelmed by supporting her husband financially and emotionally:

I am very stressed out. I am supporting my husband. When he lost his work during the pandemic, his mental health deteriorated because he started feeling guilty that he is not providing for me and his kids. I must be strong to support him, but I know that I am emotionally tired. How can I be strong for my husband to support him when I am so tired?

Hadeel, a 29-year-old social worker and mother of two, also described her feeling of being trapped in Lebanon as her family was forced to flee bombing and direct attacks in Syria, to be faced with many other challenges in Lebanon, making it difficult for her to feel at peace:

We don’t feel comfortable from the inside. We are indeed relieved from the bombing or from being afraid of getting arrested, but still, we don’t feel comfortable. We are living in a country we don’t belong to. I will complete three years in Lebanon soon and all the time, I feel alienated here. There is nothing like our own country, but what can we do? We were forced to flee.

Financial situation and the economic crisis

The economic crisis and inflation of prices in Lebanon severely affect Syrian refugee mothers. Informants told us that the cash assistance they received from the United Nations High Commissioner for Refugees (UNHCR) is not sufficient to cover their basic needs of rent, food, and their newborns’ needs. Rana, a 20-year-old mother of three who is seven months postpartum, described her family’s financial situation:

We receive 400,000 LL (equivalent to 260 USD) from the United Nations (UNHCR), but our expenses are much more. I have three young children in diapers, and they all need to drink milk.

Nadia, a 27-year-old mother of five, agreed with Rana and stated:

The situation is so bad. My kids are in great need, and we cannot provide for them. Everything is so expensive; we cannot buy anything anymore.

Four of the eight mothers we interviewed described an element of stress caused by not being able to secure for their children’s basic needs, such as diapers or milk. Rana described her feelings when she could not afford milk and had to restrict her children’s milk consumption:

Most days, I try not to let the children drink milk as much so I can keep more supply until I have money to buy more. This thing is affecting me so much, honestly. I don’t want to prevent my kids from drinking milk, but at the same time, the financial situation is hard, and milk is expensive.

Some mothers explained that they had to take loans to pay for their children’s basic needs. For example, 19-year-old Manar, mother of two, explained:

I am very stressed because I am not able to provide the simplest of things for my children such as diapers, and milk, except by taking a loan. We can’t even afford a bag of bread; we are eating by taking a loan. The people who lend us money come and knock on our door and there is no work in Lebanon at all so we can’t pay them back.

Similarly, Nadia, a 27-year-old mother of five who is six months postpartum, told us:

In the winter, we took a loan to pay for heating gas. We had to. We have a baby, and it was cold. We didn’t want him to get sick.

Most informants mentioned that their husbands had challenges securing an income because of the pandemic and financial crisis. Rana, a 20-year-old mother of three, explained:

My husband used to work every day, but now he goes to work for one or two days and has to stop because of the lockdown.

Nadia told us about her husband’s efforts to collect and sell recycled waste to provide some income for the family:

He collects used plastic and metal from around so he can sell them and provide for us. What can we do? We are forced to do this so we can live. We are a large family, and we have many expenses.

A 20-year-old mother of three, Rana, described when she was not able to secure the basic needs of her children:

I feel very sad when my children ask me for something, and I am not able to provide it for them. It is one of the hardest things to face when my child asks for something, and I, as a parent, cannot provide it. If my husband works and we have a monthly income, this will help me feel much better. This would relieve me mentally.

All mothers agreed that the financial situation is a major stressor for them and if it was improved, it would relieve much of their day-to-day stress.

Humanitarian aid money, provided by non-governmental organizations (NGOs), was described as not reliable nor consistent by most informants. Most reported not receiving any aid, despite living in refugee settlements and having multiple children. According to Rana, heating gas was often distributed during the winter, but it was unreliable:

Some days they distribute, and on others, they don’t, and we must buy it when we don’t get it.

Health and access to health care

Although health care is subsidized for Syrians in Lebanon, it is not provided for free. For childbirth, mothers must pay certain fees for the baby’s delivery and medications. Two mothers reported that they had to wait to get access to the hospital until they were able to provide enough money to pay for the transportation or the cost of health care services. This situation happened to Sara, who narrated her experience of waiting all night – while in labor – to get a loan from friends to pay the expenses.

We had to wait until morning to go to the hospital. I didn’t have money to pay for the transportation.

Similarly, Manar, who had severe anemia after giving birth to her baby, was not able to purchase the needed medication prescribed by her doctor to treat her condition.

I gave birth 20 days ago, and the doctor told me to take three medications. I was only able to purchase one of them.

Manar also compared the situation to giving birth to her first baby two years ago.

It is very different. With the first baby, I didn’t have this much stress. Even the price for the delivery at the hospital was lower at that time. This time we also had to pay for the COVID-19 test in addition to the delivery.

Rest and sleep are major contributors to the mother’s health and wellbeing. Nadia told us how her responsibilities prevented her from taking the rest she needed for her episiotomy wound to heal, which made it even worse and infected.

After a month of giving birth, I felt the suture was hurting so much, but I still got up and took care of my kids and the house. After that, I became sick and was bedridden for weeks.

Similarly, sleep deprivation was a common theme described by mothers. Sara told us about her experience of sleep deprivation as her older school-age children were staying home all day, which makes it difficult to rest during the day to replace the lost sleep during the night.

I sleep two hours each night, and during the day, it is difficult to sleep because of other duties around the house.

The pandemic and social isolation

All mothers admitted that the pandemic has negatively affected them. Ameerah, who is a Syrian social worker and works closely with Syrian refugee women in Bekaa Valley, described the situation as suffocating:

The pandemic suffocated most Syrian women and added additional stress to the stresses of being a refugee in Lebanon, having young children, losing their homes, and being away from their families.

Before the pandemic, Sara explained that Syrian refugee children spent much of their time outside playing with other children. However, fear and the pandemic-related restrictions led mothers to keep their children inside all day, often in crowded settings.

Similarly, Sara and Nadia added that public schools for Syrian refugee children were stopped from the onset of the pandemic. Online classes resumed for a very short time, after which it was found unfeasible because of the unreliable Internet connection. Boredom and crowded settings increased the tensions between mothers and their children. Sara explained:

It is very difficult. When they used to go to school for four hours, we took rest from caring for them. Now they are home all the time. It isn’t easy. Their mental health is also affected.

Nadia elaborated:

My children stay at home. They are bored because they don’t have TV and they don’t go to school. Nothing to keep them distracted from me. The whole day I am in trouble with them. I tell them to go play outside. They play outside but near the tent because we can’t let them play with the other kids.

Hadeel, a social worker, described that the increased family tension between mothers and children during the pandemic led to more adult-on-child and child-on-child violence:

I noticed that parents are hitting their children much more, and children are hitting other children when they are being hit.

Discussion

The Syrian mothers in our study described multiple challenges related to their exposure to conflict in Syria and subsequent displacement. But these challenges were further exacerbated by additional layers of adversity related to Lebanon’s economic crisis and the COVID-19 pandemic. The COVID-19 pandemic clearly had multifaceted effects on Syrian mothers, including increased social isolation, a lack of family support, heightened stress due to disrupted schooling for older children, and exacerbated financial challenges within Lebanon. These factors collectively played a role in shaping maternal mental health and, by extension, mother’s capacity to provide care for their children. These findings resonate with a wider body of research that has documented the intersecting psychological, social, and health consequences of the pandemic on a global scale, underscoring the distinctive challenges faced by already vulnerable populations (Neelam et al., 2021; Piquero et al., 2021; Prati and Mancini, 2021).

In Eastern collectivistic societies, social life and extended family are considered the main sources of social and physical support for mothers, especially those who have recently given birth (Acarturk et al., 2021). Yet, both displacement and the pandemic created barriers for the research informants to engage with their supportive social circles. A study that looked at maternal depression among Syrian refugees in Canada revealed that the single most beneficial strategy to alleviate it was reconnecting with family members (Ahmed et al., 2017). In our study, mothers who were not able to access their social networks described themselves as lonely and with no support system. Furthermore, mothers with no support system expressed neglecting their own health to care for their children. While visiting with friends and neighbors can be especially supportive for mothers with a new baby, results from our study showed that most mothers did not feel comfortable engaging with others due to the pandemic. A social worker in our study used the word ‘suffocated’ to describe the social isolation Syrian mothers experienced during this time. Similarly, a study that assessed the effect of the pandemic on Syrian refugees in Lebanon exhibited that 88 percent of informants were stressed because of staying at home during the lockdown (Hajjar and Abu-Sittah, 2021).

In addition to the pandemic-related restrictions, our informants identified a main barrier to accessing the support of family and friends was related to mobility constraints. Mobility restrictions for refugees in Lebanon result from the lack of legal documentation, the high cost of transportation, and pandemic-related restrictions. The psychosocial impact of lack of legal documentation on children and families has been discussed in research by Akesson and Coupland (2018). Living both in limbo and in fear of being arrested can put mothers in constant fear for the wellbeing of their family members, both adults and children. This fear may be heightened when one has a new baby to care for. Since March 2020, national curfews have been enforced in some local municipalities, which made it difficult and sometimes impossible for Syrians to enter and exit the informal settlements (Moawad and Andres, 2021). The already limited mobility constraints, topped by the fear of contracting the COVID-19 virus, highlight the importance of calling for political reforms to address the need for more freedom of movement for Syrians in Lebanon, whether or not there is a pandemic to contend with.

Similar to mothers, children’s mobility was heavily restricted during the pandemic, which affected the mental wellbeing of mothers (Mhaissen and Hodges, 2019). Informants discussed the stress of having their school-age children stay home all day and worrying about their mental health and future due to long periods of interrupted schooling. In Lebanon, nearly 65–70 percent of Syrian children in Lebanon did not have any access to education during the pandemic because of unreliable Internet connection and the unavailability of devices (Care International, 2020). The interrupted schooling, coupled with children’s inability to play outside, resulted in the overcrowding of homes, thereby increasing tensions between parents and children (Mhaissen and Hodges, 2019).

As O’Leary and Tsui (2021) write, ‘Family as the basic unit of our society will become our base for this battle’ against the COVID-19 pandemic. The isolation of family units from the outside world can challenge family roles and relationships. Results from our study suggested that the pandemic increased the violence between parents and children and between children and their peers. Similarly, global studies have shown similar results, especially during the lockdown (Piquero et al., 2021). This raises an issue to reconsider the living conditions of Syrian refugees in Lebanon and calls for schooling or other programs that can host children away from their parents for even a few hours a day.

Another major source of stress discussed in our study was the deterioration of the financial situation in Lebanon and the stress of the parents’ inability to provide for their children. According to the informants, their income was not sufficient to cover their basic expenses – which increased with the arrival of a new baby – forcing them to take loans. Additional economic strain was related to the pandemic, which made the necessities of life more expensive (O’Leary and Tsui, 2021). Informants also reported the struggle of their family’s breadwinner to find work opportunities to pay the loans. These findings were similar to previous studies, which showed that nearly 50 percent of Syrians in Lebanon could not afford basic needs and over 90 percent went into debt to pay for essential needs (Hajjar and Abu-Sittah, 2021). The vulnerability assessment by the International Labor Organization (2020) showed that 60 percent of the Syrian workers in Lebanon were permanently laid off. Most informants reported that they did not receive any funding from aid organizations; a few reported not receiving or having difficulty registering their new babies to receive the UNHCR’s monthly allowance for refugees. This is supported by previous research that showed that 30 percent of Syrian families assessed did not receive any support from aid organizations during the pandemic (Hajjar and Abu-Sittah, 2021). Mothers in our study described a feeling of desperation and helplessness due to their financial situation and their inability to provide for their children, which echoes previous research on the impact of economic precarity on parents (Akesson et al., 2020).

Reflecting on the theoretical framework (Figure 1), the stressors of daily life and those caused by the pandemic threaten the wellbeing of Syrian mothers and may lead to severe mental health outcomes if not addressed. Study informants reported the effect of these stressors on their mental health or the mental health of their family members. However, informants mostly attributed their stress to daily stressors, such as the financial situation and mobility restrictions, with almost no mention of the trauma experienced in Syria. Such attributions could be because informants were mostly young, had left Syria with their parents as children or adolescents, and lived most of their lives in Lebanon.

Based on the emerging themes from this study, we revised the theoretical framework to reflect the various weights of factors affecting mothers’ mental health. (Figure 2) The revised version puts more emphasis on family support, stressors of daily life, and the pandemic and less emphasis on memories of trauma, hormonal and biological changes, and personal resilience. Although the latter factors may contribute to the mental health of mothers, they were not expressed by informants in this study.

Conclusion and implications for social work

This study highlights the multiple and intersecting biopsychosocial challenges that Syrian mothers faced in light of war and displacement. The COVID-19 pandemic and Lebanon’s economic crisis further exposed the systemic inequalities that greatly impact the everyday lives of this population. The inclusion of the voices of social work practitioners adds another layer to the study, providing valuable information on the practices in place that may support or hinder these Syrian mothers. As mothers themselves, the social work practitioners provided insight into the situation faced by the mothers that they work with. Overall, this study provides important insight into the everyday struggles faced by Syrian mothers during the postnatal period and sheds light on the ways that the social work profession can respond.

The findings also point to several ways that social work practitioners and policymakers can address the needs of Syrian refugee mothers in Lebanon. The need for increased social support for mothers is perhaps one of the most important takeaways from this research. As discussed in the theoretical framework (Figure 2), interventions that foster personal resilience and emphasize existing cultural support could go a long way to balance mothers’ mental health and lead to better outcomes. Social work practitioners and policymakers can make efforts to both reinforce existing supports and create new ones. It would first be useful to determine what formal and informal supports exist to ascertain how best to assist and not duplicate efforts. For example, if women in one informal settlement are already gathering at a regular time and place to support one another and care for each other’s children, then social workers should determine how to best reinforce this existing structure. The findings also underscore the importance of creating and facilitating programs for children in order to give parents – especially mothers with new children – a break during the day, especially since so many school-age children were home during the pandemic.

The research highlighted how important mobility is for mothers with infants, and how detrimental decreased mobility can be on so many aspects of their lives. Restricted mobility compromises access to social supports that are critical for mothers in the perinatal period. Informants’ precarious legal status coupled with the COVID-19 pandemic exacerbated their immobility. Therefore, social workers should be encouraged to advocate for policies that will remove barriers to mobility, such as restrictions related to not having the proper refugee documentation and the high cost of transportation. To address the issue of economic precarity facing this population, policies that address economic precarity – such as providing families with cash, so that, they can determine their own financial priorities and how to best address them (Akesson et al., 2020) – would go a long way in supporting mothers and their families. Finally, the research noted the importance of offering alternatives to COVID-deferred education for school-age children who may not have access to the Internet or a computer, so as to alleviate the caregiving responsibilities of their parents when they are at home caring for a new baby.

The research is limited by the use of virtual rather than face-to-face interviews that were mandated by COVID-19 restrictions. However, using a phone to conduct interviews may have increased informants’ comfort, as they were not worried about being exposed to COVID-19. Overall, future research should continue to explore how multiple forms of adversity intersect to impact mothers’ lives and focus on implementing and testing interventions that aim to alleviate stressors and provide support for mothers and their families.

In their article on social work’s role in addressing the COVID-19 pandemic among immigrant populations, Cross and Gonzalez Benson (2020) demand ‘a social work response that is innovative, brave, and deeply connected to communities’. Indeed, there is much social workers can learn from the voices of mothers who have survived through multiple layers of adversity: war, displacement, the COVID-19 pandemic, and Lebanon’s economic crisis. Yet, in listening, we must also, to quote O’Leary and Tsui (2020), ‘… reflect, analyze and learn’, so as to implement better interventions for families in crisis. For example, social workers should closely examine the role of interventions, such as formal and informal social support systems that mothers themselves have created and economic programs that give mothers the power to make decisions about their own financial priorities. A comprehensive approach to the multiple layers of adversity has the potential to effectively ameliorate the potentially negative impact and contribute to their wellbeing.

Supplemental Material

sj-pdf-1-isw-10.1177_00208728241235263 – Supplemental material for Exploring stressors impacting the mental health of refugee mothers in Lebanon during COVID-19 pandemic: A qualitative study

Supplemental material, sj-pdf-1-isw-10.1177_00208728241235263 for Exploring stressors impacting the mental health of refugee mothers in Lebanon during COVID-19 pandemic: A qualitative study by Nada Alnaji, Bree Akesson and Danstan Bagenda in International Social Work

Footnotes

Acknowledgements

The authors gratefully acknowledge the support they received from their partner NGO, Multi Aid Programs Organization (MAPS) in Lebanon, including Dr Bayan Louis, Nessreen, Aida, and Heba. They would also like to acknowledge Megan Culyer for her help in reviewing and proofreading this paper.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Nada Alnaji

Bree Akesson

Supplemental material

Supplemental material for this article is available online.

Author biographies

Nada Alnaji received her PhD graduate from the Medical Sciences Interdepartmental Area (MSIA) program at the University of Nebraska Medical Center. Her research interests include maternal mental health, health in conflict, and community-based participatory research.

Bree Akesson is an assistant professor of Social Work at Wilfrid Laurier University in Canada. Her research interests include experiences of war-affected families, place-based research, and biopsychosocial impacts of domicide.

Danstan Bagenda is an assistant professor at the University of Nebraska Medical Center. His research interests include infectious diseases, focusing on mothers, children, and vulnerable populations.

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