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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 124-129

Obstetric danger signs experience and medical care sought among Saudi women: A community-based survey


1 Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
2 Department of Emergency Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
3 Department of Mathematics and Statistics, Open University, Milton Keynes, United Kingdom

Date of Submission06-Sep-2021
Date of Decision19-Oct-2021
Date of Acceptance24-Nov-2021
Date of Web Publication28-Apr-2022

Correspondence Address:
Amani Abu-Shaheen
Research Center, King Fahad Medical City, P.O. Box: 59046 Riyadh 11525
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsm.jnsm_115_21

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  Abstract 


Objective: The objective of the study is to investigate the occurrence of obstetric danger signs and medical care sought during pregnancy, delivery, and postpartum periods among Saudi women. Study Design: A cross-sectional survey was conducted on women from the Riyadh community who had delivered during the past 2 years. Sociodemographic characteristics, the occurrence of danger signs during the antenatal, delivery, and postpartum periods were recorded. Results: A total of 1397 were included in the analysis. Around 35% of the women had a history of at least one of these three danger signs during pregnancy. Five hundred forty (38.7%) participants had a history of at least one of the obstetric danger signs during a delivery. Five hundred and four (36.1%) participants had a history of at least one of the obstetric danger signs during the postpartum period. The experience of at least one obstetric danger was statistically significant and associated with the northern region of Riyadh (odds ratio [OR] = 2.03, 95% confidence interval [CI]: 1.39–2.97); a higher level of education (OR: 1.42, CI: 1.01–1.98); unemployment (OR: 0.67, CI: 0.48–0.93); and having hypertension (OR: 2.11, CI: 1.42–3.13). Conclusions: Although the coverage of ante and postnatal care is good in KSA, awareness programs regarding danger signs at grass root levels in antenatal and postnatal care are needed.

Keywords: Danger signs, delivery, obstetric, postpartum, pregnancy, primary health-care centers


How to cite this article:
Abu-Shaheen A, AlFayyad I, Heena H, Nofal A, Riaz M. Obstetric danger signs experience and medical care sought among Saudi women: A community-based survey. J Nat Sci Med 2022;5:124-9

How to cite this URL:
Abu-Shaheen A, AlFayyad I, Heena H, Nofal A, Riaz M. Obstetric danger signs experience and medical care sought among Saudi women: A community-based survey. J Nat Sci Med [serial online] 2022 [cited 2022 May 16];5:124-9. Available from: https://www.jnsmonline.org/text.asp?2022/5/2/124/344202




  Introduction Top


Pregnancy is a normal part of the life cycle, but there is always the possibility of unanticipated complications and deaths. Maternal deaths from preventable causes continue to be a significant public health burden, particularly in developing countries.[1] It has been defined as “the death of a woman while pregnant or within 42 days and up to 1 year (late maternal death); of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”[2]

About 275,288 maternal deaths were reported as a result of pregnancy or delivery worldwide.[3] Saudi Arabia's maternal mortality ratio (MMR) decreased at a moderate rate, from 21.3/100,000 live births in 1990-15.7/100,000 live births in 2015.[4] Although the gross domestic product per capita and health expenditures growth have increased remarkably in Saudi Arabia,[5] the MMR remains high in comparison to developed countries' MMR (12 per 100,000).[6] Bleeding, infections, and hypertension are the primary causes of direct obstetric deaths, while indirect causes include worsening of preexisting medical conditions during pregnancy or after delivery. Furthermore, sociocultural factors such as illiteracy, poor family planning, and a lack of emergency access to pregnancy termination all play a role.[7]

The central role in preventing and minimizing the risks of obstetric complications and deaths is the ability of women to identify obstetric danger signs and promote health-seeking behaviors.[8] During pregnancy, the most common obstetric danger signs are hands/face swelling, severe vaginal bleeding, and blurred vision. Severe vaginal bleeding, seizures, prolonged labor, and retained placenta are common during delivery. Moreover, postpartum women may experience severe bleeding, fever, and loss of consciousness. Bleeding remains the crucial cause of maternal death, contributing to one-third of death cases.[9]

Evidence-based data is critical for informing decision-makers about the development and implementation of appropriate interventions and strategies to improve women's reproductive health. Nonetheless, there is a gap in the Saudi Arabian literature reporting such studies on women's experiences with obstetric danger signs. Thus, the purpose of this study was to look into the occurrences of obstetric danger signs and medical care sought during pregnancy, delivery, and postpartum periods among Saudi women in Riyadh.


  Materials and Methods Top


A based cross-sectional survey was conducted among Saudi women attending primary health-care centers (PHCCs) in the five districts of Riyadh City, Saudi Arabia. The fertility rate is 2.6% in Riyadh, Saudi Arabia.[10] The PHCCs provide free primary medical care for the residents. The PHCCs were selected using two-stage random sampling techniques. Initially, after obtaining the list of PHCCs in each district from the Department of the census in the Saudi ministry of health. Then, we have selected about one-quarter of the PHCCs from each district; next, followed by a random selection of women from each selected PHCCs. Women who indicated that they have delivered within the past 2 years were eligible to participate in this study. We excluded women who were not capable (mentally or physically) to share their information during the data collection process.

Data collection

Trained research assistants were recruited to conduct a structured interviewer-administered survey to include illiterate women and unable to understand the questionnaire designed to collect data related to obstetric danger signs. The questionnaire was developed after an in-depth literature review[11],[12],[13] and was piloted to find any difficulties or ambiguity during the interviews. The Cronbach's alpha for the questionnaire was calculated and it was 0.079.

The sociodemographic characteristics of mothers include women's age, place of residence, level of education, employment status, place of delivery, income per month, number of live births children; in addition to questions about women's reproductive history and morbidities. Besides, women were asked to report any of the danger signs experienced personally and to indicate if they sought help from health-care institutions. We captured and recorded in the questionnaire as well any signs that occurred to women during pregnancy, delivery, and postpartum periods. The main danger signs during the antenatal period include swollen hands/face severe, vaginal bleeding, and blurred vision. The main danger signs captured during delivery are prolonged labor (labor lasting >12 h), severe vaginal bleeding, convulsions, and retaining the placenta. Moreover, the danger signs during postpartum that were collected include foul-smelling vaginal discharge, severe vaginal bleeding, and high temperature. Participants were asked if they had an experience of the danger mentioned above signs, and their responses were recorded on the scale of (Yes, No, I don't know), for example, during pregnancy, swollen hands/face (Yes, No, I don't know), severe vaginal bleeding (Yes, No, I don't know), and blurred vision (Yes, No, I don't know). We coded (Yes = 1, No = 0, and I don't know = 0) and added together to compute three separate scores for during pregnancy, during delivery, and after delivery, a score <0 was considered as at least one danger sign during pregnancy, during delivery or after pregnancy. Hard copies of the completed questionnaires during the interview were examined for consistency and completeness.

Ethical considerations

We obtained written informed consent before the enrolment of each participant. The identity of the participant was maintained and kept confidential. Regulatory approval was obtained from the Directorate of PHCCs of the ministry of health and ethical approval from the Institution Review Board of King Fahad Medical (IRB number 17-049, November 28, 2018). The procedures adhered to the ethical guidelines of the Declaration of Helsinki.

Sample size estimate

The estimated sample size (n = 1425) was calculated based on the fertility rate of 2.6%, an estimated population of newborn at risk being 200,000 across Saudi Arabia, a precision of 1.00%, prevalence = 1.25%, and 95% confidence interval (CI) specified limits of 0.25%–2.25%.

Statistical analysis

Data were recorded on an Excel sheet (version 13) and managed on Stata (version 12) software for cleaning and conducting the statistical analyses. The sociodemographic characteristics, comorbidities, reproductive history, antenatal care, and postnatal care, and received treatment were summarized as frequencies and percentages. Frequencies (percentages) with (95%-CI) were computed for the obstetric danger signs that happened to the participants and the care they received. The occurrence of at least one danger sign during pregnancy was computed, and its association with demographics was assessed using logistic regression analyses.


  Results Top


A random sample of 1428 women from the five regions (Central 16.7%, South 13.4%, North 16.7%, West 16.7%, and East 36.5%) of Riyadh, the capital city of Saudi Arabia, was interviewed. Thirty-one women (2%) did not deliver the baby and were excluded from this analysis. The majority (70%) of the women were aged between 26–40 years. Nearly one-third of the women were educated to a university degree level. The majority were unemployed (83%), and about 39% had a very monthly low income. Around (38%) had 4 or more children. Only (13%) of the mothers had a history of diabetes mellitus, (8%) hypertension, and 4% had heart, lung, liver, or kidney problems.

Participants' experience with obstetric danger signs and consequent sought medical care

[Table 1] displays women's history of obstetric danger signs during pregnancy, delivery, and postpartum periods. The most common reported obstetric danger signs during pregnancy were swollen hands/face 294 (21.1%), followed by severe vaginal bleeding 213 (15.3%), and blurred vision (13.9%). Around 35% of the women experienced at least one of these three danger signs during pregnancy. During delivery, 23.1% of the women indicated prolonged labor (>12 h), 15.5% of the women had retained placenta, and 6.5% had convulsions. Five hundred and forty (38.7%) participants experienced at least one of the obstetric danger signs during a delivery.
Table 1: Participants' experience of obstetric danger signs (n=1397)

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For postpartum, the foul-smelling vaginal discharge and high fevers were the most common reported obstetric danger signs 368 (26.3%) and 166 (11.9%), respectively. Five hundred and four (36.1%) participants experienced at least one of the obstetric danger signs during the postpartum period.

Around 36% of the participants sought medical care after the experience. Of whom, 249 (49.1%) participants visited the PHCCs.

Higher odds of the experience of at least one obstetric danger sign was statistically significant and associated with the northern region of Riyadh (odds ratio [OR] = 2.03, 95% CI: 1.39–2.97); a higher level of education (OR = 1.42, 95% CI: 1.01–1.98); while lower odds of the experience were associated with unemployment (OR = 0.67, 95% CI: 0.48–0.93). Moreover, participants who had any other health issues were more likely to experience at least one obstetric danger sign during pregnancy (OR = 1.61, 95% CI: 1.27–2.06), including hypertension (OR = 2.11, 95% CI: 1.42–3.13) [Table 2].
Table 2: Participants' characteristics and their association with the experience of at least one obstetric danger signs (n=1397)

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Above three fourth (86%) of the participants had attended the recommended visits (>4) of ANC. A statistically significant difference was found between ANC visits (more than 10 visits) and the experience of at least one of the obstetric danger signs [Table 3].
Table 3: Antenatal and postnatal care visits association with the experience of at least one obstetric danger signs (n=1397)

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  Discussion Top


Adequate knowledge and awareness of obstetric danger signs are essential for women to inform their decision for seeking medical care. However, measuring the obstetric danger signs is significant to quantify its magnitudes to untimely improve the existent maternal programs or augment the efforts further. This study represents the first nationwide report of women's experience of obstetric danger signs during pregnancy, delivery, and postpartum periods, and their health-seeking behaviors. Previous studies reporting the real experience of obstetric danger signs were almost nonexistent. All studies reported were addressing women's knowledge of obstetric danger signs.

The current study showed a considerable prevalence of experiencing at least one of the obstetric complications during pregnancy (35.2%), during delivery (38.7%), and postpartum (36.1%). We inquired about the experience of the three major obstetric danger signs during pregnancy (swollen hands/face, severe vaginal bleeding, and blurred vision) identified by the Maternal Neonatal Program of JHPIEGO.[14]

Severe vaginal bleeding has been considered a quality indicator for evaluating obstetric care in developed countries.[15],[16],[17],[18] In our study, 50% of obstetric bleeding occurred during pregnancy, 5.4% during delivery, and 9.5% during postpartum. A population-based cohort study conducted in Netherland among pregnant women (n = 371,021) reported 1606 (4.5%) cases with severe vaginal bleeding, of which 3% in early pregnancy, 9% during delivery, and 88% postpartum.[19] Moreover, severe vaginal bleeding was described in 3501 (1.1%) women out of 307,415 from January 1999 to April 2004, recorded in the Medical Birth Registry of Norway.[20] Data from the United States indicated that 2.9% of all births are complicated by bleeding.[21],[22] The immediate postpartum morbidity due to bleeding includes ICU admission, acute renal failure, peripartum hysterectomies, sepsis, and deaths.[20] Several studies identified postpartum bleeding as the main cause of maternal morbidity and mortality globally. Such a significant prevalence of 9.5% of postpartum bleeding must be viewed with particular concern given the availability of modernization of health care and effective drugs and surgical techniques to compact underlying causes of bleeding.

Hands/face swelling was the most frequently experienced obstetric complication during pregnancy as reported by nearly one-fifth of the women, followed by severe vaginal bleeding (15.3%), and blurred vision (13.9%).

Remarkably, this result was dissimilar to the existing literature which reported vaginal bleeding as the top perceived obstetric danger sign experienced during pregnancy.[23],[24],[25],[26],[27],[28],[29] Three regional studies conducted in Egypt and Jordan ranked vaginal bleeding as the top perceived obstetric danger sign experienced during pregnancy with a prevalence ranged between.[23],[24],[28] Other studies as well from Sub-Saharan Africa and Asia as well have shown vaginal bleeding as the top perceived obstetric danger sign experienced during pregnancy.[25],[27],[29],[30]

At delivery and postpartum, fewer women with vaginal bleeding were observed. Less than half of the women had prolonged labor time (>12 h) and retained placenta, and only a quarter had a convulsion. At postpartum, less than a half reported foul-smelling vaginal discharge, and a quarter reported high fever. During all periods, the majority of the women had a history of at least one of the three antenatal danger signs. The percentage of women with a history of obstetric danger signs reported in this study is higher than the recently conducted study in Ethiopia, which reports that only 8.9% of the women experienced danger signs during pregnancy,[31] while the findings of our study are very close to that reported by Bintabara et al.[26]

The experience of at least one obstetric danger sign was statistically significant and associated with the northern region of Riyadh, level of education, and unemployment. Therefore, the public health department needs to consider programs for educating women about the obstetric danger signs to increase the level of their knowledge and awareness.

Only 36% of the participants sought medical care consequent to the experience of obstetric danger signs. Of whom, 49.1% of participants visited the PHCCs. Around 86% of the participants had attended the recommended visits (>4) to ANC. A statistically significant difference was found between ANC visits (more than 10 visits) and the experience of at least one of the obstetric danger signs. One of the most significant roles of ANC is to provide health information and services that can meaningfully enhance the health of women and their infants.[32] Furthermore, ANC appears to have a positive impact on the utilization of postnatal health-care services.[33] Empirical evidence demonstrates that four ANC visits are sufficient for uncomplicated pregnancies, and more are needed in case of complications;[34] hence, the World Health Organization recommends at least four ANC visits in the course of pregnancy.

To confirm our apparent data of obstetric danger signs and to evaluate and validate this data with clinical practice in Saudi Arabia, we recommend a prospective longitudinal cohort study to measure incidence, risk factors, fatality rates, and substandard care. Further studies in this field are needed to cover the whole region of the KSA.

The strength of the current study is that it represents the first nationwide report of women's experience of obstetric danger signs during pregnancy, delivery, and postpartum periods and their health-seeking behaviors in Riyadh city. However, the results of our study need a careful interpretation; it is a cross-sectional study in which information was collected by a researcher a couple of months after the delivery. The limitations of this study are that the study might have different degrees of recall bias among women who did or did not experienced obstetric danger signs. The lack of women's knowledge of the danger signs may also have contaminated the reports.

This is one of the studies in Saudi Arabia that reports the proportion or experiences of women with obstetric danger signs during different periods of pregnancy, delivery, and postpartum. A considerable proportion of women did not seek medical care subsequent to experiencing obstetrical danger signs. Although the coverage of ante and postnatal care is good in KSA, awareness programs regarding danger signs at grass root levels in antenatal and postnatal care are needed to improve health outcomes.

Acknowledgments

The authors would like to thank the research center at King Fahad medical city for funding this study.

Financial support and sponsorship

This project was funded by the Grant Management Department, King Fahad Medical City. The funder does not have any role in the design of the study or collection, analysis, interpretation of data, and in writing the manuscript.

Conflicts of interest

There are no conflicts of interest.



 
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