Caesarean section in countries of the Eastern Mediterranean Region.

This paper reviews global data on caesarean section (CS) focusing on Eastern Mediterranean Region (EMR) countries for which data could be obtained. CS rates in the EMR tend to average around 10%. The data, however, are often not representative of the whole country, being mostly hospital rather than community based. Global and regional CS trends, determinants, and outcomes are presented. Controversies and consensus over the indications for CS are reviewed. The cost of rising CS rates, women's involvement in decision-making, the role of health workers, data quality and legal aspects are highlighted, with discussion of the aim of reducing unduly high CS rates and promoting high-quality maternity care.

The antenatal care debate.

The antenatal care debate has focused on the frequency of antenatal care, its content, continuity, quality, organization, effectiveness and impact on morbidity and mortality. Established antenatal care schedules have been called into question. Randomized controlled trials comparing reduced schedules with routine antenatal care have shown similar or better outcomes for the reduced protocols. Furthermore, midwives, with or without physicians, can provide continuous maternity care comparable to obstetrician-led care. Some women disliked the new protocol, but a reduced protocol of high quality provided by competent midwives is cost-effective, spares scarce physicians and ensures women's satisfaction. It is recommended globally.

Reflections on maternal mortality in two decades.

The paper examines developments in the assessment and prevention of maternal mortality over the past 2 decades through review of the relevant literature. Problems of classifying and ranking causes, changing methodologies, discrepancies and illogical trends are demonstrated. Identifying causes of maternal mortality by surveillance and death reviews, rather than measuring ratios, appears to be more effective. Process indicators are considered as important as outcome indicators for monitoring safe motherhood. International technical reappraisal of maternal mortality is needed.

Integrating maternal and child health with primary health care in Saudi Arabia.

Integration is an important tool for successful implementation of components of a comprehensive health programme. We describe strategies adopted to integrate the Saudi maternal and child health (MCH) activities with other primary health care (PHC) components in order to achieve optimal quality care. Achieving such integration was one of the specific objectives of the MCH programme. Besides training MCH workers, other important tools of MCH/PHC integration included: organization, supervision, continuing education, data management and health systems research. The strengths and weaknesses of integration are discussed while the opportunities, limitations and implications are reviewed.

Maternal and child health in Saudi Arabia. Study design and methodology.

Saudi Maternal and Child Health Survey was designed to study the utilisation of maternal health services by ever-married women of child-bearing age, by measuring level of tetanus vaccination coverage; breastfeeding and weaning knowledge, attitude and practices; and by measuring the level of vaccination coverage with BCG, DPT, Poliomyelitis and measles vaccines among children 1-2 years old at the national level. The standard world health organization (WHO) cluster technique was employed. The kingdom was divided into five geographical areas. The sampling frame used was available at the Ministry of Health (MOH) in the form of ascending cumulative frequency tables where the catchment areas of 1625 health centres (HC) constitute primary sampling units (PSUs). Thirty clusters were randomly selected from each of the five geographic areas, and 40 household per cluster were used. The target populations included: (i) the ever-married Saudi females in the child-bearing age (15-49 years), (ii) children less than 5 years old, and (iii) children 1-2 years old. The respondents were interviewed using a questionnaire. The quality of data was assured by pre-coding of data which was edited throughout the field work period. A 4-day workshop was held for the interviewers and supervisors 48 hours prior to commencement of the survey. During the workshop, interviewers were instructed to read the questions precisely, were acquainted with survey methodology in general, pretested the questionnaire, received guide manual, instruction notes, progress sheets and follow-up formats for referring to when needed. The investigators were in the field during the first few days to solve any problem arising.

Antenatal care, attitudes, and practices.

This paper discusses attitudes and practices of antenatal care in Saudi Arabia, based on the results of the maternal and child health survey of 1991. The survey covered a cluster random sample of 6306 households, with 6294 ever-married Saudi women 15-49 years of age out of whom 1050 were pregnant. The interview questionnaire included maternal care data on current pregnancies and births in the sample, totaling 4777 children less than 5 years old. Coverage of antenatal care and frequency of visits among pregnancies identified, by whom and where, and reasons for not attending antenatal services by age, urban-rural, geographical, and educational differentials. Proportions pregnant at the time of the survey were 17 per cent; antenatal care attendance for the whole sample reached 86 per cent; frequencies of one or two visits were 37 per cent; and three or four visits 25 per cent; those checked by a physician were 85 per cent, while 88 per cent attended governmental facilities. Those with timely attendance were 85 per cent. However, almost one-third of non-attenders (30 per cent) believed they did not need antenatal care. Though utilization of antenatal care services is already high, it has to be further increased through health education and publicity, emphasizing the couples role.

Overview on breastfeeding patterns in Saudi Arabia.

A national cross-sectional study was carried out in 1991 to investigate child feeding patterns in addition to other MCH issues. The target population was the last live birth born within 5 years preceding the data of the interview. The data were collected by interviewing the mothers of the eligible children using a precoded questionnaire. The total sample size was 3608 children and their mothers were chosen randomly through a multistage cluster sampling technique with representation of different regions. The results observed revealed a previous history of breastfeeding among 92.4 and 94.5 per cent of urban and rural studied children, respectively. The mean duration of breastfeeding among studied children in the urban and rural communities, were 11 and 13 months, respectively. Illiteracy of the parents was associated with a longer breastfeeding duration. Moreover, the results revealed that, the higher the current age of mothers, the longer the average duration of breastfeeding. Governmental health facilities and mass media constituted the main source of essential information about child feeding. The results are further interpreted and suitable recommendations are made.

Coverage and quality of natal and postnatal care: women's perceptions, Saudi Arabia.

This paper discusses natal and postnatal care services in Saudi Arabia, as revealed by the National Maternal & Child Health Survey of 1991. The latter was based on a national random sample of 150 clusters, with 6306 households, from urban and rural areas, of five geographic regions. The target of 6294 ever-married Saudi women, 15-49 years old included 6020 currently married women, of whom 1050 reported a pregnancy. Data on maternal care were analysed, including where and why natal care was attended, and for both natal and postnatal care, how much and by whom, by respondents' age, urban-rural residence, geographical location, and education of wife and husband. About three-quarters of the respondents had one or more births within the 5 years preceding the survey, with a total of 4777 children under six. Institutional deliveries reached 86 per cent and about 90 per cent of deliveries were attended by physicians or nurses with a ratio of 2:1. Postnatal care attendance amounted to 88 per cent mainly by physicians than nurses with a ratio of 5:1. In general, the above results describe relatively high coverage with natal and postnatal care services, which can still be improved through health education and community support, particularly of the women. Judging by the high level of institutional care and physician involvement, good quality of care is implied, but needs to be further confirmed, by defining morbidity and mortality patterns.

Nuptiality pattern in Saudi Arabia.

The data of this work are based on the 'Saudi Maternal and Child Health Survey' conducted in 1991. This was a nationwide house to house field survey. The study included 6294 ever-married Saudi female in the childbearing age who represent the target population. They were randomly selected from both urban and rural settings of the five geographical areas of Saudi Arabia. The mean current age of the sample of ever-married women was 31 years and the mean age at first marriage was 17 and 16 years for urban and rural females, respectively. Education was associated with upward shift of the age at first marriage. About 20 per cent of the sampled ever-married Saudi females got married before their 15th birthday and 83 per cent before reaching 20 years of age. These percentages are even higher in rural than urban settings. The overall percentage of women who were currently married at the time of the survey was 96 per cent. The divorced and widowed women of childbearing age were 2 and 3 per cent, respectively, of the total. Husband's educational level had positive impact on the frequency of divorce. The latter was highest among women married to illiterate husbands with a dose response pattern. Comparison has been made with the situation 4 years ago. An increase in literacy rates among Saudi ever-married women and their husbands was observed, however, a significant (P < 0.05) difference still exists between female and male literacy rates (38 and 71 per cent, respectively). The events of early marriage, before the age of 15 years, became less frequent. There is an overall decline in teenage marriages which explains a large part of the recent changes observed in nuptiality and pattern of birth in Saudi Arabia.

National Immunization Coverage Survey Saudi Arabia, 1991.

A nationwide survey was carried-out aiming at determination of immunization coverage level against the six killer diseases of childhood (tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, and measles). Variations between geographical zones, urban-rural settings, age, education and mother's employment, father's education, and child's birth order were studied. The standard WHO cluster technique was used. The sample (1102 children) was restricted to Saudi children 1-2 years old. Interviewers were exposed to training and methods of calibration, and involved in a pilot survey. Nationally, the survey showed very high coverage levels, BCG was the highest (99 per cent), measles was the lowest (90 per cent), whereas the three doses of DPT (diphtheria, pertussis and tetanus) and TOPV (trivalent oral polio vaccine) were in between (98, 96 and 94 per cent, respectively). There was no marked differences between urban-rural settings. The western zone showed the lowest coverage by all vaccines. The national coverage by the six vaccines reached 86 per cent correctly immunized (according to WHO standards), 14 per cent partially immunized and 1 per cent non-immunized. Immunization coverage was higher for children to younger mothers. The non-immunized group belonged exclusively to illiterate mothers (1 per cent). Children to mothers with basic education showed the highest coverage (88 per cent). Birth order had negative effect on coverage. Nationally, 88 per cent of children had immunization certificate while 12 per cent had not. The eastern and central zones had the highest percentages of children with certificates (92 and 91 per cent, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Caesarean section in countries of the Eastern Mediterranean Region

This paper reviews global data on caesarean section [CS] focusing on Eastern Mediterranean Region [EMR] countries for which data could be obtained. CS rates in the EMR tend to average around 10%. The data, however, are often not representative of the whole country, being mostly hospital rather than community based. Global and regional CS trends, determinants, and outcomes are presented. Controversies and consensus over the indications for CS are reviewed. The cost of rising CS rates, women's involvement in decision-making, the role of health workers, data quality and legal aspects are highlighted, with discussion of the aim of reducing unduly high CS rates and promoting high-quality maternity care

The antenatal care debate

The antenatal care debate has focused on the frequency of antenatal care, its content, continuity, quality, organization, effectiveness and impact on morbidity and mortality. Established antenatal care schedules have been called into question. Randomized controlled trials comparing reduced schedules with routine antenatal care have shown similar or better outcomes for the reduced protocols. Furthermore, midwives, with or without physicians, can provide continuous maternity care comparable to obstetrician-led care. Some women disliked the new protocol, but a reduced protocol of high quality provided by competent midwives is cost-effective, spares scarce physicians and ensures women's satisfaction. It is recommended globally

Reflections on maternal mortality in two decades

The paper examines developments in the assessment and prevention of maternal mortality over the past 2 decades through review of the relevant literature. Problems of classifying and ranking causes, changing methodologies, discrepancies and illogical trends are demonstrated. Identifying causes of maternal mortality by surveillance and death reviews, rather than measuring ratios, appears to be more effective. Process indicators are considered as important as outcome indicators for monitoring safe motherhood. International technical reappraisal of maternal mortality is needed

Integrating maternal and child health with primary health care in Saudi Arabia

Integration is an important tool for successful implementation of components of a comprehensive health programme. We describe strategies adopted to integrate the Saudi maternal and child health [MCH] activities with other primary health care [PHC] components in order to achieve optimal quality care. Achieving such integration was one of the specific objectives of the MCH programme. Besides training MCH workers, other important tools of MCH/PHC integration included: organization, supervision, continuing education, data management and health systems research. The strengths and weaknesses of integration are discussed while the opportunities, limitations and implications are reviewed