The Saudi Journal ofObstetrics and Gynecology

The official journal of‘‘The Saudi Society of Obstetrics

and Gynecology’’.

Volume 1 - No. 2 - 1440 H - 2019 Gالجمعية السعودية لأمراض النساء و الولادة

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Editor in ChiefHassan Salah Abduljabbar

GeneralProf.Abdullah Basalamah Dr. Fawzia Ahmad Haibib Dr. Hessah Aldhami Dr. Nora Saeed Algahtani

Reproductive Medicine Prof. Hasan S. Jamal Dr. Hamad Sufyan Dr. Mohmmad Albaqmi

Oncology Dr. Ismail Badawi FRCSC Prof. Khalid Sait Dr. Emad Saqr

Fetal MaternalProf. Nabeel S. BondagjiDr. Yasir katib Dr. Yasir Sabr

International advisors Dr. Mohmmad Abu AlgharDr. Jamal Abu Soror

Urogynecologi Dr. Ahmad Al-BaderDr. Ghadeer Al-SheikhDr. Faisal KashgariDr. Sameera Al-Basri

Saudi Journal of Obstetrics & Gynecology

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The Saudi Journal of obstructsand gynecology

• Is an official publication of the Saudi society of obstetrics and gynecology. • The Journal publish original peer review work in obstetrics and gynecology and relat-ed subjects.• Copyright ; once an article accepted for publication is SJOG . No copy transferor whole or part of the material published should be attempted prior to permission from the SJOG editor.

Peer Review Policy of The Saudi Journal of obstetrics and gynecology:

• Highest standards of peer review• Increasing the efficiency of the process• All research articles published in the Saudi journal of obstetrics and gynecology undergo full peer review.• At least two suitably qualified experts review all research articles .• The journals’ Editors-in-Chief based on the reviews provided make all publication decisions.• All submitted manuscripts treated as confidential documents.• Members of international Editorial Boards lend insight, advice and guidance to the Editors-in –Chief generally and to assist decision making on specific submissions.• Manuscripts with contents outside the scope will not be considered for review.

• Managing Editors and Editorial Assistants provide the administrative support that allows The Saudi Journal of obstetrics and gynecology to maintain the integrity of peer review while delivering rapid turnaround and maximum efficiency to authors, reviewers and editors alike. Plagiarism policyAll the submitted manuscripts for publication are checked for plagiarism after submission and before starting review.Plagiarism is when author attempts to pass someone else’s work as his or her own.Duplicate publication ( sometimes called self- plagiarism, occurs when an author reuses substantial parts of his or her own published work without providing the appropriate referenes )If more than 30% of the paper is plagiarized- the article may be rejected and the same is notified to the author.The manuscripts in which the plagiarism is detected are handled based on the

extent of the plagiarism. 5% .

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Women’s Empowerment and Women’s health Rights in Saudi Arabia

I graduated in 1401 AH / 1981 AD among the first batch of the Faculty of Medicine at King Abdul-Aziz University, unfortunately my generation was not well versed in health rights, nor was it in our medical dictionary at the time. Nonetheless, my interest began when I started practicing and working during my training period in different hospitals. For example, when some women needed to have a Caesarean Section, the husband was requested to sign the consent form of approval regardless of the opinion of the patient? I began to deeply research medical rights and Islamic jurisprudence and found that the Sharia guaranties the right of women to consent for their own medical and surgical issues, and even ensured it by the rules and regulations of the Ministry of Health since 1404 AH / 1984.(1,2

In 2006 I was diagnosed to have breast cancer, and discovered I am ignorant about my rights as a cancer patient, so I started to focus on cancer patient’s reproductive health rights, and as time goes, I was surprised by how much we as health care providers as well as patients are ignorant about the reproductive rights of young patients with cancer.

We conducted a research and collected information from medical students, as well as health practitioners, on their knowledge of the laws and regulations of the Ministry of Health concerning the health rights aspects of Saudi female patients. The results showed the lack of knowledge and ignorance of rules andregulationsof the Ministry of Health regulating many aspects ofhealth rights, particularly the misconceptions about theguardianship system in health care in particular. (3)This is reflected in the daily health practice, whichin turn threatened to increase the rate ofcomplications, medical morbidities and evenmortalities. (4) The main reason for misconceptionsabout health rights in Saudi Arabia is ignoranceand not absence of rules andregulations. (5)

Samia M Al-Amoudi

Founder and Head of Health Empowerment and Health Rights Unit at Collage of Medicine ,KAUCEO M.H. Al-Amoudi Center of Excellence in Breast CancerProfessor Obstetrician Gynecologist, College of Medicine KAU. King Abdulaziz University, Jeddah, Saudi Arabia

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In view of the above, and based on studies that showed lack of knowledge and ignorance of

rules and regulations about women’s health rights in Saudi Arabia

(6,7),the first unit for health empowerment and women’s health rights in the Arab region was established in August 2016. The team of this unit is a group of distinguished faculty members from the department of obstetrics and gynecology, surgery, Family and community medicine, nursing, physiology and medical education.

Thanks be to God and His Generosity, we have been successful that health empowerment and health rights issues were integrated in the curriculum of the Faculty of Medicine at King Abdul Aziz University since 2016. These were integrated in the teaching of the clinical years. On 5th of November 2018 the project was presented to the Saudi Universities Medical Collages Dean’s committee at Collage of Medicine, King Saud university, Riyadh and the committee opinion was that there is a great need to include it in the curriculum of medical collages and their recommendations that was included in the minutes to his Excellence the Minister of Higher Education were to include Health empowerment and Women’s health rights and implement it in the curricula of Medical schools all universities.

In October 2017, we launched the first initiative for reproductive health rights of cancer patients, and the first “Reproductive Health Rights Counselling Clinic for cancer Patients, the objectives were to counsel young cancer patients before they start treatment, to

empower them with their health rights as there is lack of knowledge about cancer patients’ rights(8) , knowledge about impact of some kinds of cancer treatment on their future fertility, and the options available in view of Islamic perception and Fatwas.

Recently January 2019 we have established the first Health Empowerment Clinic at king Abdulaziz University Hospital, in collaboration with Obstetric and Gynecology department, the objectives of this clinic are to provide counselling for pregnant and non-pregnant women, as well as their husbands regarding their health rights, like right to have access to antenatal care, right to discuss options of pain management, plan of delivery, and most importantly their right to sign consent for their surgery particularly caesarean section without the need for husband approval.

This is the story of the birth of the first health empowerment and health rights unit at King Abdulaziz University. We have achieved a great deal and we still have aspirations and achievements that we hope to accomplish. Our dream is to have an impact on medical education at all levels, to achieve transformation in accordance with our government Saudi vision 2030 which includes women’s empowerment as one of the major pillars in this transformation.

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In Saudi Arabia women’s rights including health rights are escalating. In May 2017 G, a historic royal decree number (33322) was issued and announced by Custodian of two holey mosque King Salman Bin AbdulAziz , to empower women and provide services without requesting the approval of male guardian , and human rights commission was directed to empower all with knowledge about these rights. This is the historic transition in women’ empowerment and women’s health rights in Saudi Arabia.

References:1. Al-Amoudi SM. Health empowerment and health rights in Saudi Arabia. Saudi medical journal. 2017 Aug;38(8):785. 2. Ministry of Health. Circulation no. 11/26/84484. 2012.3. Al-Amoudi SM, Al-Harbi AA, Al-Sayegh NY, Eldeek BS, Kafy SM, Al-Ahwal MS, Bondagji NS. Health rights knowledge among medical school students at King Abdulaziz University, Jeddah, Saudi Arabia. PlOS one. 2017 May 1;12(5):e0176714.4. Al Zeayer N, Cutts R, Abu-Aisha H. Women in Saudi Arabia: Do they not have the right to give their own consent for medical procedures? Saudi Med J 1985; 6:74-77.5. Committee on the Elimination of Discrimination Against Women. Concluding comments of the Committee on Saudi Arabia. United Nations Convention on the Elimination of All Forms of Discrimination against Women, Fortieth Session 14 Jan-1 Feb 2008. http://www2.ohchr.org/English/bodies/cedaw/ dosc/CEDAW.C.SAU.CO.2en.pdf6. Alghanim SA. Assessing knowledge of the patient bill of rights in central Saudi Arabia: a survey of primary health care providers and recipients. Ann Saudi Med. 2012; 32:151–155. PMID: 223668287. El-Sobkey Salwa B., Almoajel Alyah M., Al-Muammar May N.. Knowledge and attitude of Saudi health profession students regarding patient’s bill of rights. Int J Health Policy Manag. 2014; 3(3):117–122. https://doi.org/10.15171/ijhpm.2014.73 PMID: 251976758. Al-Amoudi SM. Cancer Diagnosis: Who has the Right to Know? J Women’s Health Issues

Care. 2013; 2:3.

Women’s Empowerment and Women’s health Rights in Saudi Arabia

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زواج القاصرات بين الرفض والقبول

الأستاذ الدكتور / حسن صالح جمال أستاذ طب النساء والولادة وأطفال الأنابيب

جامعة الملك عبد العزيز في جدة كلية الطب المملكة العربية السعودية

المقدمةأبعاد المشكلة

تباين الآراء والأحكام بين الدول صندوق الأمم المتحدة للسكان وزواج القاصرات

المقدمة:في التطور المجتمعات التعامل في قي من مجتمع في يتوفر قد التكنولوجيا ووسائل الإتصال المطورة والر عاملات ولكن للأسف يفتقر إلى المبادئ الأساسية التي تساعد على تنمية دور النساء والحفاظ عليها والم سلبيا على صحة فيتم التمسك بأفكار مستندة على عادات وتقاليد وتراث متراكم والتي باتت تشكل أثرا النساء النفسية والجسدية والإجتماعية

. وفي السنوات الأخيرة وعلى مستوى العالم أجمع أصبح موضوع “ زواج القاصرات “ يحتل الصدارة في المؤتمرات الدولية والهيئات المتعلقة بصحة المرأة من مختلف الجوانب وتناست بعض المجتمعات أن الفتاة في عمرهاوما والولادة والحمل الزواج لتجربة الإستعداد على قادرة غير الصغير هذه على جسد دمار إلى تؤدي قد ومضاعفات سلبية آثار من تسببه في اضطرابات فضلا عن والنفسية العضوية الناحية من الصغيرة العلاقة الجنسية بين الزوجين ناتج عن عدم ادراك الطفلة لطبيعة العلاقةالزواج يعنيه لما الصغيرة الزوجة تفهم وعدم التكيف عدم واضطرابات ومسؤولية الأسرة ، وفي المقابل قد يكون هناك 16 في سن الـ ن بعض الفتيات ممن ه ؤهلهن لمواجهة ولديهن من الفكر والثقافة والنضج مما

. ي مثلا مسؤولية الزواج والحمل والولادة ولذلك يجب مناقشة موضوع زواج القاصرات بشيء من الإتزان آخذين في الإعتبار عوامل كثيرة ومهمةتملي على المسؤولين وضع قواعد وقرارات واضحة ومقبولة من جميع النواحي سواء الشرعية أوالإجتماعية أو الطبية ، ولعلنا في هذه الورقة نستعرض “ زواج القاصرات “من النواحي سواء الطبية أو غير الطبية مع بعض الإحصائيات والآراء والقوانين في بعضيمكن ولكن سهلة ليست كثيرة لهذه الأفضل الحل هو وما العالم دول تناولها بشيء من الحكمة والعقلانية التي القضية الشائكة والتي تحمل

أبعادا عطي كل تحفظ للمرأة كرامتها وسعادتها والحفاظ

الجسدية والنفسية ومكانتها الإجتماعية على صحتها وي ذي حق حقه ، وتحفظ المجتمعات من الإنحراف

عن المحظورات

أبعاد القضية:سن بتحديد الإنسان حقوق مطالبات قضية أثارت لزواج القاصرات في دول عديدة واجتماعيا شرعيا جدلا وذلك لتحديد سن معينة من جهة ورفض للتحديد من جهة أخرى . فمنهم من يرى أن تحديد السن عند بينما رآى 16 أو 15 أن بعض الفتيات تكون مؤهلةللفتاة خصوصا ظلم عشر الثامنة سن في للزواج القضية وترك معين سن تحديد عدم الآخر القسم

! مفتوحة في الواقع أن هذه القضية نوقشت مرات عديدة وفيلم ولكن مرموقة جهات من كثيرة ودورات مؤتمرات ذلك من ويتضح واحد قرار على اجماع هناك يكن الجوانب جميع من شاملة دراسات إلى بحاجة أننا واصدار فتوى جماعية حول هذا الموضوع ومن جهاتالإسلامي الفقه العلماء ومجامع كبار كهيئة معتمدة

والمؤتمرات الخاصة بالتكاثر وطب النساء والولادة

زواج القاصرات من منظور طبي إحصائيات وأرقام

الخلاصة والتوصيات ما هو المطلوب ؟؟

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الحرمان من مرحلة الطفولة والحرمان العاطفي من رعاية الوالدين

الحرمان من فرصة التعليم للطفلة الزواج المبكر يحرم الطفلة حقوقها الطفولية وحقوقها كأم

مما يزيد من نسبة تعرضها للعنف الأسريوهي طفلها وبصحة بنفسها بالإهتمام القاصر جهل حامل والتربية بعد الولادة يؤدي إلى مشاكل صحية كبيرة

لها ولطفلها قد تصل في بعض الحالات إلى الوفاةالأسباب أحد هي القاصرات وزواج المبكر الزواج إليه سجلات تشير ما الأسري حسب للتفكك الرئيسية

القضاءزيادة نسبة الطلاق في هذا الزواج المبكر

بالرغم من أن للشرع الحكيم رأي واضح حول زواج القاصرات ممن لم يبلغن سن التميز خاصة إذا كان الز ر على زواج ص وج يكبر هذه الطفلة القاصر بسنوات كثيرة وقد يكون في سن جدها إلا أن البعض ي إلى الوضع المادي عند هذا الزواج السنين إلى من هو أكبر منها بعشرات القاصر ابنته الصغيرة ناظرا الجديد بغض النظر عن الآثار السيئة والمشاكل النفسية والصحية التي تتعرض لها هذه الفتاة المغلوب على أمرها التي لا تعرف أبجديات الحياة الزوجية واساسياتها ودورها تجاه زوج

. طاعن في السن ودعونا نستعرض بعض آراء العلماء والفقهاء عن زواج القاصرات

في بعض الدول العربية والإسلامية

وقد رأت مجموعة من المختصون ورجال دين مسلمون ومسيحيونعلماء بهيئة الأول المسئول أيد بينما القاصرات زواج رفض السودان والأمين العام بينما أي لهيئة علماء السودان البروفيسور محمد عثمان صالح إلى عدم منع زواج القاصرات حقق بإعتبارهالصغيرة زواج يمنع لا الإسلام إن “ وقال كثيرة منافع يحقق وأنه مباح “ وأن الإسلام يحث الشباب على الزواج لصونهم من

الإنحراف وارتكاب الفاحشةبأن قال الكودة يوسف د/ الإسلامي الوسط حزب رئيس أما المبكر الزواج نتيجة القاصر بالطفلة هناك أضرار كثيرة تلحق تتمثل في عدم قدرتها على تحمل مسؤولية الحياة الزوجية وتركهاودينية اجتماعية ومبررات دوافع هناك أن وأوضح . للدراسة

وثقافية تدعو إلى زواج الصغيرات في المجتمعات العربية ممثل مجلس الكنائس السوداني الأب أنطونيس فاكيوس قال بأن18 الزواج ب يحدد سن للمسيحيين الشخصية الأحوال قانون

سنة وأن يكون الرجل أكبر من المرأة بسنتين ممثلة صندوق الأمم المتحدة السيدة / أمينة محمد أن الصندوق يعتقد أن الإحتفال بيوم المرأة نادى بتضافر الجهود والتنسيق معالظاهرة بأن موضحه القاصرات زواج لمنع الآخرين الشركاء منتشرة في جنوب آيسا وأفريقيا جنوب الصحراء . وأكدت أن زواج الطفلة يؤدي إلى عواقب وخيمة ربما تؤدي إلى مشاكل صحية خطيرة قد يؤدي بعضها إلى الوفاة بإعتبار أن الطفلة لم يكتملبأن وأفادت والأمومة والحمل للزواج والنفسي الجسدي نموها %95 من حالات الحمل وسط المراهقات بين أعمار 15-19 تحدث داخل الزواج ، واعتبرت أن زواج الطفلة فيه انتهاك لحقوق الإنسان فهو يحرمهن من طفولتهن ويقطع تعليمهن وفيه خطرنعظم في قسرا يتم الطفلة زواج بأن وأضافت ، حياتهن على

الحالات لأن الطفلات نادرا ما يعطين موافقتهن الكاملة وحسب مسح عام 2010م في السودان أفادت د/ رؤى الخالدي بأن 38 % من النساء في السودان يتزوجن في سن مبكرة فيوالاجتماغي النفسي و الجسدي الفتاة نمو فيه يكتمل لم وقت

لمواجهة الحياة الزوجية

وزواج القاصر أو الزواج المبكر يحمل بين ثناياه مشاكل عديدة، نوجزها فيما يلي

الإختلاف في الآراء والقوانين حول زواج القاصرات

في السودان احتدم خلاف بين مشاركين في ندوة نظمتها وزارة الإرشاد والأوقاف مع صندوق الأمم المتحدة للسكان

حول مخاطر زواج الطفلة القاصر

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في اليمن أقامت منظمة ) سياج لحماية الطفولة ( في اليمن ندوةوالقانون الشرع بين القاصرات تحت عنوان “ زواج والعرف الإجتماعي “ نوقشت فيها الأضرار المترتبة

على زواج القاصراتالصحة مستشار الكامل عبدالله / الدكتور وأشار الندوة المتحدة في هذه الإنجابية في صندوق الأمم والقاصرين القاصرات زواج مشكلة حجم أن إلى 25% أن أوضحت دراسة وهناك كبيرة اليمن في من النساء في اليمن يتزوجن في سن أقل من 15 عام )%70 في الريف اليمني( وقد أشار ايضا الىالزواج عن الناجمة والمخاطر الصحية الأضرار المبكر للفتيات فضلا عن زواج القاصرات مشيرا الى أن اليمن تمثا معدلات عالية في الوفاة بين الأمهات من ذوات الزواج المبكر ومواليدهن و أوضح دكتور كامل بأن سبب الزواج في سن مبكر في اليمن يعود الى أسباب اقتصادية زاجتماعية وتعليمية حيث الفقر

وانعدام الوعي وقلة التعليمبأن” زواج المحطوري دكتور/ مرتضى أفاد كما منتقدابشدة باطل” وادراكها رضاها دون الصغيرة من وصفهم ب )زواج المناسبات والمصالح والزواجالثقافة ضحية اليمن في المرأة أن وقال السياحي( الاسلام الى يمت لا الذي المتراكم والتراث البدوية

بصلة أما دكتور / حسن الأهدل أستاذ الفقه وأصوله بكلية الشريعة بجامعة صنعاء فقد أكد عدم جواز تزويج واجبار الفتاة إلا بعد أن تكون عاقلة وبالغة برضاها

واختيارهاالتكليف مناط والعقل العقل مناطه الشرع أن وقال وهذا ما أخذ به القانون اليمني من أن سن الزواج لا يقل عن 18 سنة وفي تقرير رسمي مؤخرا من اليمن يشير الى أن 8 حالات وفاة تجدث يوميا في اليمنفي والولادة المبكر والحمل الصغيرات زواج بسبب

ظل غياب المتطلبات الصحية اللازمةفي المملكة العربية السعودية

تظل المملكة العربية السعودية حتى اليوم بدون سن جهة من دقيقة احصائية توجد ولا للزواج قانوني

مختصة ترصد عدد حالات زواج

القاصرات مما يجعل زواج القاصرات في السعودية بدون تقنين ويشجع على المزيد من هذه الزيجات التي تظهر في شكل من

الزيجات التجارية . واعتبر حقوقيونبمجلس الشورى السعودي وجمعية حقوق الإنسان في

كبيرة اجتماعية مشكلة ي شكل القاصرات الفتيات زواج أن السعودية واستنكر مجلس الشور لحقوق الإنسان وعلى الرغم مثل انتهاكا ى هذا

الزواج واعتبره ي من ذلك لم توضح هذه الدراسات سن الزواجالمدينة وقد اظهر استطلاع شامل لمعظم قرى ومدن المملكة رصد موقع الإلكتروني لبعض حالات زواج القاصرات من مناطق مختلفة بالمملكة عن عدم رضا الغالبية من المواطنين وعاقدي النكاح على هذا الزواج خاصة لمن

هن تحت سن ال 15 عاما وقد حددت اللجنة الطبية المنبثقة من وزارة الصحة السعودية في عام 2010يتسبب في ظهور مشكلات صحية جسدية قد القاصرات أن زواج م من فقد اللجنة تقرير وبحسب مبكرة سن في المتزوجات الفتيات بين ونفسية

أظهرت وجود آثار سلبية لزواج القاصرات تتمثل في أربعة جوانب أضرار نفسية وجسدية للأمهات القصر )الحرمان بمعانيه المختلفة(مخاطر

نفسية وجسدية للأطفالزيادة حالات الإجهاض والولادة المبكرة وهشاشة العظام

أمراض نفسية كثيرة قد تؤدي إلى استخدام أدوية نفسية أو الإدمان و قد قامت حملة أيضا لمنع زواج القاصرات في السعودية عن طريق مجلة سيدتي شارك فيها سماحة الشيخ أ.د. محمد النميمي عضو مجمع الفقه الإسلامي الدولي الذي أكد معارضته لهذا النواع من الزواج منذ أكثر من 10 سنوات وقال يجب أن يكون هناك فحص طبي للتأكد من القدرة الجسدية للفتاة وشروط مثل القدرة المالية للزوج ورأى بأن سن الفتاة يجب أن يكون

أكثر من 15 عاما كما أفاد د. محمد علي البار استشاري الأمراض الباطنية والخبير بمجمع الفقه الإسلامي بأن “ زواج القاصرات ل 13 أو 12 بإعتبار أن الفتاة في سن مرفوض تماما لا تزا طفلة ولا يمكنها تحمل مسؤوليات الزواج إذ لابد أن تكون الفتاة على درجة من الوعي وأن تكون راضية وأن يتم استئذانها كما نورد ما ذكره الشيخ عبدالله المنيع عضو هيئة كبار العلماء والمستشار بالديوان الملكي بأن زواج القاصر مرفوض وقال “ القاصرة من الفتيات هي في الواقع في مستوى لا تستطيع فيه أن تعرف ما ينفعها مما يضرها في الغالب ولهذا كان على وليها مسؤولية كبرى في أي تصرف يعدل بزواجها

وهي في سن الطفولة مع ملاحظة أن سن الطفولة يصل إلى حد التكليف ، فمتى كانت قاصرة عن التكليف الشرعي

فهي في حكم الطفلة

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وبناءا على ذلك فلا يجوز لولي القاصرة أن يتصرف أو يؤثر عليهالتزويجها بمن لا تتحقق مصلحتها بالإرتباط به

وفي الآونة الأخيرة وتحديدا في يناير 2019 أقر مجلس الشورىالسعودي منع زواج القاصرين ذكرا كان أو أنثى

وحسب الضوابط القانونية ، فقد اقتصر عقد النكاح لمن أعمارهم بين ال15 عاما وال18 عاما على المحكمة المختصة أو من يقوم مقامها

وفق الضوابط المعدة بهذا الشأن يذكر أن قراءات مجلس الشورى هي بمثابة توصيات من حق السلطة التنفيذية الأخذ بها أو رفضها ، ولا يعتد بأي قرار من المجلس إلا

في حال صدور أمر ملكي بهادولة العراق

في عام 2011 أظهرت نتائج المسح المتكامل للأوضاع الإجتماعية والصحية للمرأة العراقية والذي أجراه الجهاز المركزي للإحصاء بأن %27 من النساء المتزوجات في العراق تزوجن بعمر دون 18 عاماوتكون السن في كبير فارق 15 عاما مع وجود ال دون 5% و

الطفلة الزوجة الثانية والثالثة و يعد قانون العراق متوافقا مع القوانين الدولية للحد الأدنى للزواج 18 عام ويمنع القانون زواج الفتاة دون ال 15 عام منعا باتا ويعطىالتقدير للقاضي و برضا الوالدين في تزويج الفتاة بين -15 18 عاما

جمهورية مصر العربيةفتيات زوجوا مأذونا 60 ضبط عن مصرية أمنية حملة أسفرت قاصرات لم يبلغن السن القانونية للزواج وكانت وزيرة الدولة للأسرة والسكان وقد كشفت في دراسة حديثة أجريت على 3 مراكز بمحافظة 6 اكتوبر عام 2010 م أظهرت أن نسبة زواج القاصرات بلغ 74% بينما بلغت نسبة زواج القاصرات بلغ %74 بينما بلغت نسبة الزواج

العرفي 29% و أوضحت بأن الذين يستندون الى صحة هذا الزواج يقولون بأن الاسلام لم يحدد سنا معينا للزواج وفي هذا الصدد وجهت د/ سعادصالح أستاذ الفقه المقارن بجامعة الأزهر رسالة إلى جميع المجامعالفقهية لتطبق حديث الرسول صلى الله عليه وسلم حين جاءتهالخنساء بنت خدام ، وقالت أن أباها زوجها من ابن أخيه

وهي كارهه فرد النبي ذلك الزواج ودعت إلى تحديدأعمار المتزوجين

الحياة . وهنا إشارة إلى عدم موافقة الرسول صلى الله عليهوسلم على هذا الزواج لأن فيه شيء من الإكراه

زواج بأن أفتى فقد جمعه علي الشيخ مصر مفتي أما القاصرات للأطفال يجب معاقبة من يفعله أو يقوم به سواء الأبوين أو المحاميين أو الوسطاء)السماسرة( كما قال المفتيجدها عمر في لرجل القاصر ابنته يزوح الذي )الأب بأن يعتبر فاسقا وتسقط ولايته على أبناءه( مشيرا الى أنه لا بد من

العقاب ردعا لمواجهة هذه الظاهرةوفي هذا تأكيد إلى عدم زواج القاصرات من كبار السن

في المغرب رفعت المملكة المغربية سن الزواج من ال 16 عاما الى ال 18 عاما في عام 2004 م على أمل مكافحة زواج القاصرات لكن بيانات وزارة العدل المغربية أظهرت أن الأرقام استمرت في الزيادة لتصل إلى 27 حالة في عام 2016 بزيادة تقاربويقول القانوني السن رفع قبل عليه كانت عما 50% ال

بعض النشطاء أن النسبة أعلى من ذلك صندوق الأمم المتحدة للسكان وزواج القاصرات

أرقام و احصائيات من المؤلم أن ينظر المختصون في دول العالم إلى تقارير القاصرات للسكان عن مشكلة زواج المتحدة الأمم صندوق وقد رأينا تحذير صندوق الأمم المتحدة للسكان من تفاقم زواج القاصرات وتوقع الصندوق أن يتزوج أكثر من 14 مليون فتاة تحت سن ال 18 سنويا خلال العقد المقبل قائلا بأن هذا العدد قد يزداد إلى أكثر من 15 مليون في الفترة من عام 2021 الى عام 2030 م كما ذكر تقرير الصندوق أنه مع زيادة هذه الزيجات سوف يزداد عدد “ القاصرات الحوامل “ وسيصحب ذلك زيادة في الوفيات بين الفتيات كما حث التقرير الحكومات على اعتماد قوانين ترفع سن الزواج إلى الثامنة عشر للشاباتالالتزام على الحكومات هذه على حرص أكد كما والشبان

بهذه القوانين

حتى والعقلي النفسي التقارب لتحصيل متقاربة لتكون موافقة عدم إلى إشارة وهنا . الحياة استقرار تضمن الرسول صلى الله عليه وسلم على هذا الزواج لأن فيه

شيء من الإكراه والسني حتى تضمن استقرار

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وفي تقرير الصندوق لعام 2010 م أعلنت 158 دولة بأن 18 عام هو السن القانوني الأدنى

الذي يسمح عنده بزواج الفتيان دون موافقة آبائهن أعلنت 146 دولة بأن الفتيات يتزوجن تحت سن 18 عاما

بموافقة آبائهن أعلنت 52 دولة بأن الفتيات يتزوجن تحت سن 15 عاما

بموافقة آبائهنفي يتزوجن اللواتي الفتيات نسبة أن التقرير أفاد كما المناطق في المسجلة تلك الأرياف ضعف سن مبكرة في الحضرية ، في حين أن نسبة الفتيات اللواتي لم يتلقين أي تعليم هي أعلى بثلاث مرات من نسبة اللاتي حصلن على

تعليم ثانوي أو تابعن دراسات عليا كما حذر صندوق الأمم المتحدة للسكان من أن يصل عدد50 العمر ل الخامسة عشر من بلوغهن قبل المتزوجات مليون زوجة بحلول عام 2020 م اذا استمر الوضع على

ما هو عليه وقد أفاد في هذا الصدد اليونوسيف بأن نحو ثلث الفتيات

يتزوجن في الدول النامية قبل بلوغهن ال 18 عامازواج القاصرات من منظور طبي

بعض تأثير مدى ندرك الطب عالم في أننا شك لا خاصة الإنسان على صحة والتقاليد والعادات السلوكيات على المدى البعيد . وعندما ننظر نحن الأطباء إلى خطورة الزواج المبكر في بعض المجتمعات العربية وغير العربيةالزواج مؤيدين علماء لهذا السلبية فإننا ندرك مدى الآثار النفس والإجتماع ما يسببه هذا الزواج من مشاكل نفسية و

جسدية واجتماعية وعلى مستوى العالم فإن الأبحاث والدراسات لا زالت مستمرةويمكن . وسلبياته المبكر الزواج أخطار الكشف عن في تقسيم ومناقشة المشاكل الصحية للزواج المبكر إلى أربعة

محاور رئيسية على الوجه التاليالأضرار الجسدية للفتاةالأضرار النفسية للفتاة

الأضرار الناجمة عن الحمل و الولادةالأضرار الناجمة وأثرها على الطفل

الأضرار الجسدية:نتيجة لعدم اكتمال نمو الأعضاء

التناسلية ) النضج الجسماني ( للفتاة)في السن المبكرة )10-8 سنوات مثلا

تتعرض مثل هذه الفتاة الى تمزق في المهبلوالشرج وتشوه في الجهاز التناسلي الخارجي

للفتاة الصغيرةالأضرار النفسية:

تعاني الزوجة القاصر من الآثار النفسية التاليةأ. الحرمان بكل معانيه )أشكاله)

ب. الشعور بالدونية تشعر هذه الطفلة أنها مجرد سلعة تم بيعها والتخلص منها ويلعب

العامل الإقتصادي دور كبير في زواج القاصراتج. الشعور بالعبودية للزوج

للزوج بالعبودية مصابة الزوجة تصبح الزوجة سن لصغر نظرا وأهل الزوج خاصة في حدوث بعض الإعتداءات الجسدية واللفظية

د. الممارسات الجنسية القصرية أشارت بعض الدراسات بأن أكثر من %80 من الزوجات القاصرات لا يرغبن في الجنس سواء في بداية الحياة الزوجية أو لاحقا بسببالتي تؤدي الى تهكتات الممارسات الجنسية القصرية و الوحشية وتشوهات في الأعضاء التناسلية الداخلية والخارجية وهذا يؤدي الى

مشاكل نفسية سيئةه. مشكلة الطلاق

أشارت الدراسات في عدة دول إلى ارتفاع نسبة الطلاق في زواج القاصرات لقلة وذلك نظرا خبرتها بالحياة الزوجية وغير مؤهلة

لرعاية الزوج والأطفال وتدبير أمور منزلهاو. مشاكل و أعراض نفسية أخرى

قد الكثيرة النفسية الضغوط و الفتاة هذه تعيشها التي للظروف تتعرض هذه الطفلة الصغيرة لأمراض نفسية و

أعراض مؤلمة نوجزها في التالي

50%10%

الوسواس القهريالادمان والمخدرات

استخدام المهدئات النفسيةالهيستيريا والفصام

اضطراب في العلاقات الجنسية

يتعرضون للاكتئاب والقلقحالات انتحار وقتل الأبناء

الحرمان من مرحلة الطفولة والمراهقةالحرمان من عاطفة وحنان والديها

الحرمان من حقها في اختيار الزوج الحرمان من حقها في التعليم

-1-2-3-4

وفي حال عدم التصدي لهذه المشكلة فإن المتوقع بحلولعام 2030 م أن يكون زواج القاصرات كما يلي

مليون فتاة في جنوب آسيامليون فتاة في افريقيا جنوب الصحراء الكبرى

مليون فتاة في امريكا اللاتنية و الكاريبي

13070

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الأضرار الناجمة عن الحمل والولادة: حذرت لجان طبية متخصصة على مستوى وزارات الصحة في عدة دول عربية وغير عربية من تبعات الزواج المبكر وحدوث الحمل في سن مبكرة لما يحمله هذا الحمل من مضاعفات على

صحة الفتاة وجنينها نوجزها في النقاط التاليةفي بحدوثه مقارنة الفئة هذه في الإجهاض نسبة ارتفاع

الفئات الأخرى حدوث الولادة المبكرة وهذه تحمل مضاعفات كثيرة تشمل

المخاطر التالية قصور في الجهاز التنفسي للجنين لعدم اكتمال وظيفة ونمو

الرئتينبالشلل الإصابة ومخاطر والعقلي الجسدي النمو تأخر

الدماغي للجنينالإصابة بالعمى والإعاقات السمعية

الحاجة إلى عملية قيصرية بسبب حجم الحوض واضطراباتصحة الجنين

مشكلات صحية للجنين:الدورة في القصور نتيجة الأكسجين وقلة الجنين اختناق

الدموية المغذية لجسده لضعف عمل المشيمةنمو جسدي هذيل البنيةقصور في النمو العقلي

الحاجة إلى عناية مركزة بعد الولادةالأضرار الناجمة وتأثيرها على حياة الطفل

السعودية عن العربية المملكة في وطنية طبية لجنة حذرت سلبيات زواج القاصرات وبحسب تقرير اللجنة فقد تبين وجود آثار سلبية كثيرة لزواج القاصرات من ضمنها صحة الأطفال لهؤلآء الأمهات الصغيرات في السن ، فقد أشارت هذه اللجنةإلى بالإضافة الأطفال لهؤلاء الذهني النمو تأخر إلى خطر الأطفال لهؤلاء الصحيحة التربوية الرعاية وضعف انعدام بسبب عدم قيام الأم القاصر بواجبها التربوي الصحيح وعدمإلى يؤدي هذا كل التربية لأساسيات والنضج الخبرة وجود أطفال غير أصحاء ويشكلون عبئا على المجتمع و عبئا على

النظام الصحي في البلاد

زواج القاصرات ما هو الحل وما هي التوصيات ؟؟واقع ومن القاصرات زواج لموضوع السابق العرض من يتضح الدراسات والأبحاث والإحصائيات بأن زواج القاصرات وضع لها قوانين وشروط عملية ويمكن قنن وي مشكلة شائكة في جميعالسلبيات نقلل من أن نستطيع لكي تطبيقها مالم ت المجتمعات في المبكر للزواج مزايا هناك الإيجابيات لأن من كثير ونكسب هذا العصر وحماية الشباب والشابات من الوقوع في المحرم نتيجةومن عاما 18 ال سن الفتاة بلوغ وشرط الزواج مشروع تأجيل التالية حول موضوع زواج بالتوصيات فإننا نوصي المنطلق هذا

القاصراتأولا: زواج القاصرات على كبار السن

مما سبق ذكره فإن زواج القاصرات من أزواج في سن آبائهن أو أجدادهن فيه كثير من السلبيات سواء الجسدية أو الإجتماعية أو النفسية خاصة عند تجاهل موافقة الفتاة الصغيرة على هذا الإرتباط الغير متكافأ ولذلك وجب حماية هذه الفتاة والتصدي لهذا الإرتباطعليها كتب الطفلة هذه حياة وقسوة على مآسي من يحمله لما الحرمان من أشياء كثيرة في حياتها بسبب أنانية هذا الزوج التي لا

تدرك أبعاد هذا الإرتباط وي الطاعن في السنثانيا: زواج القاصرات من الشباب

عندما الكثير خاصة الشيء الإيجابيات من تحمل الزيجات هذه تحمي لأنها الشاب وعمر الفتاة عمر بين تناسب هناك يكون أولادنا وبناتنا من العلاقات الغير شرعية وارتكاب ما لا يرضاه دين الإسلام في مجتمعه ويجب دعم مثل هذه الزيجات في حال توفر

الشروط التي سوف يأتي ذكرها في الفقرة الرابعة من التوصياتثالثا: السن المقترحة في زواج القاصرات

والإقتصادية والإجتماعية الديموغرافية العوامل لإختلاف نظرا القاصرات من المختلفة وما يحمله زواج المجتمعات والطبية بين السن يكون بأن نوصي فإننا واجتماعية جسدية نفسية مشاكل المقبول لزواج القاصرات هو سن ال15 وليست ال18 عاما لأننا

نستطيع أن نحقق من الإيجابيات أكثر ونقلل من السلبياترابعا: الشروط المقترحة لزواج القاصرات في سن ال15 عاماالقاصرات في سن ال15 عاما دون لا نريد أن نضع سن زواج النظر والتأكد من صلاحية ونجاح هذا الزواج وهذا الإرتباط المبكر

ولذلك فإننا نوصي بالشروط التالية موافقة الفتاة القاصر ورضاها عن هذا الزواج عن طريق القاضي

دون ضغوط خارجيةالقدرة الجسدية والفكرية لهذه الفتاة لتحمل أعباءومسؤوليات الحياة الزوجية .من ضمن شروط

فحوصات ما قبل الزواج عن طريق جهاتولجان متخصصة

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القدرة المادية المعقولة والمقبولة والظروف الإجتماعية والفكرية للزوج الشاب لكي تعيش حياة كريمة وسعيدة والإقلال من حدوث مشاكل زوجية التي قد تنتهي لا قدر الله بالإنفصال خلو هذا الزوج من الربح المادي للولي والمتاجرة بحياة

ومستقبل هذه الفتاة الصغيرة من قبل ولي الأمر )والدها أو أخوها مثلا(ألا يكون فارق السن بين الزوجين أكثر من15 عام لكي يكون هناك توافق نسبي بين الزوجين فكريا واجتماعيا ونفسيا وصى للزوجين بتجنب الحمل في السنتين الأولى بعد الزواج للإقلال من الأعراض الجانبية ي للزواج المبكر والحمل

والولادة في سن مبكرة والتأكد من استقرار الحياة الزوجية بينهما )هذه توصية وليست شرط(

ما هو المطلوب ؟؟ مما سبق طرحه حول زواج القاصرات وما يحمل من مشاكل شائكة وعديدة يتضح عدم وجود دراسات بحثية علمية دقيقة ومكثفة حول زواج القاصرات والمطلوب من المسؤولين في الوزارات والهيئات والجهات المعنية في جميع الدول العربية والإسلامية القيام بهذه الدراسات ودعمها لتكون الصورة أكثر وبالتالي عمل توصيات أكثر دقة وواقعية حول هذا الموضوع الحساس والشائك وحتى يتم هذا

وضوحا نستطيع تقسيم زواج النساء إلى ثلاث مجموعات

أرجو أن أكون قد وفقت في عرض موضوع زواج القاصرات من الأبحاث والذي يحتاج مزيدا والدراسات لنقف على رؤية واضحةومنصفة للفتاة لتعيش حياة سعيدة والإقلال من المشاكل الصحية والنفسية والإجتماعية

والله من وراء القصد

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المراجع

المراجع العربيةتقرير صندوق الأمم المتحدة للسكان عن “ زواج القاصرات 2010 م .

تقرير وزارة الصحة في المملكة العربية السعودية حول “ الآثار الصحية المترتبة على زواج صغار السن “ 2010مالمسح الإجتماعي والإقتصادي للأسرة / الجهاز المركزي للإحصاء 2007 العراق .

المسح المتكامل للأوضاع الإجتماعية والصحية للمرأة العراقية / الجهاز المركزي للاحصاء عام 2011 العراقتوصيات ندوة “ مخاطر زواج الطفلة / وزارة الإرشاد والأوقاف السوداني بالتعاون مع صندوق الأمم المتحدة للسكان 2009 م

الأضرار الصحية للزواج المبكر / مجلة التايم الاميركية د. يان لوستارت2010م .

English Resources:1. Naqvi M.M. Naseem A. Maternal And Fetal Risks Associated with Teenage And Adult Pregnancy , Journal of Rawalpindi Medicen College 2010 ; 14: 40 -42 2. A.Alwahab A. Pregnancy Complication and outcome Among Teenager Thi – Qar Medical Journal ; Voi (5) N (3) : 2011 (87 – 93) 3. Slowinski K. Unplanned Teenage Pregnancy and the support Needs of young Mother Dept of Human Service , South Australia November 2001 4. Pattanapisalsak C. Obstetric outcome of Teenage Primigrarida in Su – ngai kolok Hospital , Thailand . J Med Assoc Thai 2011 ; 94(2) : 139 - 46

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The impact of transferring a poor quality embryo along with a high quality embryo on the clinical pregnancy rate

Kutbi BKing Abdulaziz University Hospital

Abstract Objectives:In older literature it was suggested that when two embryos are transferred (DET), the addition ofa poor-quality embryo might decrease the chances of pregnancy of a good quality embryo. The objective of this study was to assess the validity of this hypothesis in a clinical setting. We also wanted to compare these results with single embryo transfer in good prognosis patients who had more than embryo to transfer.Material and methods:Retrospective cohort study of fresh double embryo transfer between 2008-2009 at the OvoFertility Clinic. We looked at the results of double embryos transfers.Three groups of patients were therefore compared:Group1: transfer of two good quality embryos (n=64) was compared to Group2-transfer of onegood quality embryo with one poor/average quality embryo (n=77). These groups werecompared with a cohort of good quality single

embryo transfers (n= 16).Pregnancy rates (PR) and

multiple pregnancy rate (MPR) were compared by

Chi-Square.

Results:PR were 65% (46 pregnancies out of 64 transfers) and 58% (45 pregnancies out of 77 transfers)for group 1 and 2 respectively (P=0.38) while MPR were 41% and 33% respectively (P= 0.32 )Good prognosis “elective” (when more than one embryo was available) single fresh embryotransferred: PR=50%.Conclusions:This study suggests that the simultaneous transfer of one poor or average quality embryo did notdecrease the chances of implantation of a good quality embryo but the addition of a good qualityembryo increases the MPR.Keywords: IntroductionEmbryo morphological quality is a good predictor of successful in vitro fertilization treatment and good perinatal outcome. Or on et al (1). Increasingly the transfer of a single blastocyst is the option of choice to maximise pregnancy rate while minimising the risk of multiple

pregnancy rate. (2)

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out. Group 1 (64 patient cycles) underwent DET with two high quality embryos. Group 2 (77 patient cycles) underwent DET with one HQE and one poor quality embryo. Group 3 (16 patient cycles) was the control group with the transfer of asingle high quality embryo.

Embryo quality:At the study’s time period, embryos were classified using Steer’s (7) classification:

Grade IV: Equal symmetrical blastomeres. Smooth membranes, translucent cytoplasm and no fragmentationGrade III: Uneven blastomeres, less than 10% fragmentation.Grade II: Moderate (10-50%) fragmentationGrade I: Extensive (>50%) fragmentation, pronucleate single cell embryos or other aberrationsGrade IV are considered high quality embryos, and grades III and II are considered poor quality. Grade I embryos were discarded. The clinical pregnancy rate, defined as the intrauterine presence of a fetal heart at 8 weeks gestation on ultrasound and the multiple pregnancy rate was compared between the three groups.

Statistical analysis using chi-square was performed with a value of p<0.05 being considered as significant.

However for different reasons the transfer of more than one embryo is still used in many clinics and for various circumstances. Clearly the preference is always to use high quality embryos (HQE) for transfer, but this is not always possible when an IVF cycle results in only one high quality and other poor quality embryos. This creates a dilemma whether to transfer both of the embryos or only the high quality embryo.

It was suggested by Macklon and Brosens in 2014 (3) that the human endometrium responds differently when exposed to high quality embryos as compared to poor quality embryos. The proposed response activates a different set of genes based on the presence of a poor quality embryo thereby reducing the implantation potential of both the high quality embryo and the poorer one.

This area of study remains controversial and there is limited literature on the subject. A more recent study found no difference in the implantation rate when transferring embryos of different qualities. (4) Indeed this year at an international conference, two abstracts were presented both demonstrating opposite findings as to the impact of transferring a HQE along with a poor quality embryo. (5, 6)MethodsA retrospective analysis of all cycles undergoing double embryo transfer (DET) were included between 2008 and 2009 prior to the implementation of regulations in the province of Quebec which limited the number of embryos that could be transferred and the circumstances in which a double embryo transfer could be carried

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Result

Clinical pregnancy Multiple pregnancy rate rate

Group 1 65% (a) 41% (d)

Group 2 58% (b) 33% (e)

Group 3 50% (c) 0%

p-value : a vs. b = 0.38 d vs. e = 0.32For the group with two high quality embryos, both the pregnancy rate and the rate of multiple gestations are highest.

For the second group, with two embryos of different quality, the pregnancy rate was lower, but not detrimental (65% vs 58%, p-value 0.38), especially when compared with the control group (50% CPR).

The multiple pregnancy rate, while lower in the group with different quality embryos, was still comparable and not statistically significant (41% vs 33%, p value 0.32).

Discussion:To date the limited data presented on the question of whether the dET of a higher quality embryo along with a poorer quality embryo leaves the question unanswered. Our data supports that presented by Wintner et al and Tailor et al suggesting no impact of transferring a poor quality embryo along with a high quality embryo on the chance of implantation.

Although the transfer of a single embryo should be the goal in the vast majority of cycles of IVF there may be occasions when dET is indicated and in those countries and regions that dET is permitted under the law it would be important to understand the risk of impacting or otherwise the pregnancy rate when two high quality embryos are not available for the patient.

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References1- Oron G , S on WY , Buckett W , Tulandi T , Holzner H . The association between embryo quality and perinatal outcome of singletons born after single embryo transfers: a pilot study. Hum Reprod. 2014; 29: 1444-51.2- F. Bissonnette, S. Phillips, H. Holzer, N. Mahutte, P. St-Michel, J. Gunby, I.J. Kadoch.Working to eliminate multiple pregnancies: a success story in Québec. RBM Online. 2011. 23(4):500-5043- Macklom NS, Brosens JJ . The human endometrium as a sensor of embryo quality. Biol Reprod. 2014 Oct; 91(4): 98. Doi: 10.1095/biolreprod. 114.122846. Epud 2014 Sep 3.4- Wintner EM , Hershko-Klement A , Tzadikevitch K , Ghetler Y , Gonen O , Wintner O , Shulman A , Wiser A. Does the transfer of a poor quality embryo together with a goodquality embryo affect the In Vitro Fertilization (IVF) outcome? J Ovarian Res. 2017;10:2 Published online 2017 Jan 13. Doi: 10.1186/s13048-016-0297-95- Richardson A, Davey T, Lyndsey Z, Hopkisson J, Raine-Fenning N. For womenundergoing double embryo transfer on day five, the addition of a poor quality embryomay have a detrimental effect on the assisted reproduction outcome. The proceedings ofthe British Fertility Society 2017.6- Tailor S, Vourliotis M, Francis G, Papoff F, Flouri C, Sotirchou G, Almeida P. Does theadditional transfer of a poor quality blastocyst affect clinical outcome? The proceedingsof the British Fertility Society 2017.7- Steer CV, Mills CL, Tan SL, Campell S, Edwards RG. The cumulative embryo score: apredictive embryo scoring technique to select the optimal number of embryos to transfer

in an in vitro fertilization and embryo transfer programme

Further studies looking at the interaction of embryos in culture and in vivo are required to help answer these questions.Additional transfer of a poor quality blastocyst affect clinical outcome? The proceedings of the British Fertility Society 2017.7- Steer CV, Mills CL, Tan SL, Campell S, Edwards RG. The cumulative embryo score: a predictive embryo scoring technique to select the optimal number of embryos to transfer in an in vitro fertilization and embryo transfer programme

The impact of transferring a poor quality embryo along with a high quality

embryo onthe clinical pregnancy rate

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Knowledge and perception of Health Rights and Health Empowermentamong Saudi women

Kafy S.(1), Al-Amoudi S. (2), Jar A. (3),Bugshan S. (4)., Al-Ahmadi J(5)., Bondagji N. (6)

King Abdulaziz University Hospital Faculty of MedicineKing Abdulaziz UniversityJeddah-Saudi ArabiaAbstract BackgroundHealth Empowerment is defined by the WHO as “The process through which people gain greater control over decisions and actions affecting their health”. In the Kingdom of Saudi Arabia (KSA), the right to health care is stated in article 31 of the “Basic Laws of Saudi Arabia”, and in 2006 the Ministry of Health (MoH) issued the “Patient’s Bill of Rights (PBR)” to highlight the different aspects of health rights. However many patients are unaware of these bills, and in fact, studies have shown insufficiency of knowledge on health rights among medical students, and even some practitioners in health care. Objective The aim of this study is to assess women’s knowledge on health empowerment and health rights in Saudi Arabia, and to draw attention to areas of deficient information. Methods

This cross-sectional survey was conductedover six months, between July and

December 2016, at King AbdulazizUniversity Hospital (KAUH) in

Jeddah, Saudi Arabia. We

randomly approached all women attending the OBGYN outpatient clinics. Data collected was coded, cross-checked and entered on daily basis. Descriptive and conducted comparative analyses were using (SPSS) version 22.0 (SPSS Inc., Chicago, IL, USA). Categorical variables were expressed in counts and percentages, whereas continuous variables in means and standard deviations. ResultFive hundred and sixty-five women were included in this survey, with a response rate of (94.2%). The mean age of (29.7 ± 11.0) years. Regarding educational levels, most women were holders of bachelor degrees (53.6%). Participants were asked if they knew what is meant by “Health rights”, and while (55.2%) claimed they did, (33.1%) denied any knowledge of health rights.On the other hand, whenasked about encountering

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the concept of “Health Empowerment”,only (30.8%) of all participants confirmed they have, while (59.1%) said they never did. Social Media was the most common source of information on “Health Empowerment” as identified by (37.9%) of respondents.ConclusionThere is increased awareness about the importance of women’s health rights, yet much is still needed to raise awareness on relevant issues, and to ensure provision of good quality health care. More research and evidence-based interventions must be adopted to share relevant information with the public and health professionals.

1 Department of Obstetrics and Gynecology, Faculty of Medicine, King Abdul-Aziz University, Member of Health Empowerment and Health Rights Unit, ,Faculty of Medicine, King Abdul-Aziz University Jeddah, Saudi Arabia.2 Head of Health Empowerment and Health Rights Unit, ,Faculty of Medicine, King Abdul-Aziz University, Department, of Obstetrics and Gynecology, Faculty of Medicine, King Abdul-Aziz University ,Sheikh Mohammed Hussein Al-Amoudi Center of Excellence in Breast Cancer, King Abdul-Aziz University, Jeddah, Saudi Arabia3 Faculty of Medicine, King Abdul-Aziz University, Jeddah, Saudi Arabia4 King Abdul-Aziz University Hospitals, Jeddah, Saudi Arabia5 Departments of Family Medicine, Faculty of Medicine, King Abdul-Aziz University, Member

of Health Empowerment and Health RightsUnit, ,Faculty of Medicine, King Abdul

Aziz University ,Jeddah, Saudi Arabia6 Departments of Obstetrics and

Gynecology, Faculty of

Medicine, King Abdul-AzizUniversity, Member of Health Empowerment and Health Rights Unit, ,Faculty of Medicine, King Abdul-Aziz University, Jeddah, Saudi Arabia

IntroductionAttaining the highest possible standards of health is a fundamental human right for every individual, as stated in the World Health Organization’s (WHO) Constitution. (1) This obligates countries to ratify their populations’ health rights in their constitutions, and install the appropriate measures to provide equal access to health care. (2-3) Acknowledging individuals’ health rights, and encouraging them to exercise these rights is core for optimal health care provision. (4-5) Health empowerment is defined by the WHO as “The process through which people gain greater control over decisions and actions affecting their health”. (6-7) Much global attention is directed towards empowering patients, (8) especially lately since patients’ empowerment programs were attributed to improved doctor-patient relationships, better mental health, healthy diet, and other favorable health outcomes. (8-10) In the Kingdom of Saudi Arabia (KSA), the right to health care is stated in article 31 of the “Basic Laws of Saudi Arabia”, and in 2006 the Ministryof Health (MoH) issued the “Patient’s Bill of Rights (PBR)” to highlight the different aspects of health rights such as; acknowledging patients’ rights of confidentiality,

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safety, respect and appreciation, thenecessity of involving patients intheir healthcare decision making, and theneed for comprehensive systems for complaints and suggestions in all healthcare establishments.(11) These health rights are available as an online electronic document, and are printed in posters and manuals in most healthcare facilities in Saudi Arabia. (10-11) However many patients are unaware of these bills, (12) and in fact, studies have shown insufficiency of knowledge on health rights among medical students, and even some practitioners in health care. (13-14) This indeed has emphasized the importance of educating patients on health rights, and laid the foundation for patients’ empowerment, (14) especially after the launch of the 2030 Saudi Developmental Vision, calling for empowerment of all stakeholders in order to achieve success and ensure sustainability. (15) Among the strongest named stakeholders are women, with much of the 2030 recommendations focusing on women empowerment within the different sector in the kingdom such as; health, education and employment, (16) and while women empowerment was associated with attainment of favorable outcomes in other settings, (17) little is known about women’s empowerment in health, and their awareness on health rights in Saudi Arabia.

The aim of this study is to assess women’s knowledge on health empowerment and health rights in Saudi Arabia, and to drew attention to

areas of deficient information.

Material and method:This cross-sectional survey was conducted over six months, between July and December 2016, at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia. We randomly approached all women attending the Obstetrics & Gynecology (OBGYN) outpatient clinics during the study period, irrespective of their age, health status and reason for hospital visit. The approximate monthly rate of OBGYN clinics visitors at KAUH is 100 per month, and thus, we targeted 600 participants for this survey. Ethical approval was obtained from the Research Ethical and Technical Committee at KAUH, and all other necessary administrative approvals were secured prior to data collection. Upon approval to join, participants were reassured about the confidentiality of their personal data, and were asked to provide a signed informed consent.

For this survey, and after reviewing the literature, and upon accommodating for the local context and national health regulations, we constructed an Arabic, self-administered, three-part questionnaire, which was pre-tested and validated in a pilot study. The three parts explored on the following information; the first part

covered “Demographic data” such as; age, marital status,

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were holders of bachelor degrees (53.6%), while (26.2%) only finished secondary school. Only (4.1%) of all respondents were illiterate. (Table 1) details the demographic characteristics of the all participants.

Participants were asked if they knew what is meant by “Health rights”, and while (55.2%) claimed they did, (33.1%) denied any knowledge of health rights, (7.4%) felt they were not sure, and (4.3%) gave no answer (Figure 1.A). For the (312) participants who knew what was meant by “Health Rights”, (30.8%) got their information from “Hospital posters”, (26.9%) from the “Internet”, (26.6%) from the “Media”, and (22.4%) from “their doctors”. More resources are shown in (Figure 2). On the other hand, when asked about encountering the concept of “Health Empowerment”, only (30.8%) of all participants confirmed they have, while (59.1%) said they never did, (8.5%) did not know what the concept meant, and (1.6%) did not answer the question (Figure 1.B). Social Media was the most common source of information on “Health Empowerment” as identified by (37.9%) of respondents, followed by “their educational curriculum” for (30.5%) and the “Internet” for (29.5%). Only (14.4%) claimed to know about “Health Empowerment” from their “Doctors”. More resources are shown in (Figure 3).We further explored the participants’knowledge on “Health rights”, where(91.7%) agreed that knowing theirhealth rights can improve theirhealth status, and in fact (84.1%)felt it is important to integratethis information in schools’curricula (Figure 4).

nationality, andeducational level, the secondpart delved into the knowledge on “Health Empowerment and Health Rights” in general including; sources of information, its value to patients, its acceptability by local culture, and the health rights of some special groups. Lastly, the third part assessed the participants’ knowledge about women’s need for guardians’ approvals when making critical health decisions. For most questions, participants were asked to provide one of three responses; “Yes,” “No,” or “I don’t know”. Participants were encouraged to answer all questions, yet those unanswered were entered and analyzed as so.

Statistical AnalysisData collected was coded, cross-checked and entered on daily basis. Descriptive and comparative analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 22.0 (SPSS Inc., Chicago, IL, USA). Categorical variables were expressed in counts and percentages, whereas continuous variables in means and standard deviations.

Results:Five hundred and sixty-five women were included in this survey, with a response rate of (94.2%). As we included all women who were present at the OBGYN clinics and agreed to participate, including both patients and co-patients, the respondents’ages ranged between (16 – 70) years, with a mean age of (29.7 ± 11.0) years. The majority of our participants were Saudi (71.5%), with half of them single (49.1%), and the other (43.7%) were married. Regardingeducational levels, most women

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Out of the latter group,(53.7%) suggested that

teaching “Health rights”should be started as early

as “Preparatory Schools”.Although (89.4%) felt spreading

information on “Health rights” isthe responsibility of the Ministry

of Health (MoH), only (28.3%) confirmed that their doctors acutely explained their health rights to them (Figure 4). We also explored on the respondents’ views with regard to the health rights of some groups, and namely if they felt that the health rights of women in Saudi Arabia are affected by customs, and around two thirds of all participants (66.2%) admitted it did (Figure 5). We also asked the participants about the health rights of some special groups, and whether these are incorporated in the Saudi health system. About (73.5%) recognized that the health rights of “People with Disability” were incorporated in the system, and (65.3%) confirmed that those of the “Elderly” are also incorporated in the system (Figure 5).

For the third part of the questionnaire, more questions were posed about women rights, and more specifically about women’s need to secure their guardians’ approvals upon making critical health decisions. The participating women concurred to their need for guardians’ approvals as follows; upon “Admission” (45.1%), on “Discharge” (45.8%), for “Medical Treatment” (33.8%), and for “Surgical Procedure” (49.4%). (Figure 6) details the responses of all participants on the former questions.

DiscussionIt has been noted that educating women about their health rights and empowering them to hold control of their healthcare is essential

for patient’s safety, and to reduce overall morbidities and mortalities. (18) Studies focusing on lack of awareness on health rights and patients’ empowerment in general are limited in the Middle east, and more specifically in Saudi Arabia, making assessment of the true magnitude of this problem rather difficult, with minimal reporting on corrective interventions.

In this study only (55.2%) and (30.8%) confirmed their knowledge of what is meant by health rights and health empowerment respectively. These percentages correspond to the percentage of women who were holders of bachelor degrees (53.6%) indicating a good link between education of women and their awareness on their health rights, and possibly their overall health empowerment. Both Alghanim (2012) and El-Sobkey et al. (2014) reach similar conclusions, with a significant relationship between the patients’ levels of education and their level of awarenesson health rights. (19-20) While this indicates the empowerment that may be achieved byeducation, it also highlights serious and alarming shortages of information for women of lower educational levels, or for those who are illiterate.There is to adopt appropriate interventions to reach out to these groups in order to enhance their awareness on health rights.With regard to the named sources of knowledge on health rights, our participants identified a very diverse group, and some of which

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were in-hospital sources such as “Hospital Posters” for (30.8%), and “Doctors” for (22.4%) of the participants respectively. In another study in Saudi Arabia, the main in-hospital sources of information on patient’s rights were nurses, posters, and doctors (33.33%, 31.75%, and 23.81%) respectively, (21) quite similarly for both studies. Yet, despite the growing literature identifying “Health professionals” as the most trusted and common source of information, for both of the mentioned Saudi studies “Doctors” were the least acknowledged source of information. This may reflect on the underestimation of doctors to their influential role in rising patients’ awareness on their rights, a finding that was confirmed in another study conducted in Saudi Arabia, and stressed on the need to intervene in this aspect. (12) Appropriate measure should be adopted to educate health professionals on patients’ rights, and their role in spreading information among patients.

The internet and media represent only (26.9%) and (26.6%) of sources on health rights that were named in our study, despite the notable tele-communication advancements in Saudi Arabia. In fact, social media nowadays is considered a strong informative tool to reach different communities, (23) and especially younger generations. If utilized carefully, social media could effectively raise awareness on health rights, though linking the latter to communities’ social values and interests. In our study (91.7%) of participants agreed that knowing their health rights can improve

their health status, and (84%) suggested that to include it in

school’s curricula.Ignorance on health rights as well as the rules and regulations

of the Ministry of health

can lead to fatal outcomes. Abu Aisha reported an incident in 1984 of maternal and fetal deaths following ruptured uterus of a woman in labor, after the husband’s refusal to consent for caesarean section, and the medical team failing to recognize and advocate for the women’s right to consent for herself. (21) This emphasizes the need for educating both public and professionals on health rights as was recommended by our participants.

When deeply assessing the knowledge of these women groups on health rights, we noted good knowledge on special groups incorporated in the Patients Bills of Rights, since (73.5%) acknowledged the appropriate incorporation of “People with disability” in the health system, and (65.3%) confirmed the inclusion of “Elderly” health rights in the system. Despite the former, the women lacked much knowledge on their own rights, reflected by the (45%) who confirmed the need for a male’s guardian aproval in the case of admission or discharge. Furthermore, we noted a misconception about women rights to consent for their own medical treatment and/or surgical procedures. In fact, about half of the women who participated in this study believed that a male guardian approval is need for surgical management.

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This could be explained by thenature of the customs and social restraints of women in Saudi Arabia, as reflected in the responses of (66%) participants themselves. Yet, with the 2030 vision, much focus is devoted towards women’s protection and empowerment, and there is a need to adopt appropriate educational interventions to raise women awareness on their health rights, starting in schools and including health facilities.

Conclusion: There is increased awareness about the importance of women’s health rights, yet much is still needed to raise awareness on relevant issues, and to ensure provision of good quality health care. More research and evidence-based interventions must be adopted to share relevant information with the public and health professionals.Acknowledgment: We express our gratitude to the team members of Sheikh Mohammed Hussein Al-Amoudi Center of Excellence in Breast Cancer – King Abdu-Aziz University, and Special thanks to medical students Hadeel khateeb, Malak Alshammari, Batool Alkhazal, Shahad Alshammari, and Haya Najaifan.

Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company.

References

1. Constitution of the World Health Organization. 1946. International Health Conference. Bull World Health Organ. 2002; 80(12):983-4. 2. Nowrin I, Fatema K, Natasha K, Ahsan GU, Ali L. Patients awareness of health right: a hospital-based pilot study from Dhaka City. Epidemiology (sunnyvale). 2015;5(202):2161-1165. 3. World Health Organization. Working together for health: the World health report 2006: policy briefs.4. England NH. Involving people in their own health and care: Statutory guidance for clinical commissioning groups and NHS England. Leeds, England. 2017.5. Delaney LJ. Patient-centred care as an approach to improving health care in Australia. Collegian. 2017 Mar 6. 6. World Health Organization. Patient empowerment and health care. The first global patient safety challenge: clean care is safer care. WHO guidelines on hand hygiene in health care. Geneva, Switzerland: World Health Organization. 2009. 7. World Health Organization. Health promotion glossary. Geneva: World Health Organization; 1998.

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8. Wallerstein N. What is the evidence on effectiveness of empowerment to improve health? Copenhagen: WHO Regional Office for Europe. Health Evidence Network report. 2006.9. Kennedy A, Reeves D, Bower P, Lee V, Middleton E, Richardson G, et al. The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised controlled trial. J Epidemiol Community Health. 2007; 61: 254–261. 10. Lorig K, Ritter PL, Villa FJ, Armas J. Community-based peer-led diabetes self-management: a randomized trial. Diabetes Educ. 2009; 35: 641–651. 11. Ministry of Health. Patient’s Bill of Rights and Responsibilities. Riyadh (KSA): Ministry of Health. Available:http://www.moh.gov.sa/en/HealthAwareness/EducationalContent/HealthTips/Pages/Tips-2011-1-29-001.aspx12. Almoajel AM. Hospitalized patients’ awareness of their rights in Saudi governmental hospital. Middle-East Journal of Scientific Research. 2012; 11(3):329-5. 13. Al-Amoudi SM, Al-Harbi AA, Al-Sayegh NY, Eldeek BS, Kafy SM, Al-Ahwal MS, Bondagji NS. Health rights knowledge among medical school students at King Abdulaziz University,Jeddah, Saudi Arabia PloS one. 2017 May 1; 12(5):e0176714.14. Al-Amoudi SM. Health empowerment and health rights in Saudi Arabia. Saudi medical journal. 2017 Aug;

38(8):785.

15. Alshuwaikhat HM, Mohammed I. Sustainability matters in national development visions—Evidence from Saudi Arabia’s Vision for 2030. Sustainability. 2017 Mar 9; 9(3):408. 16. Elmulthum N, Elsayed I. Prospects of Saudi Women’s Contribution to Job Market under Saudi Vision 2030: An Empirical Analysis 1999-2015. International Journal of Applied Sociology. 2017; 7(1):20-7. 17. Nasrabadi AN, Sabzevari S, Bonabi TN. Women empowerment through health information seeking: a qualitative study. International journal of community based nursing and midwifery. 2015 Apr; 3(2):105.18. Temmerman M, Khosla R, Laski L, Mathews Z, Say L. Women’s health priorities and interventions. bmj. 2015 Sep 14; 351:h4147.19. Alghanim S. Assessing knowledge of the patient bill of rights in central Saudi Arabia: A survey of primary health care providers and recipients. Annals of Saudi Medicine. 2012; 32, 151-155.20. El-Sobkey S, Almoajel A, Al-Muammar M: Knowledge and attitude of Saudi health professions’ students regarding patient’s bill of rights. International Journal of Health Policy and Management. 2014; 3,117-122.21. Abu-Aisha H. Women in SaudiArabia: Do they not have the right to give their own consent or medical procedures? Saudi Med J. 1985; 6: 74-77.

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22. Cutilli CC. Seeking health information: what sources do yourpatients use? Orthopaedic nursing. 2010 May 1; 29(3):214-9.23. Ventola CL. Social media and health care professionals: benefits, risks, andbest practices. Pharmacy and Therapeutics. 2014 Jul; 39(7):491.

Table (1): General Characteristics (n=565)

Characteristics Total (Mean ± SD)

Age 2 9.7 ± 11.0

Characteristics Total N (%)

Nationality

Saudi 404 (71.5%)

Non-Saudi 129 (22.8%)

Missing 32 (5.7%)

Marital Status

Single 277 (49.1%)

Married 247 (43.7%)

Divorced 2 6 (4.6%)

Widow 3 (0.5%)

Missing 12 (2.1%)

Educational Level

Illiterate 23 (4.1%)

Preparatory 5 5 (9.7%)

Secondary 148 (26.2%)

Bachelor 303 (53.6%)

Postgraduate 21 (3.7%)

Missing 15 (2.7%) 26

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Figure (2): Sources of Knowledge on “Health Empowerment” (n=174)

Figure (1): Knowledge on “Health Empowerment” & “Health Rights”

(n=565)

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Figure (2): Sources of Knowledge on “Health Empowerment” (n=174)

Figure (4): General Knowledge on “Health Rights” (n=565)

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Figure (5): “Health Rights” of these groupsincorporated in the Saudi Health System? (n=565)

Figure (6): Knowledge on “Health Rights” for women (n=565)

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Conditions Associated with Intrauterine Fetal Demise (IUFD) in pregnant women at King Abdul Aziz University (KAUH). A Five-Year Experience.

Conclusion: IUFD is one of the worse outcome of pregnancy resulting in significant emotional and physical distress to the mother. There are several factors (maternal, fetal & placenta) associated with it many of which can be avoided by providing good and consistent antenatal care.

1Department of Medicine, King Abdul-Aziz University, Jeddah, Saudi Arabia

2Department of Obstetrics and Gynecology, King Abdul-Aziz University, Jeddah, Saudi Arabia

Corresponding author:Jehad J. Qashqari Email Address: maherford8@gmail.comDepartment of Medicine, King Abdul-Aziz University, Jeddah, Saudi Arabia

AbstractBackground: Intrauterine fetal demise (IUFD) is the death of the fetus after twenty weeks of gestation but before the onset of labor. In more than 50% of cases, the etiology of antepartum fetal death is not known or cannot be determined. Several factors attributed to the risk of IUFD. This study aimed to determine the incidence of IUFD, as well as associated conditions.Method: This retrospective study enrolled all pregnant women who had a delivery at King Abdul-Aziz University Hospital (KAUH) between 2011 to 2015. Results: During the last five years, 248 verified IUFD cases were reported. The mean age was 30.59. Saudi nationality represents 27 % of the study population.Regarding risk factors, Preeclampsia represent 17.7% and congenital malformation represent 7.3% of the

conditions associated with IUFD. Of the total population,

spontaneous vaginal delivery 58.9% followed by CS 28.6 %.

Abdullah M. Kafy MBBS 1Maher G. Alsharif MBBS 1Muath A. Marghalani MBBS 1 Moayad K. Almaimani MBBS 1 Jehad J. Qashqari MBBS 1Ayman Oraif MD, FRCSC 2

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IntroductionMortality proportion among children is considered one of the most important predictor about country’s development, where most of these deaths occur during the period between 22th week of pregnancy and the first month of life. (1,2) one of the many conditions responsible for mortality among children is intrauterine fetal demise (IUDF), which is defined as the death of the fetus after twenty weeks of gestation but before the onset of labor with birth weight > 500gm. (3) In more than 50% of cases, the etiology of antepartum fetal death is not known or cannot be determined. (3) Several maternal, placental or fetal factors attributed to the risk of IUFD such as (hypertension of pregnancy, diabetes, high parity, advanced maternal age, abruption placenta, congenital anomalies, intrauterine growth retardation, severe fetal growth restriction (FGR) or cord accident). (4,5,6) In addition, several studies showed that unexplained fetal deaths happen even with women who had consistent antenatal care. (6,7)

Several studies reported 3 million cases/ year of IUFD around the world where 70% of the cases occurred in thedeveloping countries in Asia and Sub

Saharan Africa together due toseveral factors such as: inadequate

of prenatal care, and lack ofhealth care facilities. (3,4,8)

Over the last five decades there was huge positive changes in the model of antenatal care (ANC). Which shows that early antenatal care has a substantial influence on the maternal and fetal health, because of early diagnosis, teaching women the labor signs, referring to competent obstetrician-gynecologist, therefore preventing complication and subsequently IUFD. (8,9,10) This study aimed to determine the incidence of IUFD, as well as associated conditions among pregnant women who delivered at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia.

Subject and MethodThis retrospective study enrolled all pregnant women who delivered at KAUH between 2011 to 2015. The following data were collected from delivery log books and the hospital electronic system (age, gestational, parity, BMI and mode of delivery). Statistical analysis

The collected data were analyzed using the SPSS Statistical Software Package, version 20. Parametric data were expressed as mean and standard deviations (minimum and maximum) and non-parametric data are expressed as number (percentage). Chi-square was used as a test of significance for comparison of qualitative data. Significance was considered at P value less than 0.05.

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ResultsTable (1) Incidence of Intrauterine fetal demise (IUFD)according to year of the study

Figure (1) Distribution of the IUFD according to years

Years Total Number of Year Intra-uterine Fetal Death(IUFD) Verified IUFD 2011 64 (1.3) 86 (1.7) 48312012 58 (1.1) 78 (1.4) 53852013 66 (1.5) 89 (2) 42762014 3710 50 (1.3) 27 (.07)2015 3637 43 (1.1) 33 (.09)Total 248 346

Table (1) showed total number and percentage of IUFD and verified IUFD. The incidence rates of verified IUFD were 1.3, 1.1, 1.5, 0.07 and 0.09 respectively from 2011 to 2015. No significant difference was detected

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Table (2) Age of the mother, Parity and Gestational age of the studied confirmed IUFD

Table (3) Nationality of the Studied Verified IUFD.

Table (3) showed nationality of the studied confirmed IUFD.

Table (2) showed Age of the mother, Parity and gestational age of the studied confirmed IUFD. The mean age was 30.59 year, the median parity was 2 and the gestational age was 32.22 weeks

Min-Maximum

SD Median Mean Variables

(17-43) 6.75 26 26.59Age

(2-14) 2.58 22.5Parity

(20-46) 6.98 33 32.22 Gestational Age

IUFD Nationality

Percentage Number

(27) 67 Saudi

(6)15 Pakistani

(.4) 1 Egyptian

(1.2) 3 Bangladeshi

(1.6) 4 Afghan

(1.2) 3 Burmese

(27) 15 Chines

(6) 3 Ethiopian

(.34) 1 Filipino

(1.6)4 Indian

(.8) 2 Jordanian

(.4) 1 Lebanese

(.4) 1 Moroccan

(2.4) 6 Malaysian

(26.6) 66 Somalian

(1.6) 4 Syrian

(11.3) 28 Yemeni

(9.7) 24 Missing

248 Total

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Figure (2) Nationality of the Studied Verified IUFD.

Table (4) Showed Risk factor of the studied confirmed IUFD.

Table (5) Mode of delivery of verified IUFD.

Table (5) showed mode of delivery of confirmed IUFD

No Mode of delivery

(58.9) 146 SVD

(4.8) 12 VD ventose

4.8) 12 VD forceps

(28.6) 71 CS

(2.8) 7 Missing

248 Total

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Figure (3) Mode of delivery of verified IUFD

Table (6) Relation between booking status and year of the study for verified IUFD.

Table (6) Relation between booking status and year of the study for confirmed IUFD. There was lower booking rate in 2014 and 2015 than other years.

Test of sigUnbooked

N %

Booked

N %

Chi-square test

P =0.005**

28 (21.4) 36 (31) 2011

30 (22.9) 28 (24.1) 2012

30 (22.9) 36 (31) 2013

17 (13) 10 (8.6) 2014

26 (19.8) 6 (5.2) 2015

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Figure (4) Relation between booking status and year of the study for verified IUFD.

Discussion:

The rate of IUFD cases are different between countries, cities, even differ from year to year, this variance due to the fact that there are several factors such as antenatal care service quality, the argument between researchers in determining gestational age and weight of the fetus in the definition of IUFD. (4,7) Several studies were carried out to define the risk factors causing IUFD, these factors divided to three main categories: maternal, placental and fetal factors, such as poor antenatal care, preterm delivery, low birth weight, congenital, maternal age & chronic illness (Gestational Diabetes & hypertension). (7,11)

As regards to maternal factors associated with fetus death, several studies addressed the relation between

maternal age and IUFD, where childbearing women younger than 20 and older than 40 years

are more likely to have stillbirth than women ingroup age 24-35 years and the problem

become more obvious in women aged ≥ 40 years. (12,13) In addition to that, the relation between maternal age and both gestational age and birth weight are confirmed. Where women older than 40 years have more chance to go through cesarean section (C/S) and have macrocosmic neonate. (13,14) The results of the current study is consistent with the previous studiesand showed that themean age score was30.6±6.7.

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Placental complications, preeclampsia , and umbilical cord are important risk factors associated with IUFD , where 2.7% of obstructed fetal blood flow death cases are linked to nuchal cord in 23% of the cases and 1% of true umbilical knots , where there is need for pathological anatomy examination to detect if knot or nuchal cord are the real cause of death , where it could induce rupture or inflammation and cause placental abruption which is fetal in 0.12% of the cases and presents as bleeding and abdominal pain . (14,15)

Congenital anomalies are the biggest risk factor causing perinatal death. in the current study 14 cases (5.6%) had congenital anomalies. (16)

Several studies addressed the ability of preventing and avoiding the majority of the previous risk factors by providing a appropriate level of antenatal care (ANC), where a good level of antenatal care helps in controlling a lot of factors such as: blood glucose, blood pressure, earlier diagnosis of congenital anomalies, folic Acid, which provide a chance of intervention in high risk cases. (7,9) A study was done in Ethiopia study recorded that the variety in ANC between urban

& rural areas induced different rates ofIUFD cases. (2) Another study

reported that 38% of the IUGRcases didn’t have any antenatal

care.

(17) Furthermore, a South African study in 2015 stated that managing maternal health conditions by intrapartum care during the three semesters had a favorable effect on reducing IUFD cases. (18) All the studies highlighted the following statement, when there is previous unexplained IUFD there is a great need of intensive ANC to reduce stillbirth incidence or at least provide the parents with explanation of the cause of fetus death. (7,19) The result of the current study consistent with previous studies where the rate of IUFD was less among booked mother than un-booked mother.

Conclusion:

In conclusion, IUFD is a traumatic event for both the parents and the obstetrician. Even with the high improvement in the quality of health care field still there is significant rate of IUFD cases, due to several factors (maternal, fetal & placenta). Providing appropriate level of antenatal care helped in reducing IUFD incidence. Further studies need to be carried out using a multicenter approach to include more participants and to explore more factors affecting IUFD, thus increasing the information about this unfavorable event to develop more suitable and effective health strategies to decrease and prevent IUFD. Also, there is a need for more educational programs to raise the level ofawareness about the importance ofantenatal care and its impact onreducing fetal death rateamong the community.

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References1. Koshida S, Ono T, Tsuji S, Murakami T, Takahashi K. “Recommendations for preventing stillbirth: a regional population-based study in Japan during 2007-2011”. Tohoku J Exp Med. 2015;235(2):145-9. 2. Gizaw M, Molla M, Mekonnen W . “Trends and risk factors for neonatal mortality in Butajira District, South Central Ethiopia, (1987-2008): a prospective cohort study” BMC Pregnancy Childbirth. 2014 ; 11:14:64. 3. Silver RM, Varner MW, Reddy U, Goldenberg R, Pinar H, Conway D, Bukowski R, Carpenter M, Hogue C, Willinger M, Dudley D, Saade G, Stoll B . “ Work-up of stillbirth: a review of the evidence”.. Am J Obstet Gynecol. 2007;196 (5): 433–4444. Choudhary A, Vineeta GuptaV. “ Epidemiology of Intrauterine Fetal Deaths: A Study In Tertiary Referral Centre In Uttarakhand IOSR”. Journal of Dental and Medical Sciences (IOSR-JDMS) 2014; 13( 3 ): 03-06 5. Huang DY, Usher RH, Kramer MS, Yang H, Morin L, Fretts RC. “Determinants of unexplained ante-partum fetal death”. JObstet Gynaecol 2000; 95: 215-221.6. Singh N, Pandey K, Gupta N, Arya AK , Pratap C,Naik R: “A retrospective study of 296 cases of intra uterine fetal deaths at a tertiary care center in Kanpur, India”. Int J Reprod Contracept Obstet Gynecol 2013, (2):141-1467. Lamia A. Shaaban LA, Al-Saleh RA, Alwafi BM , Al-Raddad RMi. “Associated risk factors with ante-partum intra-uterine fetal death”. Saudi Med J 2006; 27 (1): 76-798. Sharma S, Sidhu H, and Kaur S. “Analytical study of intrauterine fetal death cases and associated maternal conditions”. Int J Appl Basic Med Res. 2016 Jan-Mar; 6(1): 11–13.9. Roxanne Beauclair R, Petro G and Myer L . “The association between timing of initiation of antenatal care and stillbirths: a retrospective cohort study of pregnant women in Cape Town, South Africa “. BMC Pregnancy and Childbirth 2014; 14:204

Conflict of InterestAll the participants of this research declare no conflict of interest.

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10. Yakoob MY, Lawn JE, Darmstadt GL, Bhutta ZA: Stillbirths. “Epidemiology, evidence, and priorities for action”. Semin Perinatol 2010 ; 34(6):387–394.11. BerhanY, BerhanA. “A Meta-Analysis of Selected Maternal and Fetal Factors for Perinatal Mortality”. Ethiop J Health Sci. 2014; 24(0 Suppl): 55–68.12. Mutz-Dehbalaie I, Scheier M, Jerabek-Klestil S, Brantner C, Windbichler GH, Leitner H, Egle D, Ramoni A, Oberaigner W . “Perinatal mortality and advanced maternal age”. Gynecol Obstet Invest. 2014;77(1):50-7. 13. Weng YH, Yang CY, Chiu YW. “Risk Assessment of Adverse Birth Outcomes in Relation to Maternal Age”. PLoS One. 2014;9(12):e114843.14. Siddiqui F ,Lucy Kean Intrauterine K. “ Intrauterine fetal death “. Obstetrics, Gynecology and reproductive Medicine . 2008 ; 19:115. Kidron D, Bernheim J, Aviram R . “Placental findings contributing to fetal death, a study of 120 stillbirths between 23 and 40 weeks gestation”. Placenta. 2009;30(8):700-4. 16. Unterscheider J, O’Donoghue K, Daly S, Michael P, Geary M, Kennelly MM, et al. “ Fetal growth restriction and the risk of perinatal mortality–case studies from the multicenter PORTO study”. BMC Pregnancy Childbirth. 2014 ;14:63. 17. Gebhardt S, Oberholzer L. “ Elective Delivery at Term after a Previous Unexplained Intra-Uterine Fetal Death: Audit of Delivery Outcome at Tygerberg Hospital, South Africa”. PLoS One. 2015;10(6):e0130254. 18. Allanson ER, Muller M, Pattinson RC . “Causes of perinatal mortality and associated maternal complications in a South African province: challenges in predicting poor outcomes”. BMC Pregnancy Childbirth. 2015; 15:37. 19. Mohamed MS, Zahran KM, Mohamed HS, Galal H, Mustafa AM. “ Pattern of glucose intolerance among pregnant women with unexplained IUFD”. Middle East Fertility Society Journal. 2015; 20, 43–47.

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Awareness of Saudi women about the right to sign the consent for their breast surgery

system. Patients were interviewed and asked who signed the consent for procedure, if the women signed or her guardian signed what was the reason? if husband signed why did he sign .Doctors position who attended , explained and witnessed the consent whether consultant or others were recorded. Results: A total of 124 patients who underwent breast surgery were studied between 2014-2015 at King Abdulaziz University Hospital , King Faisal Specialty hospital and Baksh private hospital.. Saudi patients were 70.2%, non Saudi were 29.8%. Majority underwent Lumpectomy 37.9% followed by mastectomy 33.1% , and interventional radiological procedures ( like wire localization , biopsy) wire biopsy were 21.8% Patient signed consent in 87.1% of cases, husband in 4.8%, son 4% . Resident attended and signed the form with the patients in 61.3%, registrars in 21.8% , and consultant in 12.1% of cases.Detailed information were collected from the patient and from the person who did signthe consent to clarify the reason behind taking the decision and sign the form of agreement. Husband did not sign in 95.5% of cases, andwhen he took this action it was because doctor asked him to sign in 3.2% of cases ,in 0.8 %of cases because he thought it is his right to sign

Tashkandi H1.,Al-Amoudi S2.,Zaidi NH.1,ElDeek B.3, Kafi S5,Kafi A.4, Sait W.4,Marzouki A4., Bondagji N5.

AbstractBackground: There is misconception that women in Saudi Arabia need their male guardian’s permission to access health care facilities. Women themselves are not all aware of their health rights and the right to sign for their medical and/or surgical procedures.Objectives: The objective of this study is to assess knowledge and awareness of women regarding their rights to consent for their surgical breast surgery procedures.Methods: A cross sectional multicenter prospective study was carried out from 2014-2015 at King Abdulaziz University Hospital , King Faisal Specialty Hospital and Baksh private hospital. The objectives of the study were explained in detail to the patients , and a questionnaire written in Arabic was used to interview female patients who agreed to participate. The following demographic data were collected: nationality, occupation, and education level. Type of surgical procedures ( breast biopsy, lumpectomy, mastectomies , reconstructive procedures) were collected from hospital files and hospital information 40

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or wife condition did not allow her to sign so, he signed in 0.8% of cases.In 75% of cases she signed as she was aware of her right to sign , in 16.6% she signed because doctor asked her to sign , and she signed in 8.3% of cases because her husband was not around . Patient did not sign in 43.7% of cases because doctor did not ask her to sign, and she did not know that it is her right to sign in 37.6% of cases and she was afraid to sign in 6.2% of cases so not to have confrontation with her husband and in 18.7% of cases she was minor under age of 18.Conclusion: There is wide spread notion that Saudi women are not aware of their rights to sign consent for their breast surgeries. Our study shows that majority of Saudi women are well aware of their right to sign consent for their breast surgeries. Health rights and consent in particular call for the strong need to empower all women with knowledge , rules and regulations of ministry of health.

1Department of surgery, Faculty of Medicine, King Abdelaziz University ,Jeddah ,Saudi Arabia 2Health Empowerment and Health Rights Unit, Faculty of Medicine, King Abdulaziz University, Sheikh Mohammed Hussein Al-Amoudi Center of Excellence in Breast Cancer, department of Obstetrics and Gynecology, Faculty of Medicine, King Abdulaziz University, King Abdulaziz University, Jeddah, Saudi Arabia

3Medical Education, Faculty of Medicine, King Abdulaziz University, Faculty of Medicine, Mansoura University, Egypt4Department of Obstetrics and Gynecology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia5Department of Obstetrics and Gynecology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia , health Empowerment and Health Rights Unit, Faculty of Medicine, King Abdulaziz University3Medical Education, Faculty of Medicine, King Abdulaziz University, Faculty of Medicine, Mansoura University, Egypt4Department of Obstetrics and Gynecology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia5Department of Obstetrics and Gynecology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia , health Empowerment and Health Rights Unit, Faculty of Medicine, King Abdulaziz University

*Corresponding author: Email: dr.samia_amoudi@hotmail.com

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Introduction:Medical practice has changed considerably over last decade and more emphasis is given on patient’s confidentiality, patient’s rights of privacy and consent. Informed consent can be verbal or written. A complete informed consent consists of disclosure of information, competence of patient to understand, comprehend nature of situation to make decision and effective communication [1]. Consent form was first used in 1900 for research to control transmission of yellow fever in Cuba [2]. There are evidences that formal consent was used dating back to 17 th century in Arab world [3]. Informed consent is used worldwide for invasive procedures or surgical procedures. In Arab countries there is strong cultural believes and practices regarding gender roles in families. There is misconception that women in Saudi Arabia need male guardian approval for surgery[4] , which is not true as according to Fatwa of Islamic scholars and ministry of health policies and procedures that was issued in 1984., adult sound minded women has the right to consent for herself for medical and surgical issues , breast surgery is one example.[5,6] .The objective of this study was to assess knowledge and awareness of women regarding her right to consent for her surgical breast surgery procedures.Materials and methods:A cross sectional multicenter prospective study was carried out from 2014-2015 at King Abdulaziz University Hospital , King Faisal Specialty Hospital and Baksh private hospital. The study was approved by the Biomedical Research Ethical

Committee at the Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia and king FaisalSpecialty hospital . The objectivesof the study were explained in detail to the patients , and a questionnaire written in Arabic was used to interview female patients who agreed to participate. The following demographic data were collected: nationality, occupation, and education level. Type of surgical procedures ( breast biopsy, lumpectomy, mastectomies , reconstructive procedures) were collected from hospital files and hospital information system. Patients were interviewed and asked who signed the consent for procedure, If guardian signed what was the reason?, if husband signed why did he sign .Doctors position who attended , explained and witnessed the consent whether consultant or others were recorded. Statistical AnalysesStatistical analysis was performed by a qualified statistician. Results are expressed as numbers and percentages. Significance was considered at P < 0.05. Statistical analyses were conducted using SPSS, version 22 (SPSS, Chicago, IL, USA).

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Results :A total of 124 patients who underwent breast surgery were studied between 2014-2015 at King Abdulaziz University Hospital , King Faisal Specialty hospital and Baksh private hospital.. Saudi patients were 70.2%, non Saudi were 29.8%. Predominant profession was housewife 63.7%, followed by teacher 15.3% . Majority were literate with university degree 45.2%,high school 32.5% and primary school 13.7% .Illiterates were 9.7%(Table - 1). Majority underwent Lumpectomy 37.9% followed by mastectomy 33.1% , and interventional radiological procedures ( like wire localization , biopsy) wire biopsy were 21.8% (Table-2). Patient signed consent in 87.1% of cases, husband in 4.8%, son 4% . Resident attended and signed the form with the patients in 61.3%, registrars in 21.8% , and consultant in 12.1% of cases(Table-3).In (Table-4) more detailed information were collected from the patient and from the person who did sign the consent to clarify the reason behind taking the decision and sign the form of agreement. Husband did not sign in 95.5% of cases, and when he took this action it was because doctor asked him to sign in 3.2% of cases ,in 0.8 % of cases because he thought it is his right to sign or wife condition did not

allow her to sign so, he signed in0.8% of cases.

Patient signed in 75% of cases as she was aware of her right to sign , in 16.6% she signed because doctor asked her to sign , and she signed in 8.3% of cases because her husband was not around .Out of the patient who did not sign the consent , 43.7% of cases did not sign because doctor did not ask her to sign, and she did not know that it is her right to sign in 37.6% of cases and she was afraid to sign in 6.2% of cases so not to have confrontation with her husband and in 18.7% of cases she was minor under age of 18.(Table-4).

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Table -1(Demographic data)

Table (2): Type of procedures

Number Percentage %

Saudi 87 7 0.2 Non Saudi 37 2 9.8

House wife 79 6 3.7 Student 8 6.5 Teacher 19 1 5.3 Doctor 5 4.0 Other Employment 13 1 0.5

Illiterate 12 9 .7 Primary school 17 1 3.7 High school 39 3 2.5 University degree 56 4 5.2

Number Percentage %

Surgical Procedure

Lumpectomy 47 3 7.9

Mastectomy 41 3 3.1

procedure 9 7.3

procedures ( wire

27 2 1.8

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Table (3): (Consent performed)

Valid Number Percentage %

Who signed consent?

Husband 6 4.8 Patient 108 87.1 Mother 1 .8 Son 5 4.0 Daughter's husband 1 .8 Father 1 .8 nephew 2 1.6

Husband 82 6 6.1 Father 11 8 .9 Brother 13 1 0.5 Son 10 8 .1 Mother 5 4 uncle 3 2.4

Grade of H ealth professional w ho s igned consent

Registrar 27 2 1.8 Resident 76 6 1.3 Consultant 15 1 2.1 Nurse 6 4.8

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Table (3): (Consent performed)

Valid Number Percept %

Why did husband sign?

Doctor asked him to sign 4 3.2 Husband thought it is his right to sign 1 0.8

1 0.8 Husband did not sign 118 95.1

She knew it is her right to sign 81 7 5 Husband not available 9 8.3 Doctor asked her to sign 18 1 6.6

sign?

Doctor did not asked her to sign 7 43.7 She did not know that she has right to sign consent 6 37.5

She was afraid to sign 1 6.2 -18 years) 3 18.7

Discussion: Signing an informed consent requires patient to be aware of nature of surgical procedure, it’s need, probable outcomes and expected complications, this is the objective of Health empowerment and why it is important as it helps to provide the correct information that help the patient in taking the right decision. An educated person understands better about need of surgical intervention , any alternate form of treatment and surgical procedure and its complications. So consent should be written in simple language which can be clearlyread by less educated patient[7]. Educated females were aware of breastconservative surgery and they opted for it so majority of them underwentlumpectomy (37.9%) followed by mastectomy.

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Guidance for medical practitioner in SaudiArabia in the form of manual states thatpatients has right to the access of ‘good’ treatment right to give consent for anymedical intervention, right of confidentiality of his / her medical information, and the right to refuse treatment against medical advice[8].Saudi law treats men and women alike in choosing health related issues.So any female patient has same rights to agree or refuse any form of investigation or treatment. In our study we found majority of consents (87.1%) were signed by female patients , remaining 12.9% ofconsents were signed by husband or other family member. This result was not different from a study conducted in 2012 where among patients aged 40–49 years, 85% of the consent forms were signed by the patient herself, however, for the remaining patients, consent forms were signed by male guardians.[9] These figures indicates that until this moment not all female patients are aware of their rights to consent for their own surgeries.

We tried to find out the reasons in these remaining cases that why female patient did not sign consent. Husband signed consent in minority (4.8%)of cases because wife was not in condition to sign, other reason for him to sign was because doctor asked him to sign(3.2%). Husband thought it is his right to sign consent in minority of cases (0.8%).

The Ministry of Health (MOH) issued the Patient’s Bill of Rights in 2006 [5]. The MOH affirms these health rights in its policies and procedures manual and through periodic circulars [6]. In a study conducted by Alghanim, among 242 Saudi physicians and nurses, only 66.1% were aware of the MOH Patients’ Bill of Rights [10]. In another study conducted by Al-Amoudi et al 2017 to assess medical students health rights knowledge at Faculty of Medicine, King AbdulAziz University Saudi Arabia , 42.3% of the students medical students were not aware that a female patient has the right to provide her own consent for surgery[11] .

The other serious point in this study is the fact that the consent was signed by resident in majority of cases 61.3% , while signed by consultant in only 12.1% of cases ( Table 3).This calls for more attention and emphasizing the right of the patients and responsibility of the most senior i.e. the consultant himself to ensure empowering of patients with detailed informed consent.

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Conclusion:There is wide spread notion that Saudi women are not aware of their rights to sign consent for their breast surgeries. Our study shows that majority of Saudi women are well aware of their right to sign consent for their breast surgeries. Health rights and consent in particular call for the strong need to empower all women with knowledge , rules and regulations of ministry of health.

DisclosureThe authors have nothing to disclose regarding this study.

FundingThis is funded by Sheikh Mohammed Hussein Al-Amoudi Center of Excellence in Breast Cancer, King Abdulaziz University, Jeddah, Saudi Arabia

AcknowledgmentSpecial thanks to Nurse Sara Bugshan and Karen Lopez for their assistance during the preparation of this study

References:1. DunnLB, JesteDV. Enhancing informed consent for research and treatment. Neuro psycho pharmacology . 2001;24:595–607.

2. Güereña-Burgueño F. The Centennial of the Yellow Fever Commission and the use of Informed Consent in Medical Research. Salud Publica Mex. 2002;44(2):140-4.

3. Christopoulos P, Falagas ME, Gourzis P, Trompoukis C: Aspects of informed consent in medical practice in the eastern Mediterranean region during the 17th and 18th centuries. World J Surg 2007, 31:1587–1591.

4. Committee on the Elimination of Discrimination Against Women, Fortieth Session 14Jan-1Feb 08, CEDAW/SAU/co/2 Concluding comments of theCommittee on Saudi Arabia. Available from http:/www2.ohchr.org/English

bodies/cedaw/dosc CEDAW.C.SAU.CO.2 en.pdf

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References:

5. General Directorate of Patient Relations Program. Health tips: Patient’s Billof Rights and responsibilities. Ministry of health portal, Kingdom of SaudiArabia. 2010. Available from: http://www.moh.gov.sa/en/healthawarnesseducationalcontent/healthtips/pages/tips-2011-1-29-001.aspx

6. Ministry of Health Circulation no 11/26/84484 on 14th February 2012.

7. DeCosta A, D’Souza N, Krishnan S, Chhabra MS, Shihaam I, Goswami K. Community based trials and informed consent in rural North India. J Med Ethics. 2004;30:318–23.

8. Al-Jarallah JS, Aisha HA, Al-Mazroo Am, Al-Wazzan KA, Al-Zahrani S. In ethics of the medical profession Manual guide for medical practitioners. 2nd ed. Riyadh, Saudi Arabia: Saudi Council for Health Specialties; 2003. Physician’s duties towards patients; pp. 13–21.-Council of Senior Scholars’ Resolution No. 93..

9. Al-Amoudi S. The Right of Saudi Women to Sign for their Health Care in Saudi Arabia, Fact and Fiction. Life Science Journal 2012;9(4) 3143–3146.

10. Alghanim SA. Assessing knowledge of the patient bill of rights in central Saudi Arabia: a survey of primary health care providers and recipients. Ann Saudi Med. 2012;32:151–155. 11. Al-Amoudi S., Al-Harbi A., Al-Sayegh N., Eldeek B., Kafy S., Al-Ahwal M., Bondagji B. Health rights knowledge among medical school students at King Abdulaziz University, Jeddah, Saudi Arabia. PLOS ONE | https://doi.org/10.1371/journal.pone.0176714 May 1, 2017

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Prevalence and Causes of Maternal Mortality from1997-2017 in King Abdulaziz University Hospital, Jeddah, Saudi

ArabiaThe economic, social and psychological burdens of this problem are felt worldwide, with 830 maternal deaths occurring daily due to direct and indirect preventable obstetric causes, despite high underreporting rates, especially in rural andremote areas (3). More than one third of all mortalities occur in India and Nigeria, and over 99% in developing countries.Moreover, maternal mortality is considered the leading cause of death among women of reproductive age (2).Maternal age associated with high gravidity is a risk factor for maternal mortality in developing countries, unlike developed countries, according to the WHO. One in every 180 fifteen-year-old pregnant females in developing countries is expected to die, whereas one in every 4,900 in developed countries is expected to have the same mortality outcome (*). Therefore, maternal mortality ratios not only highlight disparities in medical care between high and low-income countries but also between upper and lower social classes within subpopulations of the same country.A recently published Mexican study concluded that the probability of a maternal death correlates with geographic location, social condition and maternal age, making it possible and a responsibility to identify and label women at risk. Consistent with the previous notion, the Mexican Ministry of Health reported that the states with the worse poverty and Human

Development Index had higher maternal death ratios (10).

Sondos A. Al-Turkistani1,Sumayah A. Al-Moshawah,Murooj M. Al-Ahmadi,Abeer A. Samman, Mai D. Al-Nufaei,Amro M Al-Hibshi,Samera F Al-Basri2,Talal Bakhsh.

King Abdulaziz University Hospital,

Introduction. Maternal mortality is a vital indicator of not only the efficacy of the health care provided in a particular region, but also the accessibility of quality healthcare to patients on all rungs of the social ladder (1). According to the World Health Organization (WHO), “Maternal mortality is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.”

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A 3-year study conducted in Saudi Arabia in 1995 found the risk of maternal mortality was higher among grand multiparous (>7), under-educated, economically underprivileged and un-booked (first time visitor to that particular hospital) mothers (6) thereby emphasizing the need for physicians (decision-makers) to acquire skills to identify and treat women at risk.Over the past 20 years, causes of maternal mortality worldwide have changed due to advancements in maternal care, accessible and safe abortion measures and the introduction of broad-spectrum antibiotics. The WHO (13) identified severe hemorrhage, infection, hypertension and unsafe abortions as leading causes of maternal mortality. A study conducted between 1980 and 1999 in a fellow-developing country, namely Ethiopia, reported that the top leading causes of maternal deaths among Ethiopian mothers, in decreasing order, were abortion-related complications (31%), obstructed labor and uterine rupture (29%), sepsis and infection (21%) and hemorrhage (12%) (5). A later Saudi study reported that the top causes of maternal deaths varied among hemorrhage, pulmonary embolism and uterine rupture (6).

Hemorrhage and high blood pressure have been identified as leading causes of maternal mortality worldwide. The afore mentioned causes of infection, unsafe abortions and obstructed labor also contribute to the total number of maternal deaths (4).

The United Nations launched the Fifth United Nations Millennium Development Goal (MDG), to improve maternal health as

an international priority in 2002, with the aim of reducing maternal mortality by 75% between2005 and 2015. Although these goals have not been met completely, substantial progress has been achieved. A 45% global decrease in the incidence of maternal mortality was reported in 2015, which was equivalent to a decrease from 380 maternal deaths to 210 per 100,000 live births (7) representing a 2.3% decline per year (13).

The WHO reported a decrease in Saudi Arabia’s annual rate of maternal deaths by 5.5 %, which has been estimated to be a 73.9% reduction in rates over the same period. This reduction represents a substantial decrease with respect to the reduction rates in neighboring countries, such as Kuwait, Bahrain, Qatar, the UAE and Egypt, with 42.9%, 42.3%, 55%, 64% and 45%, respectively, similar to the previously mentioned global rate of reduction (8).Nevertheless, maternal mortality rates remain high and the MDG is a global challenge that will be achieved only if it is addressed with solutions based on empirical evidence of the extent and significance of this problem. This study aimed to provide physicians, decision makers and stakeholders with knowledge of the prevalence of maternal mortality and itsleading causes over the last 20 years andto update of the status of KingAbdulaziz University Hospital(KAUH) with respect tomaternal mortality and itscontributions to the reductionand prevention of maternal deaths.

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MethodsThis study was a retrospective chart review of patient

records conducted at KAUH in Jeddah, Saudi Arabia, which includedall maternal deaths between January 1997 and December 2017,and excluded accidental and incidental deaths. After obtaining ethical approval from the

KAUH institutional review board, the team thoroughly examined all mortalitylists between 1997 and 2017to identify maternal deaths.Data on 30 patients were retrieved from patients’ records and were thoroughlyreviewed and analyzed. The data included, but were not limited to, age, ethnicity,

parity, gestational age, booking status, whether the patient was considered a highrisk pregnancy or not, whether the age of the patient was considered medically

advanced or not, the presence of pregnancy-related diseases and the direct cause of death.

Data were analyzed using SPSS 16.0 (SPSS Inc., Chicago, IL, USA). The results are expressed as means, medians and ranges for quantitative variables, and as percentages and charts for categorical variables. Associations between variables were analyzed using the t-test and a p-value less than 0.05 was considered statistically significant.

Results and Discussion. This section presents study study’s findings regarding the performance of KAUH over the past 20-years and its contributions to achieving the MDG.

Table 1. Demographic and medical characteristics of the patients in this study (N = 30)

Age.

Minimum M aximum M ean

19 5 1

Advanced maternal age.

Yes N (%)

40% 60%

Ethnicity. (in descending order)

Saudi N on- Saudi

2 0 % 80 %

Somali 8 (26.70%)

Saudi 6 (20.00%)

Chadian 4 (13.30%)

Yemeni 4 (13.30%)

Filipino 2 (6.70%)

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Burmese 2 (6.70%)

Nigerian 1 (3.30%)

Sudanese 1 (3.30%)

Pakistani 1 (3.30%)

Ethiopian 1 (3.30%)

Gravidity.

Minimum Maximum Mean % of GMP

2 13 5.3

Medical history.

High Risk No risk Missing data

19 (63.30%) 7 (23.30%) 4 (13.30%)

Presentation status.

Hb <10 mg/dL >10 mg/dL Missing data

12 (40.00%) 12 (40.00%) 6 (20.00%)

BP Abnormal < 110 mmHg >140 mmHg Mean Missing data

63% 10

Patients

9

patients

120.54

mmHg

5

patients

Length of hospital stay.

Minimum Maximum Mean

Same day as admission 179 days 13.6 days

Years of deaths.

Minimum Maximum

1997, 2000, 2003, 2006, 2009, 2016 2008, 2013

0 deaths recorded 4 deaths recorded

Months of deaths.

January 2 (6.70%) Moharram 0

February 1 (3.30%) Safar 1 (3.30%)

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March 2 (6.70%) Rabea’ 1 2 (6.70%)

April 2 (6.70%) Rabea’ 2 0

May 3 (10.00%) Jamad 1 5(16.70%)

June 1 (3.30%) Jamad 2 0

July 2 (6.70%) Rajab 2 (6.70%)

August 6 (20.00%) Sha’aban 2 (6.70%)

September 3 (10.00%) Ramadan 4 (13.30%)

October 1 (3.30%) Shawal 4 (13.30%)

November 5 (16.70%) Dhul Qidah 4 (13.30%)

December 2 (6.70%) Dhul Hijjah 6 (20.00%)

-call hours. O n-call hours 1 2 (40.00%) 1 8 (60.00%) Mode of delivery. Vaginal C esarean

11(36.66%) E mergency

2 (6.66%) 7 (23.33%) 11(36.66%)

Cause of death. Pre-eclampsia 11(36.66%) Sepsis 5 (16.66%) Hemorrhage 5(16.66%) 3 (10.00%) 2(6.66%) Embolism 2(6.66%) Liver disease 1 (3.33%)

GMP = grand multiparity; Daytime versus on-call hours refers to

1. Patients’ demographic characteristics. 1.1 Age.

The minimum age recorded was 19 years and the maximum were 51 years, with no extreme values

More than three quarters of the mothers were20–40 years of age; 63% were older than 30

years and 40%

Figure 1.1: Advance maternal age patients.

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were, by definition, cases of advanced maternal age (35 years of age or older).These results do not fully support the notion that advanced maternal age per-se) as defined medically) is a risk factor for maternal mortality.

1.2 Ethnicity and race.Eighty percent of maternal deaths that occurred in KAUH throughout the study period were among non-Saudi mothers. This rate is supported by estimated population statistics released at one point during the study (2010) from the Central Department of Statistics and Information. The estimates showed that more than half of the residents of Jeddah City were non-Saudis (1,833,525 vs. 1,917,416). (16)

Figure 1.2 illustrates the different nationalities encountered in this study; therefore, it is necessary to mention that 8 out of 30 (26.7%) patients were of Somali nationality, putting the Somali race at the top of the list of deceased mothers in KAUH. This result, to some extent, is no surprise given the high percentage of Somalis residing in Jeddah City (at least among the top three subpopulations in the city) and the high number of illegal residents among them (almost 80%).Patients of Saudi nationality were second to Somalis, comprising 6 out of the 30 patients.Chadian and Yemeni mothers came in third place, comprising 13% each, of the total number of maternal deaths. The remaining 16 patients had a variety of other nationalities and had different ethnicities. Previous results indicate that the majority of deaths

were among non-Saudi women, which is consistentwith global conclusions, as non-Saudis in the

Kingdom of Saudi Arabia (KSA)aregenerally from a lower socio-economic

group than are Saudis.

Moreover, most of the individuals from these subpopulations are illegal immigrants, which narrows their choices of healthcare to private primary healthcare centers that provide low-quality care. (reference)In addition to the previously mentioned characteristics of non-Saudi subpopulations, Somali female should extremely humble jobs either as housemaids or as wives of domestic workers. (reference) They also reside in crowded and poorer areas of Jeddah, with quality resources being a luxury due to the large numbers of illegals.

Another factor that should be taken into consideration is the popular nutrient-poor high-fat and high-carbohydrate diet of Somalis, including tea with refined sugar as a staple of their traditional daily diet, which could be a major risk factor contributing to maternal morbidity. (17)It is not surprising that all three countries-of-origin are third-world developing countries that have very low Human Developing Indices (e.g., Somalia’s GNPs= 0.285,US$600 ranking it 165 out of 170 countries).The progress towards fulfilling MDG 5A in these three countries of origin are rated in the 2015 WHO report as either completely lacking or insufficient. Changes in the annual maternal mortality rates in Somalia, Chad and Yemen are extremely small or zero. Maternal mortality among these subpopulations in the KSA seemed to be influenced by layers of riskfactors previously mentioned:race, under-education, low socio-economic status

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morbidity before pregnancy, young age atmarriage, high parity and in the case of Somaliwomen, being from the second worst countryfor women worldwide, where violence and assaultare deeply embedded in the culture. (14)

Health insurance for non-Saudi residents became mandatory in 2010(15), but illegal immigration prevents the receipt of health care and is a barrier for physicians with good intentions in the emergency department (ED).

2. Patients’ past medical history. 2.1 Gravidity and parity.None of the patients died during or as a complication of her first pregnancy. Comment: The minimum gravidity of the involved mothers was 2and the maximum was 13, with a mean of 5.3, which, by definition, is grand multiparity (parity of 4 or more), a high-risk condition seen regularly among Middle Eastern and African females(18).2.2 Medical history.Of the 30 deaths, 63.3% were among women identified

in hindsight as having a high-riskpregnancy, with one of the following risk

factors:1(extreme age), 2(previouslyknown to have a non-pregnancy

related diseases ,e.g., systemic lupuserythematosus, diabetes mellitus,

or chronic liver disease), 3(havingapregnancy-related morbidity, e.g.eclampsia toxemia(PET) or gestational diabetes mellitus or as in the case of one patient, 4(multiple gestation).Although most of these women could have been identified and managed earlier in their pregnancies, why they were not remains an agonizing question.

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3. Patient presentation and hospital stay.

3.1 Presentation status.Based on the patients’ general examination on presentation to the ED, and the residents’ notes, over 50% were evaluated as sick with an ill appearance, indicating a late presentation and little or no health education of patients and their families or multiple visits to the ED ending in refused admissions, or both.

3.2 Hemoglobin and BP on admission. Figure 3.1 shows an equal distribution of patients’ Hb below and above 10mg/dl. A decrease in Hb during pregnancy is not only inversely related to birth and placental weight (12) but it also is not a favorable baseline with respect to hemorrhage, which is a common cause of maternal mortality.

Abnormal systolic blood pressure (less than 110 and more than 140 mmHg) was recorded for 63% of the patients upon admission, which is another indicator of how critically late patients tended to present.

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Figure 4.1: Displays the number of mortalities per year, showing 2008 and 2013 as the years with most deaths.

3.3 Length of hospital stay.Length of hospital stay was, on average, 13.6 days; some women died

on the same day they were admitted and one passed away 174 days afteradmission. The latter patient was a “36-year-old Sudanese un-booked female,

G13 P9 +3, unknown gestational age, known case of diabetes and hypertension,unknown whether controlled or not, presented on February 3, 2002 to a secondary

hospital and underwent an emergency lower caesarian section for an unmentionedindication, post-CS the patient arrested, documents suggest an overdose of anesthetic

was the cause, CPR was done for an undefined period of time; patient presented toKAUH on 5th of February in a vegetative state, intubated and on NG tube. On the 18th of

February and for an undocumented reason, ‘a pelvic ultrasound was performed and showed: an enlarged bulky uterus with deviation to the right side. A collection of fluid was seen posterior to the abdominal wall occupying the left aspect of the pelvis and ovaries were not seen in the pouch of Douglas.’

4. Times and years of deaths.4.1 Maternal deaths in relation to pregnancy periods.Similar to international findings, most of the maternal deaths occurred in the postpartum period, followed by the pre-natal period and during delivery with only 1 recorded death. Comment:

4.2 Years with the highest numbers of deaths.

One explanation for the higher number of deaths in 2008was the globaleconomic recession and inflation in Saudi Arabia. Between 2007 and2008, the inflation rate exceeded the rates of the previous 4-year period,between 2002 and 2006. Therefore, it is possible that people in the lower social lass turned away from their usually accessible low-quality health-care providersbecause they were part of the private sector, to a tertiary governmenthealthcare organization.

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This was possible only when patients presented in the ED the late stage of pregnancy and incritical condition due to restrictions on treating non-Saudi patients. The inability to provide resources meant that a patient had to wait at home until her medical condition deteriorated to a critical and unstable conditioner in some cases, near death.

In 2013, a legislative ruling prohibited hospitals from admitting non-Saudi patients and because the hospitals under the Ministry of Education, such as KAUH, were easier to access, a larger number of patients sought treatment there.

Similarly, a vicious cycle of waiting until one’s medical condition deteriorated to a critical state was mandatory before presenting to the ED. It is possible the women presented to the ER multiple times in better condition than that on admission, and that they showed no indications of a critical medical condition requiring lifesaving interventions. However, we have no evidence of whether this triage system-maintained records documenting this trend.

4.3 Months with the highest numbers of deaths.More than 40% of maternal deaths occurred during the months of August and November, and 56% occurred in the last 5 months of the year, beginning in August. This was after no deaths were recorded in July, which also was the only month of the year with no deaths over the past 20 years.

Similarly, according to the Hijri Calendar, approximately60% of the maternal deaths occurred in the final third of the year (Ramadan–Dul Hijjah). The highest number of deaths was recorded during the month of the Hajj, when pilgrims are abundant, and Jeddah and Makkah City are exceptionally busy. The proximity of KAUH to the highway leading to Makkah raises the question of whether the Hajj should be considered a risky time for expectant mothers.

Moreover, resident’s promotion examinations are administered during the end of the year and there is an influx of new (junior) residents beginning their rotation son the wards in October of each year. This information be generated question: Should the final months of each year be managed with more caution and recommendations regarding maternal care?Figure 7.1 : proportions of causes of mortality in KAUH over the past 20

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4.4 On-call shifts. The on-call shift on the wards in KAUH begins at 4PM and ends at 8AM, and 60% of the deaths occurred during that period. Therefore, highlighting these hours as a period to exert more caution with critical patients should be considered.

5. Mode of delivery.Spontaneous vaginal deliveries and C-sections were recorded in equal numbers (11 patients each). Seven C-sections were performed in emergency-care settings and 2 elective C-sections in the settings that were selected when they were planned.

6. Fetal outcomes.Fetal outcomes ranged between live births and deaths with almost equal percentages. Two of the 30 women had molar pregnancies.

7. Causes and patterns of deaths over the years.

7.1 Causes of maternal mortality.Pre-eclampsia and its complications were the most common cause of maternal mortality, comprising 36.7% of all deaths recorded in KAUH. In contrast, global studies show hemorrhage is the leading cause of maternal deaths in both developed and developing countries. Comment: Both sepsis and hemorrhage followed pre-eclampsia as the second leading cause in KAUH, with each responsible for 16.7% of all maternal deaths. Other causes included abortion, embolism and gestational trophoblastic disease (Figure7.1).

Figure 7.2: number and percentages of causes of maternal mortality in KAUH over the

past 20 years.

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7.2 Patterns of maternal mortality rates (MMR).

Between 1990 and 2015, the global MMR dropped a significant 44%. According to the 2015 WHO report on maternal mortality, the MMR in Saudi Arabia dropped 73.9% during that same period, with an annual 5.5% decrease in the MMR.

Despite the impressive reduction at the national level, KAUH showed fluctuations in the MMR in 2000–2017, as illustrated in Figure 7.3,compared to that of the KSA as a whole.

Figure 7.3: Blue: KSA progress as published in the WHO 2015 report. Blue: KAUH progress over the same years.

Figure 7.4: MMR / 100,000 in KAUH vs. KSA.

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Conclusions. The following conclusions are presentedwith respect to the previouslymentioned discussion points:

a. Although this study found no significant relationship between advanced maternal age and maternal mortality, mothers older than 30 years suffered more pregnancy, labor and delivery-related complications. The fact that not one case was a primigravida patient can be explained by the fact that the cases seen in tertiary care centers tend to be more complex/complicated. Somali, Chadian and Yemeni patients, due to different genetic and social reasons, were highest on the list of maternal deaths in KAUH, indicating a strong association between socioeconomic status and mortality.

b. Deceased mothers might have been easily identified as high-risk pregnancies for many reasons, such as age, morbidities prior to pregnancy and pregnancy-related morbidities. Correct identification and diagnosis is vital for prioritizing such patients and further follow-up.

c. Another conclusion is that most of the maternal deaths were among women who presented to the ED in a critically ill state, with low hemoglobin and abnormal blood pressure.

d. Maternal mortality is a product of several intertwined factors: eventful years, certain

months of the year and certain hours of the day, when larger

numbers of deaths occur than at other times.

e. Consistent with globalpatterns, the highest risk is during the postpartum period. In contrast to global results, hypertension and its complications are most often recorded as the cause of death, followed by sepsis and hemorrhage (2).

f. Spontaneous vaginal delivery is, in most cases, a natural ending of a pregnancy. C-sections were encountered as often as spontaneous vaginal deliveries in critical settings associated with maternal mortality, with most of them occurring as an emergency C-section.

g. Fetal outcomes were equally divided between deaths and live births.

h. KAUH was found to have an inconsistent MMR pattern, ranging from 0 deaths in one year to a striking 4 deaths in another year, possibly indicating unpredictable progress, which is worrisome. Details on the numbers of deaths per year are presented in Figure a1.

Limitations.This study was conducted in the KAUH environment with the hope providing a clear map of where we stand regarding maternal health. The limitations of this study are:

1-Missing data due to theconversion of old paper files

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to electronic medical records.2-Missing data due to 2009 floods and theloss of valuable documents, which mighthave been important to this study.3-Inadequate use of ICD codes and poor documentation of cases.4-Inability to track the number of times a single patient visited the ED without passing through triage.

Recommendations.Favoring patients:

- Pre-eclampsia, hemorrhage and infection were found to be the leading causes of maternal mortality in the KSA and KAUH; therefore, anemia and PET during pregnancy should be taken seriously and treated. Infections should also be anticipated.

- Specific protocols for PET should be developed.

- High-risk pregnancies should be identified correctly and prioritized for treatment.

Favoring health systems:

- Inclusive and comprehensive documentation of all cases will not only help on an institutional level,

but on a national level as well, to customize our data and tackle our own priority issues.

Favoring the national interest:

- We strongly recommend prioritizing maternal health in all healthcare centers by promoting maternal access to adequatehealthcare regardless of age, nationality andsocioeconomic status.

- Physicians and other healthcare providers should advocate for all members of society and promote health education when dealing with them.

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