|Year : 2020 | Volume
| Issue : 1 | Page : 8-12
Perinatal mortality in Saudi Arabia: Profile from a private setup
Sajjad Ur Rahman, Muhammad Hasan Abdulghani, Khalid Al Faleh, Mohammad Khalil, Mustafa Mohammad Mustafa, Jasim Anabrees, Maha Yassin Mansour, Adnan Mirza, Konstantinos Mousafeiris, Mohammad Mubarak, Mohamed Kamal
Sulaiman Al Habib Medical Group, Al Awsat Valley S, Al Olaya, Riyadh, Saudi Arabia
|Date of Submission||08-Jun-2019|
|Date of Decision||07-Nov-2019|
|Date of Acceptance||21-Nov-2019|
|Date of Web Publication||29-Jan-2020|
Prof. Sajjad Ur Rahman
Sulaiman Al Habib Medical Group, Al Awsat Valley S, Al Olaya, Riyadh, 12214
Source of Support: None, Conflict of Interest: None
Objective: Our study aimed to ascertain rates and most frequent causes of perinatal mortality in a major tertiary care private maternity and neonatal intensive care unit (NICU) setup in Saudi Arabia. We also conducted a comparative analysis with the perinatal mortality rates (PMRs) from public setup in Saudi Arabia as well as the most recent global and regional data. Study Design: This was a retrospective, analytic, and comparative study. Methodology: One-year data (from January 1, 2017, to December 31, 2017) were ascertained from the Electronic Patient Medical Records database (VIDA) as well as the annual reports of four tertiary care maternity units and NICUs of Sulaiman Al Habib Medical Group in Saudi Arabia. The data were analyzed using Excel. The outcomes were compared with the 2015 data published by the Global Burden of Disease study and 2015 data published by the Euro-Peristat Study. Results: The total number of deliveries during the study period was 14,339, whereas the total number of births was 14,593 (live births 14,543 + stillbirths 50). Perinatal deaths were 80 (50 stillbirths + 30 early neonatal mortality [ENM]). PMR was 5.48/1000 (stillbirth rate: 3.42/1000, ENM rate: 2.06/1000). Third-trimester perinatal deaths were 31 and third-trimester PMR 4.18/1000. Majority of perinatal deaths were either due to congenital anomalies and/or prematurity. The perinatal mortality outcomes were comparable with countries with a high sociodemographic index. Conclusions: The PMRs in Saudi Arabia's private setup is lower than the public setup. This may be reflective of differences in the sociodemographic and economic status of the population being served by public and private sectors as well as a difference in the level of care provided by each sector. A large prospective, multicenter study conducted over a period of 5–10 years to assess differential perinatal outcomes, their underlying factors, and the causes of high incidence of major and futile congenital fetal anomalies is warranted.
Keywords: Congenital anomalies, perinatal mortality, private medical care, Saudi Arabia, sociodemographic index, stillbirths
|How to cite this article:|
Rahman SU, Abdulghani MH, Faleh KA, Khalil M, Mustafa MM, Anabrees J, Mansour MY, Mirza A, Mousafeiris K, Mubarak M, Kamal M. Perinatal mortality in Saudi Arabia: Profile from a private setup. J Clin Neonatol 2020;9:8-12
|How to cite this URL:|
Rahman SU, Abdulghani MH, Faleh KA, Khalil M, Mustafa MM, Anabrees J, Mansour MY, Mirza A, Mousafeiris K, Mubarak M, Kamal M. Perinatal mortality in Saudi Arabia: Profile from a private setup. J Clin Neonatol [serial online] 2020 [cited 2020 Jul 13];9:8-12. Available from: http://www.jcnonweb.com/text.asp?2020/9/1/8/277225
| Introduction|| |
perinatal death, a combination of stillbirths (≥22 weeks' gestation or ≥500 g birth weight or ≥25 cm birth crown rump (CR) length) and early neonatal deaths (deaths during the first 7 days of life), is an adverse pregnancy outcome. Hence, the perinatal mortality rate (PMR) is used as an established epidemiologic indicator of perinatal care in a given health-care system/region. Perinatal deaths have been reduced by more than ten times in high-income countries over the past 100 years, and this has been described as one of the most important success stories of obstetric care. The Kingdom of Saudi Arabia (KSA) is the world's largest oil-producing country with a high socioeconomic index and a well-developed health-care system, both in public and private sectors. Trends in PMRs from public hospitals in Saudi Arabia have been reported since early 1980s. However, there are no reliable data of perinatal mortality from the private sector of Saudi Arabia. Our study reports perinatal mortality from one of the largest private multisite tertiary care maternity setups in Saudi Arabia.
| Methodology|| |
We conducted a retrospective, analytic epidemiologic study in four tertiary care hospitals of Suleiman Al Habib Medical Group (HMG) named Al Rayyan Hospital, Olaya Hospital, Sweidi Hospital, and Al Qassim Hospital. HMG is a major private sector obstetric and neonatal intensive care unit (NICU) setup, accredited by the Joint Commission International, USA. The Olaya, Al Rayyan, and Al Qassim hospitals have very active Assisted Reproductive units. Apart from inborn babies, the HMG NICUs also admit outborn babies from public and private hospitals for tertiary care service. Majority of patients admitted in HMG are financially sponsored either by their insurance companies or by the Ministry of Health (MOH). Some patients are self-sponsored.
The study was approved by the HMG-IRB (Approval No: RC 18.04.02). The data collection was exempted by IRB from taking individual patient consent. Data for one calendar year (January 2017–December 2017) were collected (on preapproved data collection forms) from the hospital electronic patient record system (called VIDA, V-0.1) as well as from the monthly and annual reports of the department of obstetrics and NICUs. All pregnant women admitted in four HMG hospitals and all newborn babies (0–27 days of life) admitted in four HMG NICUs were included in the study. For preterm babies, the PEARL study criteria of neonatal age adjusted for prematurity were used. Term babies more than 28 days postmenstrual age were excluded.
The data were assembled and analyzed on Microsoft® Office Excel 2010. The stillbirth outcomes were compared with the 1-year (2015) international data published by global, regional, and national perinatal mortality data published by the Global Burden of Disease study in 2016. The perinatal mortality data was compared with the 1-year data (2015) published by the European Perinatal Health Report 2015.
| Results|| |
The total number of deliveries during the study period was 14339 (Al Rayyan Hospital, 5471; Olaya Hospital, 3902; Sweidi Hospital, 1608; and Al Qassim Hospital, 3358). Nearly 64.2% (n = 9222) deliveries were vaginal deliveries, whereas 35.8% (5117) were C-section deliveries, including both elective and emergency C-sections.
The total number of births was 14,593 (live births 14,543 + stillbirths 50). Perinatal deaths were 80 (50 stillbirths + 30 END). PMR was 5.48/1000 (stillbirth rate [SBR]: 3.42/1000, early neonatal mortality rate: 2.06/1000). Third-trimester perinatal deaths were 31 and third-trimester PMR 4.18/1000. Majority of perinatal deaths were either due to congenital anomalies and/or prematurity.
Our PMR was much better than the PMR reported from public sector hospitals from Saudi Arabia [Table 1].,,,,,,,, Our PMR is comparable to the most recent PMR reported from some of the high sociodemographic index (SDI) European countries [Table 2]. Our SBR is better than the SBR of high-middle SDI countries and some of the regional Gulf Cooperation Council countries [Figure 1]. Complications of extreme prematurity and congenital anomalies incompatible with life were the two major causes of perinatal deaths in our study. When corrected for futility, our corrected SBR is comparable with the global SBR and the SBR of high SDI countries [Figure 1].
|Table 1: Perinatal mortality rates from public sector hospitals in Saudi Arabia 1983-2010|
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|Table 2: Perinatal mortality rate European countries* and Habib Medical Group Saudi Arabia**|
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|Figure 1: Stillbirth rates. Data source: Global Burden of Disease study 2016, Suleiman Al Habib Medical Group data (our study)|
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| Discussion|| |
Variation in perinatal mortality between public and private maternity services in the same region is well known., In the Australian state of Queensland, the PMR in 2012–2013 was higher in public hospitals than in private hospitals (11.1 vs. 7.4/1000 births). The variation is attributed to difference in the level of care between the public and private setups and the difference in the socioeconomic status of the population served by each setup. The relationship between improvement in socioeconomic status and improved perinatal outcomes is well established. The countries with high SDI have successfully reduced their PMR by more than ten times over the past 100 years.,,
The KSA is the world's largest oil-producing country with a high socioeconomic index and a GDP per capita of 45,489.83 PPP-USD. The health-care system in the country has improved rapidly over recent years, both in public and private sectors. The country spends 4.7% of its GDP on health. The government's expenditure as a percentage of all health-care spending is 62.9%, whereas the remaining is nongovernmental expenditure. This may be attributed to the country's increased wealth and the high priority of the government in providing its citizens with a high-quality health-care service. In line with the other services, maternity and newborn care in Saudi Arabia has also improved significantly over the past five decades. The initial reports of PMR in Saudi Arabia's public sector facilities were published in 1983. Since then, a number of reports have been published from various regions and at the national level.,,,,,,, The PMR of Saudi Arabia has decreased from 39.8/1000 in 1988 to 14.9/1000 in 2008. A nationwide survey of PMR from each province of Saudi Arabia was published in 1993. However, no reports have been published from the private sector institutions which currently constitute a significant part of country's health-care system. Due to increasing population size and demands coupled with uncertainty on oil-dependent economy, the government has implemented a new phased plan of health-care reforms, which includes the introduction of a cooperative health insurance scheme, closely followed by privatization of the nation's hospitals. This will increase the size as well as the responsibility of private sector in sustaining a high-quality health-care system.
Dr. Sulaiman Al Habib Medical Group (HMG) is a major private-sector health-care organization in Saudi Arabia which provides comprehensive high-quality tertiary care maternity and NICU services. HMG caters the segment of Saudi population which has high SDI. HMG hospitals are very often used by the Ministry of Health (MoH) as an outsource to take over critical patients when the public sector hospitals start running a high census. Recently, MOH has awarded HMG a contract to take over and manage two of its large tertiary care NICUs. Our current study is the first of its kind to ascertain and analyze the perinatal mortality in HMG hospitals which will be a fair representative of the private sector of Saudi Arabia. The PMR in HMG hospitals is much better than the PMR reported from many Saudi Arabia's public sector hospitals [Table 1]. The PMR of HMG hospitals is comparable to many high SDI European countries [Table 2]. The SBR of HMG is also comparable to global SBR and SBR of high SDI countries [Figure 1]. HMG SBR is lower than the national SBR of some of the region's wealthiest countries [Figure 1]. One possible reason for this difference is the kind of population being served by the two sectors. The public sector hospitals are open walk-in facilities serving across the board all levels of population, whereas HMG is a private service availed only by a population with high SDI. The other possible reason could be a better health care being provided at private hospitals. The comparative study of public and private hospitals' perinatal mortality by Adams et al. in Australia also reported a higher PMR in public sector hospitals as compared to private sector hospitals. However, they could not attribute this disparity to population differences. Instead, they concluded that differences in clinical practices between public and private hospitals seem to be partly responsible for this disparity. The same is a possible scenario in Saudi Arabia where the five-star private hospitals such as HMG are providing a direct consultant-led service as compared to public sector hospitals where the service is supervised by the consultants but not led by the consultants. The middle-grade physicians (specialists and residents) lead the service in public sector hospitals in Saudi Arabia.
Lethal congenital anomalies incompatible with life were the most common cause of perinatal deaths in our cohort. This is not a surprise. The Arab countries including Saudi Arabia have one of the highest incidences of birth defects in the world and are placed among the “red zone countries." High prevalence of consanguinity in the Arab world (40%–70%) including Saudi Arabia remains a strong contributor to the high incidence of lethal congenital anomalies.,,, In addition, the selected medical terminations for futility are rare in Saudi Arabia due to very strong religious and sociocultural practices. This increases the contribution of deaths due to futility toward PMR as compared to countries where most of these futile fetuses will be electively terminated as a part of standard perinatal care.
Our study reflects that very low neonatal mortality rates comparable to well-developed countries can be achieved in transitional countries as well. The study also supports the notion that establishing electronic health record systems in health-care facilities provides opportunities to conduct reliable perinatal epidemiologic studies. The change from paper-based health records to electronic health records may be reflective of high standards of care and a good justification of public and private spending on health systems.
Our study is based on a one-year cross-sectional data of one private institution in KSA. A longer prospective multicenter study from both public and private sector hospitals conducted over a period of 5–10 years will provide a much bigger data with better analysis of perinatal outcomes and the factors underlying any discrepancies. The data will also help in health systems planning and financing.
| Conclusions|| |
The PMR of a select high income, socially well-placed population seeking health care in a major high standard private tertiary care setup in Saudi Arabia is comparable with the global PMR and the PMR of high SDI countries. The results of our study represent the outcomes of a socioeconomically well to do stratum of population which can afford health care in a high-profile private setup. The results do not represent the population in general and may not be extrapolatable as the national data. The high incidence of major and futile congenital anomalies as a major cause of perinatal deaths warrants a well-designed and well-funded perinatal study at the national and regional levels.
We are thankful to the data collection team (Olaya: Mary Grace, Al Rayyan: Mohamed Kamal, Sweidi: Reinne Maatouk and Konstantinos Mousafeiris, Qassim: Dr. Muhammad Hasan Abdulghani) and Dr. Jasim Anabrees for critical analysis of data and manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Goldenberg RL, McClure EM, Bhutta ZA, Belizán JM, Reddy UM, Rubens CE, et al
. Stillbirths: The vision for 2020. Lancet 2011;377:1798-805.
Cartlidge PH, Stewart JH. Effect of changing the stillbirth definition on evaluation of perinatal mortality rates. Lancet 1995;346:486-8.
Woods R. Long-term trends in fetal mortality: Implications for developing countries. Bull World Health Organ 2008;86:460-6.
Al-Hanawi MK. The healthcare system in Saudi Arabia: How can we best move forward with funding to protect equitable and accessible care for all? Int J Healthc 2017;3:78-94.
Algwiser AA. Perinatal mortality at the armed forces hospital, Riyadh, Saudi Arabia: Five-year review of 22,203 Births. 1990. Ann Saudi Med1990;10:268-75.
Rahman S, Al Rifai H, El Ansari W, Nimeri N, El Tinay S, Salameh K, et al
. A PEARL study analysis of national neonatal, early neonatal, late neonatal, and corrected neonatal mortality rates in the State of Qatar during 2011: A comparison with world health statistics 2011 and Qatar's historic data over a period of 36 years (1975-2011). J Clin Neonatol 2012;1:195-201.
] [Full text]
GBD 2016 Mortality Collaborators. Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970-2016: A systematic analysis for the global burden of disease study 2016. Lancet 2017;390:1084-150.
Milaat WA, Florey CD. Perinatal mortality in Jeddah, Saudia Arabia. Int J Epidemiol 1992;21:82-90.
Al-Mejhim FM, Al-Najashi SS. Trends in perinatal mortality at king fahd hospital of the university, Al-Khobar, Saudi Arabia: A ten years study. J Family Community Med 1998;5:31-7.
Haque KN, Bashir O. Perinatal mortality at the King Khalid university hospital, Riyadh. Ann Saudi Med 1988;8:190-3.
Swailem AR, Serenius F, Edressee AW, Ohlsson A. Perinatal mortality in a Saudi maternity hospital. Acta Paediatr Scand Suppl 1988;346:57-69.
Al-Faraidy A, Dawodu A, Al-Umran K, Magbool G. Survey of perinatal mortality in the Kingdom of Saudi Arabia. Saudi Med J 1993;14:307-11.
English JD. Perinatal mortality at the North West Armed Forces Hospital, Tabuk, Saudi Arabia and the potential benefits of the biophysical profile score. Ann Saudi Med 1995;15:133-6.
Bondagji NS, Kasim EM. The corrected perinatal mortality rate. A hospital-based study in Saudi Arabia. Saudi Med J 2012;33:654-9.
Sobaih BH, Al-Shebly MM. Perinatal statistics of a 15-year period in the Central Region of Saudi Arabia. Sudan J Paediatr 2013;13:23-30.
Queensland Maternal and Perinatal Quality Council. Maternal and Perinatal Mortality and Morbidity in Queensland: Queensland Maternal and Perinatal Quality Council Report 2015. Brisbane: Queensland Health; 2015.
Adams N, Tudehope D, Gibbons KS, Flenady V. Perinatal mortality disparities between public care and private obstetrician-led care: A propensity score analysis. BJOG 2018;125:149-58.
Almalki M, Fitzgerald G, Clark M. Health care system in Saudi Arabia: An overview. East Mediterr Health J 2011;17:784-93.
Suleiman Al Habib Medical Group. Available From: http://hmg.com.sa/en/Pages/home.aspx. [Last accessed on 2019 Jun 07].
March of Dimes Birth Defects Foundation. Global Report on Birth Defects. New York: March of Dimes Birth Defects Foundation; 2006.
Bener A, Hussain R. Consanguineous unions and child health in the State of Qatar. Paediatr Perinat Epidemiol 2006;20:372-8.
Assaf S, Khawaja M, DeJong J, Mahfoud Z, Yunis K. Consanguinity and reproductive wastage in the Palestinian Territories. Paediatr Perinat Epidemiol 2009;23:107-15.
el-Hazmi MA, al-Swailem AR, Warsy AS, al-Swailem AM, Sulaimani R, al-Meshari AA. Consanguinity among the Saudi Arabian population. J Med Genet 1995;32:623-6.
El Mouzan MI, Al Salloum AA, Al Herbish AS, Qurachi MM, Al Omar AA. Consanguinity and major genetic disorders in Saudi children: A community-based cross-sectional study. Ann Saudi Med 2008;28:169-73.
Lack N, Zeitlin J, Krebs L, Künzel W, Alexander S. Methodological difficulties in the comparison of indicators of perinatal health across Europe. Eur J Obstet Gynecol Reprod Biol 2003;111 Suppl 1:S33-44.
[Table 1], [Table 2]