Better Perinatal Care in Saudi Arabia
1985; King Faisal Specialist Hospital and Research Centre; Volume: 5; Issue: 3 Linguagem: Italiano
10.5144/0256-4947.1985.169
ISSN0975-4466
Autores Tópico(s)Health and Conflict Studies
ResumoCurrent Concepts in MedicineBetter Perinatal Care in Saudi Arabia Arne OhlssonMD, FRCP(C) Arne Ohlsson Formerly: Staff Neonatologist, Division of Neonatalogy, Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia Search for more papers by this author Published Online:1 Jul 1985https://doi.org/10.5144/0256-4947.1985.169SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutINTRODUCTIONThe goal of modern reproductive medical care is to minimize perinatal mortality and the incidence of biologic, psychologic, and social handicaps.1 A continuing decline in the rate of perinatal mortality (PMR), defined as stillbirths after 28 weeks’ gestation and neonatal deaths before seven days of life per 1000 total births, is occurring in both developed and developing countries. This decline is attributable to many factors, including improved living conditions, better general health status among the population, standardization of antenatal care, regionalization of perinatal care, and new medical discoveries and treatment modalities.1 The lowest PMR in the world at the present time is that of Sweden, with 7.1 in 1981.2 The lowest infant mortality rates (IMR) are also reported from the Nordic countries, with Finland registering 6.5 (1981) and Sweden 6.8 (1982).3 PMRs and IMRs close to those of Sweden and Finland are seen in other areas where there is a similar awareness of the problems and the mothers are equally healthy.4At the present time in Saudi Arabia, a large number of lives are lost in the perinatal period because of lack of adequate care, and a large number of infants grow up handicapped. It has been estimated that for every perinatal death that occurs, two to three surviving infants will acquire a handicap from injury at birth.4 Better perinatal care decreases mortality and results in a net gain of surviving healthy children.5 The purpose of this paper is to review the literature related to reproductive medical care in Saudi Arabia and, based on this review, to make suggestions for improvements.THE HEALTH SERVICE SYSTEMSaudi Arabia, which covers an area of 2,149,000 km2, is an oil-rich country which in 1980 produced 15.5% of the world’s oil. Oil revenues accounted for 72.5% of the gross domestic product. In 1979 the per capita income was estimated at US $12,300, one of the highest in the world.6 As a result of the increase in oil revenues, the country has enjoyed rapid improvements in education, transport, communications, urbanization, and health care.In the health care sector, as in others, the shortage of well trained Saudi personnel remains the main obstacle to greater progress.6 In 1981, of the 5712 physicians working in Saudi Arabia, 576 (10%) were Saudi nationals.7 The distribution of physicians is uneven: 85% of them work in 96 hospitals and 400 private clinics in the cities, where only 40% of the population lives.7 There are 380 health centers in rural areas.7 In 1980 only three Saudi physicians were working in the southwest region, which has a population of more than 1 million, of which 75% live in rural areas.8 In 1980 there were 12,800 health assistants in the country, of whom 21% were Saudi.7Development plans for the future are impressive. For 1990, a ratio of one physician to 1200 population with 50% Saudi physicians is projected, and by the year 2000 an estimated 73% of the physicians will be Saudi.7 Although the country is divided into 10 health regions, most of the planning is centralized in the capital city of Riyadh.6 The expansion of preventive health programs is the main objective of the Health Service Systems;7 family medicine and community health are targets of the educational program at the newest faculty of medicine at Abha.8 Health authorities are thus presently pursuing health programs to provide basic primary care in rural areas.SOCIOECONOMIC DATAAge PyramidSaudi Arabia has a young population; according to the 1974 census, 48.7% were under 15 years of age, and only 4% were 65 years of age or older.9 In 1984, at least in rural areas, the age pyramid is similar, with approximately 20% to 25% of the population less than 5 years old and 50% of the population below 15 years of age.10,11 Women of child-bearing age (15 to 44 years) and children below the age of 15 constitute 65%12 to 73%10 of the total population and could thus be covered by maternal and child and school health services.10 The wide base of the age pyramid in rural villages indicates a high fertility rate and high childhood mortality.11 The birth rate in Saudi Arabia is high, approximately 45 to 50 per 1000 population,6,9 and the total fertility rate in 1974 was estimated to be seven per woman.9 The average number of children per family has been reported as 4.8,10 5.511 and 713; and 10% of the women have seven or more children.13 Consanguinity is common, and 65% of the mothers marry a cousin or other relative.12–14Marriage and TraditionsEarly marriage is common, and 1.5% of first pregnancies occur before age 15, 57% before age 16, and 65% before age 20.10,12,13,15 Traditionally, family planning has not been practiced, but more young women feel that limiting the number of pregnancies can preserve the mother’s health.12 A decreasing incidence of multiparous deliveries may indicate the greater use of contraception,16,17 and patients in the higher social classes find contraception fully acceptable.18Family life is governed by traditions and religion. Polygamy is allowed under Islam but is conditional on equal treatment of the wives. Polygamy is more common among the older generations.10,12 Premarital and extramarital sexual relations are strongly prohibited by Islamic law and are virtually unknown in rural communities.12 A husband may divorce his wife and a wife her husband in case of suffering, but the rates for divorce are negligible.10 Family ties and traditions help stabilize marital life.12 An extended family with up to three generations living together is still common in rural areas.11IncomeAlthough the per capita income is very high,6 the distribution of wealth is uneven and income is very low in some rural areas. In the late 1970s and early 1980s, the overall average monthly income per capita was 442 SR (Saudi riyals) among 200 families in Rabaiyah, Tarut Island10; and in the central desert area, the median household income was 1501 to 2000 SR per month with a median household size of nine persons.11 In Al-Qaseem 42% of the heads of households earned less than 1000 SR per month, with a median household size of 5.5 persons.12LiteracyIn the rural areas illiteracy is still prevalent; 95% of the mothers and 60% of the fathers cannot read and write.11 Most villages have a school for boys, but not all have schools for girls.11MATERNAL AND INFANT CAREPrenatal CareVery little information is available on the general health status of Saudi women, but it is regarded as very satisfactory by some authors, and the prevalence of anemia in the obstetric population is low at 1.0%13 to 2.6%.18 The levels of 25-hydroxy vitamin D (25-OHD) in maternal and cord blood are very low.19 The levels are lower in lower social classes and are correlated with living in houses without areas of direct access to the sun, which predisposes to rickets during infancy.19 Among pregnant women attending King Abdulaziz University Hospital in Jeddah, 31.2% had positive tests for Toxoplasma organisms, and seven of 688 pregnant women seroconverted with a rising titer of Toxoplasma gondii antibodies.20 The relatively low incidence of serological evidence of toxoplasmosis may be due to culinary habits, as traditionally boiled meat is preferred to raw, and pork does not exist in the country; but the risk of contracting the disease during pregnancy is relatively high.20 In the same hospital, 93% of pregnant women had hemagglutination inhibition antibodies to rubella as a result of previous exposure to the virus.21 With improved living conditions, exposure to rubella virus will occur later in life, and the need for immunization programs against rubella will increase. The incidence of asymptomatic hepatitis B carriers positive for the "e" antigen among pregnant women in Saudi Arabia is not accurately known but is probably relatively high.The genes for sickle cell disease and thalassemia are common in certain portions of the Saudi population, mainly among the Shiite segment. Hemoglobin electrophoresis screening of 2341 infants from the oases of Eastern Saudi Arabia showed 20% with S-trait and 43 with sickle cell disease (37 Hb SS and 6 sickle ß-thalassemia).22 An alphathalassemia genotype whose phenotypic expression is intermediate between the heterozygous state for alpha-thalassemia I and Hb-H disease has been found among Shiite Saudi Arabs.23 The incidence of abortion, congenital abnormalties, premature deliveries, perinatal deaths, toxemia, and infections was higher among pregnant Saudi females with sickle cell anemia than among normal pregnant women or pregnant women with sickle cell trait.24Maternal mortality in the Maternity and Children’s Hospital in Riyadh was 52/100,000 births during the years 1978 to 1980, when births totaled 55,428.13 This is high compared to rates in developed countries but lower than rates reported by developing countries.13 Hemorrhage, associated disease, pulmonary embolism, and infection were the main causes of maternal death. The main correctable factor was the patient’s failure to seek antenatal care. Maternal mortality could also be decreased by improved blood transfusion facilities in the peripheral hospitals and more adequate health education.13Pregnancy in adolescence constitutes a high-risk obstetric situation. In Saudi Arabia adolescents have an increased incidence of premature delivery, low birth weight infants, cephalopelvic disproportion, fetal malpresentations, operative delivery, and puerperal complications but no increased prevalence of preeclampsia.25 Maternal deaths due to hypertensive disease are also rare.13 Approximately 7% of Saudi mothers are Rh-negative and at risk of becoming isoimmunized, especially because antenatal and postnatal prophylaxis with anti-D immunoglobulin is not readily available.26In developed countries, approximately 15% of all pregnancies can be defined antenatally as at risk.27 The incidence of high-risk pregnancies is much higher in Saudi Arabia and has recently been reported as 25% in the southwestern region of Saudi Arabia26 and 54.4% in the Eastern Province.28Antenatal CareMost mothers do not receive adequate antenatal care, even in the capital city. Only 40% of mothers that gave birth at the Maternity and Children’s Hospital in Riyadh during 1978 to 1980 received adequate antenatal care.13 At King Faisal Military Hospital in Khamis Mushayt 49%26 and at the Maternity and Children’s Hospital in Riyadh 30%13 of the patients are seen for the first time when in labor. In 1979, the situation was similar at the Riyadh Military Hospital.18 In rural areas less than 18% have antenatal care.10DeliveryThe level of obstetric care in Saudi Arabia varies tremendously, from unattended home deliveries to delivery in institutions with the most modern facilities for fetal monitoring and maternal analgesia, with attendance by anesthesiologist, obstetrician, and neonatologist. Most births in Saudi Arabia probably still take place at home. In rural areas, 89%12 and 89.8%10 of births have been reported as home deliveries. In Riyadh, the capital, 30% of the births take place at home.13 The incidence of cesarean section varies in different institutions and was 5.8% at Central Hospital in Buraydah (1979),29 7.5% to 8.0% at King Faisal Military Hospital in Khamis Mushayt (1978–1979),15,26 8.6% at the Military Hospital in Riyadh (1978–1979),18 and 18.5% at King Faisal Specialist Hospital in Riyadh (1982).30 The different cesarean section rates not only reflect the number of high-risk mothers cared for, but also the readiness of the obstetricians to interfere surgically in response to signs of fetal distress. The perinatal mortality among infants born by cesarean section in rural areas is high, mainly because of a high stillbirth rate as mothers present late as emergencies, after hours and days of fruitless labor at home and with poor or no antenatal care.29In rural areas the practice of obstetrics is carried out by mothers, grandmothers, wise old women, and nurse-midwives, as well as in hospitals.31 Various types of manipulation are used by local healers for external cephalic version in transverse and breech presentations, and cautery is used for postpartum hemorrhage.31Perinatal and Infant Mortality and MorbidityPMR is dependent on maternal age and parity, and the infant’s birth order and gestational age.2,32 The lowest perinatal mortality is in that group of mothers 20 to 29 years of age.2 PMR and IMR are also linked to maternal socioeconomic status.33–35 Characteristics of the maternal population in Saudi Arabia predispose toward a high PMR, because many mothers belong to a low socioeconomic group, are younger than 20 or older than 29 years of age, and are grand multiparas.10–13 The PMR is minimal at 40 to 41 weeks’ gestation and for infants weighing 2500 to 4000 gm at birth.2 The low birth weight rate (LBWR = 25,000 deliveries per year) or at home, a low estimate of a PMR of 30 to 40 for the population of Riyadh is justified. The impact on the national PMR by other hospitals with better results is little at the present time as the number of deliveries is small. These lower figures are, however, important as they demonstrate that improved care reduces perinatal mortality.Table 1. Perinatal mortality in Saudi Arabia, 1976–84, and Sweden, 1981Table 1. Perinatal mortality in Saudi Arabia, 1976–84, and Sweden, 1981According to the 1974 census, the population of Saudi Arabia was 7,012,000 and the estimated growth rate of the population is 2.7%.39 Assuming a population of 9 million in 1984, a birth rate of 44/1000 population, and a PMR of 35/1000,13,860 infants die in the perinatal period annually in Saudi Arabia. Based on these assumptions, if the PMR were reduced to 7.1 (as in Sweden in 19812), 11,048 infant lives would be saved each year, and approximately 25,000 infants would be spared from handicaps.4The numbers of late fetal deaths (LFD) and early neonatal deaths (END = less than 7 days of age) are almost equal in developed countries,2 and the best-equipped and staffed institutions in Saudi Arabia show the same ratio between LFD and END (Table 1). The rates for Saudi Arabia presented in Table 1 are based on few deliveries and therefore vary considerably from year to year. No study of the total PMR for a defined geographic area has been performed and is urgently needed. Experience with END at KFSH is presented in Table 2 and compared to a large study from Iowa, USA.40 Birth weight less than 750 gm, congenital malformations, and Rh-hemolytic disease of the newborn were more common, and birth asphyxia and sepsis were less common causes of neonatal deaths at KFSH, as compared to the Iowa study. Rh-hemolytic disease is still a major problem in Saudi Arabia, even though the prevalence of Rh-negativity in mothers is only 7%,26 because there is no nationwide program for antenatal anti-D globulin prophylaxis reaching all the Rh-negative mothers.Table 2. Clinical causes of neonatal deaths at King Faisal Specialist Hospital, Riyadh, Saudi Arabia, and in Iowa40Table 2. Clinical causes of neonatal deaths at King Faisal Specialist Hospital, Riyadh, Saudi Arabia, and in Iowa40At Aramco Hospital, 56.3% of the early neonatal deaths were due to conditions originating in the perinatal period. Of these, one-third were due to disorders relating to short gestation and unspecified low birth weight; 38% died of congenital malformations.38 At Aramco, 79 deaths occurred during the first year of life, and 44.3% were due to conditions originating in the perinatal period (birth trauma, respiratory illness, low birth weight).38 Of all infant deaths at Aramco, 72% occurred in the neonatal period. In a study from Dhahran in 1967, anoxia in the perinatal period and infections in infancy were the leading causes of death.41 At Khamis Mushayt, 1.2% of the newborns had severe malformations and 4.2% minor malformations.15 At the Dhahran Health Center (November 1981–January 1982) major congenital malformations were reported in 1% of 3058 live births and 17 of 54 stillbirths; congenital malformations were a major cause of perinatal deaths.42The incidence of sepsis among neonates born at KFSH is 2/1000 live births,43,44 the same as in the West.45 Mortality associated with neonatal sepsis is still high in Saudi Arabia and was 45% in 1976–1980 at KFSH. The reasons for the high mortality were associated severe malformations and late referrals.43Salmonella species were isolated from blood in 31% of the cases.43 In the period 1980–1984, the mortality from neonatal sepsis at KFSH dropped to 31%.44 Predisposing factors for sepsis in Saudi Arabia are prematurity (45%) and congenital malformations (36% to 45%).43,44 Of 214 neonates admitted from home with infections to the Maternity and Children’s Hospital in Riyadh during February 1980 to March 1981, 22.4% died, and the highest mortality was among the low birth weight group, preterms, and light-for-date infants. The neonates tended to be from a low socioeconomic class and were bottle fed or mixed fed.46 The majority of their mothers were illiterate, and many sought medical advice at a late stage of the infant’s illness; 31.5% of the infants had been cauterized. Cauterization is a common practice in Saudi Arabia and is performed locally by a person with knowledge of "Arabic medicine". The skin of a certain area is cauterized (burnt) with a glowing iron bar. The second or third degree burn heals with scarring and depigmentation. The risk of infections is high.47 A high rate of growth of Staphylococcus aureus and S. epidermis in blood could possibly be related to the skin as an entry of infection after cauterization.46Delay in seeking medical treatment for sick infants was also a major cause of death among neonates in Al-Khobar.47 Infant mortality in Saudi Arabia (Table 3) varies tremendously, from 15.6 to 144/1000 live births.6,11,12,38,48 Again, no estimate is available for the whole population, but it is probably more than 100/1000 live births, similar to that in Sweden in 1881–1890.4 Because most of the infant mortality occurs during the neonatal period,2–4,38 to a great extent it reflects the level of perinatal care in the country. In Saudi Arabia, conditions originating in the perinatal period, congenital malformations, and infectious diseases are the major causes of infant mortality.6,11,12,36,38,41,42,46 A strikingly high number of congenital malformations (16%), physical handicaps (32%), and mental retardation (11%) were seen in a two-year review of new pediatric patients at KFSH.49 The disease pattern at the Military Hospital in Riyadh is similar.50 A study of 482 deaf children in Riyadh showed hereditary factors to be a major cause.51 In addition, polio, schistosomiasis, malaria, kala-azar, and hydatid disease are endemic in the country.49Table 3. Infant mortality in Saudi Arabia (1967–82), Sweden (1881–1982), Finland and United Kingdom (1981), and USA (1982)Table 3. Infant mortality in Saudi Arabia (1967–82), Sweden (1881–1982), Finland and United Kingdom (1981), and USA (1982)ACTION FOR IMPROVEMENTA high maternal mortality (52 per 100,000 births in Riyadh) and very high PMR (estimated at 30 to 40 per 1000 births) and IMR (estimated at >100 per 1000 live births) occur in Saudi Arabia at the present time. The composition of the maternal population giving birth is unfavorable, with many mothers less than 20 or more than 29 years old and many grand multiparas. Many mothers are illiterate and belong to a low socioeconomic group, and fertility rates are high. Antenatal care is very poor, and many deliveries take place in the home with no qualified personnel in attendance. Mothers with complications during labor, sick neonates, and infants are brought to medical care late. Consanguinity is common (65%) and contributes to the high incidence of congenital malformations and rare recessive disorders. A large number of infants and children have mental and physical handicaps related to unfavorable events in the perinatal period. Based on current projections, approximately 10,000 lives are wasted and 25,000 children become handicapped each year, if the present PMRs are compared to the best available standards in the world.Needs for genetic counseling, adequate immunization programs, health education, and improved perinatal and primary care are obvious and have been emphasized by a number of authors.1,6,8,10–13,17,18,35,43,46,47,49–55 PMR and IMR similar to those of Saudi Arabia in 1984 were seen in the Nordic countries in the late 19th century, and it took these countries many decades to reach the lowest PMR and IMR in the world. As much as possible within the context of Saudi Arabian society, by using the reproductive medical care systems of these and other countries as models56 and by adopting the guidelines for perinatal care issued by the American Academy of Pediatrics57 and the British Paediatric Association,57 Saudi Arabia should be able to improve rapidly on today’s poor statistics, especially with the strong economic resources it has available. If population growth is desired, it will not be necessary to encourage more pregnancies as better care leads to more healthy surviving infants. With further socioeconomic and educational development, the birth rate is likely to fall, but improved perinatal intact survival will result in a net gain in population. The following suggestions are offered to improve reproductive medical care in Saudi Arabia. The suggestions must be carried out under the current social system and currently available resources, including such traditional support persons as family members and other health workers.1. Educating the public to the risks in pregnancyThe most important task is to make the general public, the medical profession, and the government aware of the present waste of lives in the perinatal period and the large number of handicapped children that are added to the population each year. A better understanding of the risks involved in every pregnancy is needed. Better perinatal care leads to a net gain of normal healthy children. A sense of responsibility that involves the pregnant woman, her immediate family and friends, health authorities and professionals, and the government has to evolve.2. Better living conditionsImprovements in socioeconomic and housing conditions for lower income groups would improve PMR and IMR as these are closely related to social class.3. Education for allCompulsory basic education, including the health area, for girls and boys and availability of higher education according to capability would increase the general level of knowledge in the population and would change the attitude towards health care. Better and longer education for girls will probably also lead to marriage at a later age and thereby decrease the fertility rate. With fewer infants born to very young or grand multipara mothers, the PMR will automatically improve without any changes in the medical care system. Interesting outreach audiovisual health education via television can circumvent the present problem of a low literacy rate among the population.4. Vital statistics and epidemiologic studiesAccurate collection of vital statistics is necessary for future planning and audit of perinatal care in the country. Computerized medical birth registration would be ideal. Medical birth registration under an identification number unique to the infant born should include a summary of all major events during pregnancy, delivery, and the early neonatal period. The information should be sent to a central registry for computerization, and a copy should go to the local maternal and child health center to become part of the infant’s health record. In case of death of the infant, this would be registered under the same personal number. Studies of the total PMR in defined geographic areas and populations are urgently needed to serve as a base for future studies and development plans for health care facilities.5. Basic antenatal careStandardized antenatal care should be made available to all pregnant women locally at maternal and child health centers or by outreach nurse-midwives. Most antenatal check-ups could be done by midwives according to a protocol, and the information obtained should be recorded on a standardized chart that could be carried by the mother. The information would then be readily available at the time of delivery. If abnormalities were noted, the mother would be treated locally or referred to a higher level of antenatal care.6. RegionalizationA defined, regionalized system should be established to identify pregnancies at risk and to match the degree of risk with the expertise and sophistication of equipment in the institution selected for delivery. The country is presently divided into 10 health regions. Within each region, reproductive medical care for mother and infant should be made available at three levels, in local (level I), central (level II), and regional hospitals (level III). The number of beds at each level will depend on the number of the population. Facilities for neonatal intensive care are needed at the two highest levels of care and personnel trained to resuscitate newborns should be available in all delivery units. A surface and air transport system for mothers prior to delivery and for critically ill neonates is needed. The transport team has to be properly trained and equipped. The regional perinatal unit should be easily reached by a direct telephone line used only for communication regarding transferrals. The use of facilities within the region can be improved if the delivery units are linked to the regional center via computer. The regional center should provide leadership throughout all levels of the perinatal care system, provide an outreach teaching program, stimulate research, and improve care at all levels.7. ScreeningNewborn screening programs for hemolytic disease of the newborn, hypothyroidism, and phenylketonuria are needed. Blood banking facilities should be upgraded in the local hospitals. Antenatal screening programs for fetal disease are not warranted in Saudi Arabia at present, as therapeutic abortions are against hospital policy. However, anti-D globulin prophylaxis against Rh immunization should be available antenatally and postnatally, after blood group testing and antibody screening. Rubella immunization programs for preteenage girls should be instituted. Pregnant women should be screened for rubella immunity during pregnancy, and if they are negative, they should be offered immunization postpartum. Maternal hepatitis B screening of pregnant women should be done antenatally, and hepatitis B immune globulin and hepatitis B vaccine should be made available postnatally for the infant.8. Exchange of ideasThe establishment of a Saudi Arabian society for perinatal medicine would stimulate research, support innovative public health projects and manpower development in the reproductive medical care field, facilitate exchange of ideas, and draw public attention to this very important area of the health sector. Representatives of this society could act as advisors to the Ministry of Health.9. Sharing facilitiesCooperation between different perinatal units within and between regions is urgently needed to utilize the presently insufficient facilities to best advantage. Unification of the present efforts by individual physicians, hospitals and indigenous health workers would have a major impact on pregnancy outcome.Implementation of some or all of these suggestions is a cost-effective way to decrease the number of perinatal deaths, prevent handicaps, and avoid much human suffering. Improved reproductive medical care results in a net gain of sur
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