The Syrian government bombed areas around Damascus on Monday as part of its push to keep rebel fighters out of the capital, leaving many children among the dozens killed, anti-regime activists said.
An international aid organization cited such raids, along with rape and widespread destruction, as key factors in the exodus of more than a half-million Syrians to neighboring countries since the conflict began in March 2011.
The International Rescue Committee said it could be "months, if not years" before the refugees can return home and warned that Syria's civil war could enflame tensions in the Middle East.
After nearly two years of violence, it appears unlikely that the war will end soon. Although rebels seeking to oust President Bashar Assad have made gains in the country's north and east and outside of Damascus, they have yet to seriously challenge his hold on the capital or other parts of the country.
Earlier this month, Assad dismissed calls from the U.S. and others that he step down and vowed to keep fighting until the country is free of "terrorists" — his government's shorthand for rebels.
International diplomacy has done little to bridge the gap.
In a report released Monday, the International Rescue Committee painted a grim picture of what life has become for Syrians in war-torn areas.
Syrians face brutal killings, arbitrary arrests, torture, frequent airstrikes, sexual violence and diminishing medical services, the report said.
The 32-page report, based on interviews with Syrian refugees in Jordan, Turkey, Lebanon and Iraq in November 2012, said that many who fled the country cited rape as a primary reason.
"Many women and girls relayed accounts of being attacked in public or in their homes, primarily by armed men," the report said. "These rapes, sometimes by multiple perpetrators, often occur in front of family members."
The group did not say if the alleged perpetrators were rebels or government forces.
Anti-regime activists have reported rapes by government soldiers or pro-government thugs, and U.N. war crimes investigators reported in August that government forces and allied militias were responsible for murders, rapes and indiscriminate attacks on civilians.
The report warned that violence could keep Syria's refugees in neighboring countries for years, taxing the resources of host governments and enflaming domestic tensions, particularly in Jordan and Lebanon. It called for greater international aid in and outside of Syria as well as open borders to allow those threatened by violence to escape.
Violence continued inside Syria on Monday, as government fighter jets carried out lethal airstrikes on rebellious areas near the capital, Damascus.
One strike hit the suburb of Moadamiyeh, blasting the walls off apartment blocks and scattering rubble in the streets. Activist videos posted online showed residents searching for survivors and wrapping dead bodies in blankets. One video showed two corpses lying face down, one covered in gray cement dust. Another showed the bodies of six children laid out on a floor. The videos appeared genuine and corresponded to other Associated Press reporting.
The Britain-based Syrian Observatory for Human Rights said 13 people were killed in the Moadamiyeh blast, eight children and five women. The group, which relies on contacts in Syria, also reported deadly airstrikes in two other suburbs, saying at least 45 people were killed in and around the capital Monday, including 10 rebel fighters.
The Syrian government offered its own account of the blast in Moadamiyeh, saying "terrorists" fired a shell at the neighborhood, hitting a residential building and causing an undefined number of casualties.
The destruction in the videos, however, appeared consistent with an airstrike, not a shell attack.
Rebel fighters said the strike on Moadamiyeh came amid a government offensive to push rebel fighters from there and the adjacent southwest suburb of Daraya.
Rebels moved into the two suburbs weeks ago, but have been bogged down in clashes with government troops since then. Both areas put rebel forces within striking distance of a key military airport in the Mezzeh neighborhood.
The Observatory said Monday that the government had blown up homes between the airport and the neighborhoods to establish a buffer zone.
One fighter in the area reached Monday said the government appeared set on pushing the rebels out.
"The noise from the bombardment is astounding today," said the fighter, who gave only his first name, Iyad, for security reasons. "The regime is using all kinds of weaponry."
The U.N. says that more than 60,000 people have been killed since Syria's crisis began with anti-regime protests. The conflict has since descended into civil war, with rebel brigades across the country fighting Assad's forces.
International diplomacy has failed to end the conflict.
On Monday, the secretary general of NATO said the alliance had no plans to intervene in Syria, warning that foreign intervention could have "unpredictable regional repercussions."
Anders Fogh Rasmussen told a defense conference in Sweden that Syria is more politically, religiously and ethnically complex than Libya, where NATO airstrikes in 2011 helped rebels overthrow Moammar Gadhafi.
Still, NATO is deploying Patriot missiles along Turkey's southern border with Syria to help the alliance member guard against spillover from the war.
Russian Foreign Minister Sergey Lavrov on Monday reiterated his criticism of Western calls that Assad step down.
During a visit to Ukraine, Lavrov suggested that Assad's opponents propose their own solution to the conflict.
Syria's splintered opposition has never offered a unified view on how to end the conflict or what should follow, other than agreeing on Assad's ouster.
"If I were in the opposition's place, I would put forth my own ideas in response on how to establish a dialogue," Lavrov said.
Iyad, the fighter near Damascus, said the opposition's key demand hasn't changed.
"We have said a million times we will accept nothing less than Assad's resignation," he said.
Associated Press writers Zeina Karam in Beirut and Jim Heintz in Moscow contributed to this report.