Through the Ministry of Health, Saudi Arabia has developed a comprehensive nation-wide health service. In view of the high fertility rate, antenatal care (ANC) is an essential part of this health service.1 Studies have shown that good maternal child health services can substantially improve child survival.2 It is also associated with favorable outcome and, therefore, the improvement in the health status of both mothers and children.34 Important contributory factors to the utilization of such care apart from its availability and accessibility, are the sociodemographic characteristics of the mother.5 In Saudi Arabia, antenatal care is now widely available in the primary health care system, a familiar setting to the potential consumers.5 A study in Bangladesh has shown that the provision of health services does not guarantee its use since cultural and religious beliefs can interfere with health seeking behavior.6–8 There is, therefore, a need to note the health seeking behavior of the mothers during the antenatal period and during the first two years of life of their children. Studies on the morbidity of children under two in the community are scarce, as most research work has originated from the hospital setting. This study will examine (1) maternal socio-demographic variables that influence the utilization of antenatal care services and the health seeking behavior of mothers in the course of their children's illnesses, and (2) the morbidity pattern of children under two years of age in a two-week period.
MATERIAL AND METHODS
This was a cross-sectional study in Riyadh, the capital of Saudi Arabia in April, 2003. The sampling plan utilized a map of the residential area of Riyadh available at the Ministry of health as a convenient sampling frame. This was randomly divided into areas of household blocks. From this list of areas, a simple random sample of 4 areas was selected. In each of these areas, blocks demarcated by roads were clearly identified and from the list of blocks, a random sample of two blocks was selected from each area. A systematic sample of one in three houses was subsequently selected in the multi-stage random sampling procedure. In each selected house, all mothers with children aged below two years were included in the study.
A structured questionnaire was used for data collection. It sought information on socio-demographic characteristics of the mothers, ante-natal care, child illness in the last two weeks, if the child was seen by a physician, and if the child was admitted into hospital as a result of this illness. Hospital admission was taken as an indication of severe morbidity for the purpose of this study.
Epi-Info statistical software was used for data entry and statistical analysis. A bivariate analysis was carried out to relate socio-demographic variables to antenatal care use and other health- seeking behavior of the mother for her child under two years. Chi square test or one of its derivatives was used as appropriate with p-value set at the 0.05 level.
The demographic characteristics of the mothers in this study in relation to their use of ante-natal care during pregnancy are presented in Table 1. All 446 mothers had one child each under the age of two years. There was an overall high use of antenatal services. The proportion of mothers who had made at least one antenatal visit (ANC) was 96.6%, CI: 95.0% - 98.3% while those with six or more antenatal visits were 80.9%, CI: 77.3%, 84.6%. Only 10 women had delivered at home, giving an overall delivery at modern health facilities as 97.8%: CI: 96.4% - 99.1%. Of the 436 who had delivered in modern health facilities, 63 (14.4%) had delivered in the primary health care centers, while the others, had gone to secondary or tertiary hospitals.
The majority of mothers were older than 30 years. Very few mothers were aged below 20 years of age and they had used the ANC the least (proportion 75%) and had also made the lowest number of antenatal visits (6 or less). The use of antenatal care and a good number of visits were statistically significantly associated with age at the 5% level of probability.
Neither nationality nor occupation of the mothers had statistical significant association with the use of antenatal care, the number of antenatal visits or the place of delivery (p>0.05). However, the education of mothers was statistically significantly associated with use of ANC, the number of ANC visits and the place of delivery. There was a steady increase in the proportion utilizing ANC, having more than six antenatal visits and delivery in a modern health care facility with the rise in the level of education (p<0.001). The mothers who had no formal education had the lowest proportions of these variables as shown in Table 1. The few divorced or widowed mothers had a lower proportion in the use of ANC, attending ANC more than six times and even delivery at modern health facilities as compared to the married ones. Thus, marital status was also statistically significantly associated with these variables. All other maternal variables examined, such as parity and number of hours of work outside the home did not have any statistically significant association with the antenatal variables and place of delivery.
The health seeking behavior of mothers for their children's illnesses in the last two weeks and the percentages of those whose children had actually been admitted to hospital are shown in Table 2. Out of the total sample of mothers, 370 (82.9%) had a child who had suffered from one or more of the common illness episodes in the last two weeks. A high proportion of these mothers (90.5%) had consulted physicians for their children's illnesses, and about 12% reported that their children had been admitted into a modern health care facility as a result of the illness.
Mothers younger than twenty years of age reported the highest proportion of physicians’ consultations (87.5%) although this did not reach the level of significance. They, however, had a statistically significant high proportion of recent admissions to hospitals (p<0.001). More Saudis reported consulting physicians in modern health facilities than non-Saudis (91.5% vs 76.0%) and had higher admissions (13.0% vs 4.0%). These associations were statistically significant (p<0.05).
Physician consultation for a child's illness was also statistically significantly affected by the education of the mother, for illiterate mothers constituted the lowest proportion of women consulting physicians on their children's illness (60%). It was also significantly related to occupation (p<0.001) and the number of hours spent outside the house (p< 0.05).
Hospital admissions of sick children (12.4%), a measure of severe morbidity in this study, was also statistically significantly associated with age, nationality, and occupation (p<0.05). Parity of the mother and the number of hours at work, however, were not statistically significantly associated with hospital admission.
Table 3 shows the commonest illnesses reported by the mothers according to the age and sex distribution of the children. The commonest illness was repeated diarrhea which affected 34.3% of the children. The distribution of diarrhea by age and within each sex group were not statistically significant (p>0.05), but the highest proportion occurred between 7-12 months. There was a statistically significant linear trend in the proportions with fever (33.4%) as the age of child rose (p<0.05). The age differential of fever was statistically significant among females as opposed to males (p<0.05). Ear infections and vomiting (20.4% and 19% respectively) did not show any statistically significant association with age and sex (p>0.05). Allergy and chest infections as manifested by breathing difficulties (16%) statistically significantly increased with age, the lowest proportion being in children aged less than seven months (p<0.05). However, while a significant association was found among males, females did not show any significant trend with age (p>0.05). The frequency distribution of the common illness episodes reported and the proportions who had consulted a physician are shown in Table 4. The highest frequency of illness episodes was diarrhea and fever (34.3% and 33.4% respectively). However, difficulties in breathing, followed closely by ear infection, constituted the two highest prevalences among children of mothers who had sought medical help (94.4% and 93.3% respectively).
The study shows the use of ANC services by a high proportion of women (96.6%). This is higher than was previously reported in Saudi Arabia.1 Eighty one percent of these women had had more than six antenatal visits, a figure that was also higher than had been previously reported.9
Delivery at a modern health care facility was also high, 97.8%, 14.4% of whom had delivered at a primary health care center. These figures are higher than those reported in Al-Baha in 1994.5 This could be explained by the fact that the present sample was from Riyadh, the capital, where supply and utilization of health services was expected to be higher than in other areas. Results, therefore, are not representative of the country as a whole.
The use of ANC services was associated with age, education and marital status. Mothers who were widowed or divorced in the course of their pregnancy used the ANC services the least. This is also similar to what had been found elsewhere.10 Contrary to some previous reports, no significant association was found between nationality, parity, occupation and the number of working hours outside the home and the use of ANC services or the number of antenatal visits.911 Age and education, however, were found to be significantly associated with attendance at ANC, and more than six ANC visits. This is similar to what has been documented elsewhere.1012 Studies show, however, that categorization of women's antenatal care status on the strength of the number of visits masks a wide variation in the quality of care received.13
As regards the health seeking behavior of the mother during a child's recent illness, the study showed that a high proportion (90.5%) of ill children had been brought to the physician in the last two weeks, with a hospital admission rate of 12.4%. The high rate of physician consultation reflects a wide coverage of free hospital care and the high quality of health services.14 Children of young non-working Saudi mothers showed the highest hospital admission rate. This was statistically significant at p<0.05, while illiterate mothers had the lowest physician consultation rate, which was also statistically significant at p<0.001. Similar findings have been reported by other researchers.15 The study shows that the non-working Saudi mother is more likely to bring her child to a physician for consultation. This is expected, in view of the easy access Saudis have to the primary health care services and that in an urban sample such as this it is relatively easy for women to travel independently. Although physician consultation and hospital admission rates were generally high for the total sample, previous studies have shown that seeking medical help greatly affected the child's survival or succumbing to a respiratory illness or diarrhea.16
In the present sample, the highest proportion of illness episodes were diarrhea and fever; the highest proportion among children aged 7-12 months was diarrhea. This is similar to what has been found in other studies.61417 Breathing difficulties increased with age and although constituting the lowest of the illness episodes, was the highest among those who sought medical help, followed closely by ear infection and fever. This is understandable, as such illnesses can be distressing to both child and mother. A similar result had been documented elsewhere.6
Finally, this study highlights the need to have health education programmes that target young and illiterate mothers and those with limited education. These programmes should stress the benefits of regular attendance at ANC and well-baby clinics to mother and child. The proper and timely use of oral rehydration therapy should be taught to vulnerable groups i.e. young and illiterate mothers. Breast feeding as the optimal method of infant feeding should be consistently encouraged by health personnel as well as the media. Furthermore, individual child-doctor visits should be used as opportunities for mass and one to one health education forums on optimal maternal child health. Finally, in addition to monitoring the quantity of ANC received, there should be regular evaluation of health services, particularly antenatal care services and well-baby clinics, in order to guarantee the quality of care provided.
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