International Journal of Epidemiology Vol. 21, No.

1
© International Epidemiotogical Association 1992 Printed in Great Britain

Perinatal Mortality in Jeddah,

Saudia Arabia
WALEED A MILAAT* AND CHARLES DU V FLOREYf

Milaat W A (Department of Community Medicine and Primary Health Care, The Medical School, King Abdulaziz
University, Jeddah, Saudi Arabia) and Florey C du V. Perinatal mortality in Jeddah, Saudi Arabia. International Journal
of Epidemiology 1992; 21: 82-90.
The objective of the study was to estimate the perinatal mortality rate and to determine the antenatal and intrapartum
risk factors associated with perinatal mortality in Jeddah, Saudi Arabia. A hospital-based, case-control study was
carried out in a 40-week period in 1987-1988 in Jeddah at the Maternal and Child Health Hospital (MCH). The subjects

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comprised 323 perinatal deaths and 486 controls.
The perinatal mortality rate (PMR) for Jeddah showed a decline from 42.5 in Islamic Calendar Year 1393H (1973) and
49.5 in 1400H (1979-1980) to 31.4 per 1000 live and stillbirths in 1408H (1987-1988). The risk factors independently
associated with perinatal death included low birth weight, complications during labour, ethnic origin and mother's age
being 35 and over. In addition to lethal deformities, direct causes of perinatal death were related to low birthweight,
mechanical causes, antepartum haemorrhage and neonatal infection. No antenatal care was received by 36.5% of both
cases and controls.
The high mortality and the failure to attend for antenatal care suggest a need for closer surveillance of women
throughout their pregnancies and for improvements in both obstetric services and neonatal management.

Little is known about the risk factors and causes of
death in the perinatal period in many areas of the Arab
World. The World Health Organization estimated the
infant mortality rate for Saudi Arabia in 1987 to be 72
per 1000,' which lies in the midrange of Arab world
rates. The perinatal mortality rate (PMR) is not
routinely recorded in Saudi Arabia, although death
certificates are collected and retained. Causes of
perinatal mortality and their associated risk factors are
not available either as routinely published data or from
specialized studies.
The present study was conducted in Jeddah, the
second city of Saudi Arabia. We estimated the PMR
from deaths recorded in the city for three separate
years to determine the level and to assess the trend over
time. We also obtained baseline data on births and
deaths in the city's major hospital and have identified
the risk factors related to a consecutive series of
perinatal deaths in this hospital.2
MATERIAL AND METHODS
The Perinatal Mortality Rate Estimation
Perinatal deaths defined as stillbirths (deaths from the
28th week of pregnancy) and deaths within the first
week of life, and the total number of livebirths for the
Islamic calendar years of 1393, 1400 and 1408
(4 February 1973 to 24 January 1974, 21 November
1979 to 8 November 1980 and 26 August 1987 to
13 August 1988) were abstracted from the logbooks of
vital events registered in the three governmental
statistical health offices in Jeddah. The PMR for the
city was calculated for these years. No certificates were
available to confirm the logbook entries, nor was it
possible to ascertain whether there had been any
change in registration methods over the 16-year
period. No data were available to distinguish infants of
residents of Jeddah from those who lived elsewhere.
However, since birth registration is essentially
obligatory whereas death registration is not, the
mortality rates are likely to be underestimated.

•Department of Community Medicine and Primary Health Care, The
Medical School, King Abdulaziz University, Jeddah, Saudi Arabia.
tDepartment of Epidemiology and Public Health, University of
Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY,
UK.
Reprint requests to: Dr Waleed Milaat PO Box 984 Jeddah, 21421
Saudi Arabia.
82
The Case-Control Study
The Maternal and Child Hospital (MCH) is the main
hospital in Jeddah. It serves more than 60% of this
sector of the City's population and about 14000
infants are delivered there each year. Maternity ser-
vices for the remainder are provided by two military
 PERINATAL MORTALITY IN JEDDAH, SAUDI ARABIA
hospitals, the University Hospital, two small units of
another Ministry of Health hospital, and some private
hospitals. The MCH has no specific admission policy;
its facilities are available free of charge to all
nationalities and classes, without discrimination and as
a result, the clientele is mostly of middle to low
socioeconomic status. All singleton deaths which
occurred in MCH during the 40 weeks between
October 1987 and August 1988 were recorded and con-
trols were selected from the livebirths.
The case group consisted of all the deliveries which
ended in a stillbirth or early neonatal death (first
7 days) in the hospital in the 40-week study period.
Controls were the first two live vaginal singleton
deliveries at or after 7.00 am each day in the same
period. Mothers who had caesarean sections were
omitted because of the difficulty of interviewing them
under the conditions in the hospital. In the regression
analyses of variables related to labour, bias arising
from the sampling method was minimized by ex-
cluding caesarean cases.
Mothers were interviewed in the hospital by the first
author (WM) using a tested questionnaire and their
files were reviewed for information about biological
and socioeconomic variables, obstetric history, and
details of pregnancy and labour, complications, and
characteristics of their babies. The social class of the
mothers was based on their area of residence. Broad
geographical areas were subjectively defined according
to the local knowledge and experience of WM into
low, middle and high social class.
Data Analysis
The Statistical Package for the Social Sciences
(SPSS-X)3 was used for simple descriptive analyses
comparing cases with controls. GLIM4 was used for
multiple logistic regression analysis to determine
the association of cases with several independent
variables. All significant (P^0.05) variables in the
univariate analyses were included in a regression model
in which perinatal mortality was a binary dependent
variable. By backward elimination, all nonsignificant
independent variables were excluded from the model.
RESULTS
Perinatal Mortality Rate Estimate
The total numbers of births and perinatal deaths in-
creased over the three years 1393H, 1400H and 14O8H,
whereas the PMR was markedly lower in 1408H, the
most recent year studied (Table 1). These rates were
considered indicative rather than exact because of the
nature of the data from which they were calculated (see
Material and Methods).
83
TABLE 1 Perinatal mortality rate" in Jeddah for the Islamic
calendar years 1393 (1973), 1400 (1979-1980), and 1408 (1987-1988)
Year Total births Perinatal Perinatal
deaths mortality rate
per 1000 births
1393 14 214 604 42.5
1400 20411 1010 49.5
1408 39 219 1232 31.4
f o r all births and deaths occurring in Jeddah.
The Case-Control Sample
The sample consisted of the 323 perinatal deaths (132
stillbirths and 191 early neonatal deaths, of which 46
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were delivered by caesarean section) and 486 control
deliveries. The larger number of controls than cases
was intended to increase the power to detect associa-
tions between risk factors and perinatal mortality but
practical difficulties made it impossible to collect the
intended two controls per case. Perinatal deaths over
the study period accounted for 75.5% of total
perinatal deaths in MCH over the year, with an
average of 8.1 deaths per week.
Cases and controls were compared on various pos-
sible risk factors grouped according to whether they
were general maternal characteristics, to do with the
pregnancy itself or to do with the child (Table 2).
Mothers' age, parity and babies' birthweights are given
in subsequent Tables. Because of the possibility of bias
affecting the comparison of cases and controls due to
the exclusion from the controls of mothers who had
caesarean sections, we compared the distributions of
the antenatal variables of the cases delivered vaginally
with those delivered by caesarean section. We were
unable to demonstrate any differences of either
biological or statistical significance between the two
groups, except that those who had had caesarean sec-
tions were more likely to have had previous sections
(P<0.0001). It is thus likely that comparisons of
antenatal variables between cases and controls were
not affected by the way in which the cases and controls
were sampled. The caesarean section rate in MCH was
9.3% based on a labour room logbook survey carried
out as part of this project.2
Factors Related to the Mother
Among the maternal characteristics, only birthplace
differed significantly between the two groups. The
mothers originated from 28 different countries: 30.4%
were of Saudi origin, 25.3% were North Yamani, and
the rest originated from elsewhere (Egyptians [8.5%],
Palestinians [7.3%], Indians and Pakistanis [7.3%],
and South Yamanis [5.1%]).
84 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

TABLE 2 Mean values or dislribulions (numbers) of possible risk factors for perinatal mortality in the case-control study

Risk factor Cases Controls Significance

(n^-486) (P)

Mother
Age 321 ± 485 ±
Mean (SD) 27.3 (6.6) 26.8 (6.0) 0.2 NS
Marriage age 234 ± 484 ±
Mean (SD) 17.1 (3.8) 16.8(3.7) 0.39 NS
Place of birth 323 486
Saudi (ft) 30.0 30.7 0.02*
N Yaman (ft) 20.7 28.4
Others (ft) 49.3 40.9
Education 275 485
Illiterate (ft) 63.7 59.6 0.84 NS
Primary (ft) 13.1 13.8
Intermediate (ft) 7.3 9.9

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Secondary (ft) 9.1 9.9
University (ft) 6.9 6.8
Occupation 313 486
Housewife (ft) 92.7 95.1 0.21 NS
Smoking 222 486
Cigarette (ft) 4.1 2.5 0.41 NS
Shisha (ft) 6.3 7.8
Social class 323 480
High (ft) 20.6 24.9 0.11 NS
Middle (ft) 46.9 41.0
Low (ft) 27.7 31.0
Outside Jeddah (ft) 5.3 3.1
Consanguinity between parents 236 486
First degree (ft) 42.8 41.2 0.09 NS
Second degree (ft) 17.4 12.1
Pregnancy and labour
Gravidity 320 480
1 (ft) 14.7 9.9 0.08 NS
2-4 (ft) 36.9 42.0
5*5 48.4 48.7
History of perinatal death 205 438
previous death (ft) 24.9 10.7 <0.0001"*
Fate of last pregnancy 203 438
Abortion deaths: (ft) 10.8 11.4 0.006**
Perinatal (ft) 8.9 2.7
Late neonatal (ft) 0.5 0.9
Infant (ft) 2.0 0.7
Antenatal care 222 482
No visit (ft) 36.5 36.5 0.23 NS
2-8 visits (ft) 47.3 42.1
>8 visits (ft) 16.2 21.4
Pregnancy complications 205 306
Hypertension 14.6 8.5 0.04*
(>85 mmHg diastolic) (%) 229 484
Bleeding (ft) 22.3 3.3 •CO.0001***
Labour complications 316 486
with complications (ft) 66.2 22.8 <0.0O01*"
Induction 316 486
induced (ft) 29.4 19.8 <0.002**
Child
Sex 322 486
Male (ft) 53.4 49.2 0.27 NS
Gestational age in weeks 261 152
Mean (SD) 32.6 (5.6) 38.3 (2.8) <0.0001***

• 0 . 0 5 > P > 0 . 0 1 **0.01>P>0.001 "V-cO.001 NS Not significant

* Due to missing data, numbers available for each variable were often less than the maximum.
 PERINATAL MORTALITY IN JEDDAH, SAUDI ARABIA
Only 10% of the mothers were smokers of either
cigarettes or Shisha, a traditional water-cooled form
of smoking. Shisha smoking cannot be compared to
regular smoking in terms of frequency or habit but one
shisha could be equated to five cigarettes. Shisha
smoking was more common in the sample than cigar-
ette smoking. There was no significant difference in
the frequency of smoking between cases and controls.
Of the eight factors in Table 2 related to pregnancy
and labour, significant differences were found for six:
history of perinatal death, adverse outcome of last
pregnancy, complications of pregnancy (hypertension
and bleeding) and of labour and the use of induction.
There were also significant differences between the in-
fants' gestational ages, as would be expected, but
85
No age group was significantly more at risk than the
teenagers, although there was a nonsignificant increase
in the odds ratios in the two older groups.
A large proportion of both cases (37%) and controls
(32%) were grand multiparae. All mothers of parity 1
or more had odds ratios for perinatal death of less than
1.0, with those of parity 3 to 5 having significantly
lower mortality than those of parity 0 (Table 4).
Babies of mothers who had a complicated delivery
had 6.6 times the risk of perinatal death (Table 2). The
complications are listed in Table 5.
Attendance for antenatal care was unrelated to
mortality. The proportions having no visit were almost
identical for cases and controls.

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much missing data made this variable unsuitable for
further analysis.
Maternal ages ranged from 14 to 48 years (mean 27
years). Table 3 describes the frequency distribution by
age with the odds ratios of death for each age group.
TABLE 3 Frequency distribution of maternal age for cases and controls
Factors Related to the Infant
No significant difference in sex was noted between the
cases and controls but the frequency of stillborn
females was higher than in female early neonatal
deaths (P«0.05).

Age Cases Controls Total

group Odds 95% confidence
(years ratio interval
No. % cumft No. °h cum^d No. °h

<20 31 9.7 9.7 43 8.9 8.9 74 9.2 1.00

20-24 93 29.0 38.7 138 28.5 37.4 231 28.7 0.94 0.6-1.6
25-29 81 25.2 63.9 141 29.1 66.5 222 27.5 0.80 0.5-1.4
30-34 56 17.4 81.3 101 20.8 87.3 157 19.5 0.77 0.4-1.4
35-39 47 14.6 95.9 53 10.9 98.2 100 12.4 1.23 0.7-2.3
5.40 13 4.1 100.0 9 1.8 100.0 22 2.7 2.00 0.8-5.3

Total 321 485 806

Muting-3 X2 = 7.9on5df, P-0.16

TABLE 4 Frequency distribution of mother's parity for cases and controls

Cases Controls Totals

Parity Odds 95ft confidence
ratio interval
No. % cumft No. % cumft No %

0 54 16.9 16.9 53 10.9 10.9 107 13.3 1.00

1 50 15.6 32.5 77 15.8 26.7 127 15.8 0.64 0.4-1.1
2 43 13.4 46.0 65 13.4 40.1 108 13.4 0.65 0.4-1.1
3 27 8.4 54.4 78 16.0 56.2 105 13.0 0.34 0.2-0.6
4 27 8.4 62.8 57 11.7 67.9 84 10.4 0.47 0.3-0.8
5 24 7.5 70.3 55 11.3 79.2 79 9.8 0.43 0.2-0.9
6 27 8.4 78.8 30 6.2 85.4 57 7.1 0.88 0.5-1.7
7 23 7.2 85.8 25 5.1 90.5 48 6.0 0.90 0.5-1.8
>S 45 14.1 100.0 46 9.5 100.0 91 11.3 0.96 0.5-1.7

Total 320 486 806

rVfcsing-3 x 2 ~25.0 on 8df, P-0.0016

86 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

TABLE 5 Nature and frequency of complications during labour classification,3 and the cause-specific PMR compared
with the rates for Scotland.6 All cause-specific PMR
Complication Cases Controls Total were lower in Scotland, but the most striking contrasts
were found for mechanical causes of death and
Meconium stained liquor 36 50 86 neonatal infection which are still common causes of
Eclamptic fit 6 2 8
Pre-eclampsia 27 17 44
early neonatal death in Jeddah.
Premature ruptured membrane 27 13 40
Scar of previous caesarean 9 13 22
Intrapartum haemorrhage 41 3 44 Regression Analysis
Partial extraction of breach 27 4 31 Only three of the variables significantly related to mor-
Polyhydramnios 16 1 17
Oligohydramnios 2 1 3
tality in the univariate analyses (birthweight, com-
Cord around the neck 5 0 5 plicated delivery and place of birth of the mother) were
Impacted shoulder 5 2 7 found to be significantly related to the outcome in a
Arrived fully dilated regression analysis. These were re-analysed in a model
in the emergency room 5 4 9 to which we added maternal age and parity because of

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Total 206 110
Very preterm babies (28-32 weeks gestation), who
formed 27% of the perinatal deaths, carried a risk of
death 19 times greater than that for fullterm infants.
Preterm babies (32-36 weeks gestation) constituted
70% of the cases compared to 22% in the control
group. Of the perinatal deaths 69% were low birth-
weight (<25OO g), of which 55% were very low birth-
weight infants (<1500g). Only 7% of the controls
were low birth weight (Table 6).
Causes of Perinatal Death
Diagnosis of direct and preceding causes of death in
MCH were not standardized and the registration of
these causes did not follow the ICD codes. Table 7
describes the causes recorded for those perinatal
deaths, grouped according to the extended Aberdeen
their theoretical importance. Three outliers were iden-
316 tified in this model by graphical inspection. They made
very large contributions to the overall deviance and
were well to the right of the rest of the observations.
These were excluded from the model. After exclusion
of the outliers, the model was used for the calculation
of the adjusted odds ratios for each level of the five in-
dependent variables. Table 8 shows the regression
coefficients for each level of these variables and their
corresponding odds ratios compared to the baseline
level of the variable, after allowing for all other in-
dependent variables in the model. It shows that low
birthweight was the most significant factor associated
with perinatal death, followed by complications during
labour, mother's place of birth and being 35 years or
over. Parity was not a significant predictor of perinatal
mortality either overall or at an individual level.
Mother's age was not significant alone, but when com-
bined with the other significant variables it became a
significant predictor itself.

TABLE 6 Frequency distribution of birthweight for cases and controls

Cases Controls Total

Odds 95H confidence

Birthweighl (g) No. It cum^i No. V, cum^i No. V, ratio interval

<1000 47 14.6 14.6 0 0 0 47 5.8 _

1000- 79 24.6 39.2 2 0.4 0.4 81 10 151.4 35-642
1500- 51 15.9 55.1 5 1.0 1.4 56 6.9 39.1 15-104
2000- 45 14.0 69 1 27 5.6 7.0 72 8.9 6.39 4-11
2500- 42 13.1 82.2 161 33.1 40.1 203 25.2 1.00
3000- 32 10.0 92.2 213 43.8 84.0 245 30.4 0.58 0.3-1.0
3500- 15 4.7 96.9 60 12.3 96.3 75 9.3 0.96 0.5-1.8
>4000 10 3.1 100.0 18 3.7 100.0 28 3.5 2.13 0.9-5.0

Total 321 486 807

Missing - 2 x' = 376 on 5df, P<0.0001

 PERINATAL MORTALITY IN JEDDAH, SAUDI ARABIA 87
TABLE 7 Perinatal mortality rales (PNMR) by cause in singleton deliveries in Jeddah (MCH sample) and Scotland, 1988

Jeddah Scotland
Cause of
perinatal death No. PNMR No. % PNMR

Unknown (birthweight <2500g) 67 20.7 6.2 164 30.4 2.5

Trauma/mechanical 60 18.6 5.6 17 3.1 0.3
Congenital anomaly 58 18.0 5.4 115 21.3 1.7
Antepartum haemorrhage 34 10.5 3.2 65 12.0 1.0
Unknown (birthweight >2500 g) 25 7.7 2.3 107 19.8 1.6
Pre-eclampsia 23 7.1 2.1 26 4.8 0.4
Maternal disorder 11 3.4 1.0 23 4.3 0.4
Other causes:
Iso-immunization 1 0.4 0.1 2 0.4 0.0
Antenatal and intranatal infection 7 2.2 0.7 8 1.5 0.1
Neonatal infection 37 11.4 3.5 8 1.5 0.1

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Unclassified conditions 0 - - 5 0.9 0.0

Toul 323 100% 30.1 540 100% 8.3

Total single births for the MCH sample in Jeddah = 10721

Total single births for Scotland = 65 110
Source: Scottish figures from Ref. 6, Tables 7 and A4

TABLE 8 Partial regression coefficients (Beta) for all levels of the independent variables with their corresponding odds ratios (748 observations,
omitting three outliers, 46 caesanan sections and 12 with missing values)

Variable Beta Standard Odds 95% confidence X2 <df)*

estimate error ratio interval

General mean 7.537 5.4650

Mother's place of birth 8.8 (2)
Saudi (baseline)
N. Yaman 0.082 0.3410 1.1 0.56 to 2.12
Other 0.783 0.3022 2.2" 1.21 to 3.96
Birthweight 372.5 (2)
>25OOg (baseline)
1500-2499 g 3.143 0.3042 23.2"' 12.7 to 42.1
<1500g 11.322 5.4540 >>100. • 1.88 to > > 1 0 0
Complication in labour 48.8(1)
No (baseline)
Yes 1.665 0.2460 5.3"* 3.26 to 8.56
Mother's age (years) 8.8 (2)
< 20 (baseline)
20-34 0.908 0.5296 2.5 0.88 to 7.00
>35 1.785 0.6437 6.0** 1.69 to 21.0
Parity 13.9(10)
para 0 (baseline) -0.036 0.4431 1.0 0.40 to 2.30
para 2 -0.501 0.4988 0.6 0.23 to 1.61
para 3 -0.525 0.4785 0.6 0.23 to 1.51
para 4 -0.066 0.5086 0.9 0.35 to 2.54
para 5 -0.943 0.5357 0.4 0.14 to 1.11
para 6 0.456 0.5515 1.6 0.54 to 4.65
para 7 0.309 0.6295 1.4 0.40 to 4.68
para 8 0.787 0.6313 2.2 0.64 to 7.57
para 9 -0.306 0.7969 0.7 0.15 to 3.51
para>10 -0.578 0.7463 0.6 0.13 to 2.42

*The x J values test the significance of the whole composite variable when it is entered last into the model. AD composite variables were significant
predictors of mortality except parity, after allowing for the other variables in the model.
•0.05>P>0.01 •*0.01>/»>0.001 •••P<0.001
88 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
DISCUSSION
Perinatal Mortality Rate in Jeddah
Data related to perinatal death in Jeddah are part of
the civil registration system which monitors vital events
in the population. However, data are not published
from which the PMR can be calculated. Although the
infant mortality rate for Saudi Arabia is published and
is high by Western nations' standards, there was no
way of knowing whether the perinatal mortality in
Jeddah was comparable. To estimate the PMR and its
trend over time we reviewed appropriate registers in
Jeddah to find the number of births and perinatal
deaths. Although the PMR was found to be high, it
decreased by 35% from nearly 50 per 1000 births in
1400H to about 30 in 1408H. Whether this decline was
due to a change in the recording methods of the
registries or reflected a genuine change could not be
ascertained as no suitable data were available.
However a review of the labour-ward logbooks in
MCH for the year 14O8H found2 a perinatal mortality
rate of 40.8. Thus all the evidence suggested that PMR
were high, even if the data on which they were based
were incomplete, and that investigation of possible
reasons might lead to recommendations for change in
ante-and perinatal care.
Two major factors may have influenced perinatal
mortality in opposing directions over the review
period. There has been a rise in the socioeconomic
status of the country as a whole, associated with the
economic boom of the last two decades. This eco-
nomic change may have had the same effect as that ex-
perienced by Japan where the PMR fell dramatically
from 42.6 in 1956 to 18.8 in 1972.7 There has also been
an improvement in the delivery of the maternity and
child health services in Saudi Arabia as a result of
increased health expenditure. The increased budget
of the Ministry of Health, which provides 74% of
hospital beds in Saudi Arabia, from 1.16 billion Saudi
Riyals in 1974 to 10.74 billion in 1984 and the
establishment of specialized maternity and children's
hospitals all over the country are examples of this
improvement.8
On the other hand, changes in population structure
may have adversely influenced the PMR and other
health indices. Expatriates from all over the world
have entered Saudi Arabia in the last two decades and
created major changes in population dynamics and
family patterns. The magnitude and effect of these
changes are not yet known and no data are available
on the socioeconomic and health status of these ex-
patriates. It is believed that they are of middle to low
social class which may affect health status negatively,
since demographic change in a country's population is
known to influence PMR and other health indices.9
Jeddah's PMR is higher than in Western Countries
and this probably reflects the very different distribu-
tion of risk factors in the city. The pattern of child
bearing in Jeddah is exemplified in the MCH findings.
Mothers come from various ethnic groups and social
classes with a large proportion of high gravidity and
older age pregnancies. Early and consanguineous
marriages are also common.
Risk Factors Related to the Mother
Mother's ages covered the complete range of the fertile
period and the proportion of pregnancies in those aged
34 years and older was relatively high (15.4%) com-
pared to the proportion in Western countries (e.g. 6.6%
of all deliveries in Scotland in 198810). This pattern is
not unique to Jeddah and has been observed in other
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Arab countries. A similar picture has been reported
from a recent WHO study in Egypt" in which, of the
urban deliveries, 12% were older mothers.
Antenatal care appeared to have no benefit, although
the high non-attendance rates may have contributed to
this. However, analyses not shown here indicated that
for both cases and controls the frequency of antenatal
and labour complications were not related to receipt of
antenatal care. The apparent ineffectiveness of ante-
natal care to alter the course of pregnancy may be a
reflection of the way in which the care is perceived by
the pregnant population. In the light of the high
perinatal mortality, these findings suggest further in-
vestigation of the sociology and delivery of antenatal
care would be fruitful.
The multiple regression analysis showed that, after
allowing for the other variables in the equation, the
risk of perinatal death was lowest in the offspring of
mothers aged under 20 and that the risk was signifi-
cantly higher for the offspring of mothers aged 35
years and over (P<0.01). This contrasts with the
classical U-shaped association with mother's age12'13 of
high rates for mothers aged less than 20 years and over
30 years, and a low rate for mothers in between. It
seems in the Saudi context that youth conferred an ad-
vantage since the younger the mother the lower the risk
of perinatal death. The same conclusion was reached
by Feldstein14 from British data, after adjusting the
relation between age and perinatal mortality for parity
and social class. Youth by itself was an asset for the
survival of the infant and the U-shaped relationship
between age and perinatal mortality was due mainly to
a combined effect of social class difference and
parity.
The pattern of gravidity in Jeddah is typical for the
Middle East as documented in several studies.15"17 A
wide range of gravidity (up to gravida 19) was ac-
companied by a high overall mean gravidity of 4.8.
 PERINATAL MORTALITY IN JEDDAH, SAUDI ARABIA
The mean for mothers aged at least 40, which essen-
tially encompasses the complete fertile period, was very
high compared to the rates in Western countries—8.6,
compared with Scotland's figure for 1988 of 2.3 for
women aged 45 years.10
Women of parity 1 to 7 had lower odds of peri-
natal death than women in their first pregnancy. The
odds ratio was only above 1 in mothers who had given
birth to at least eight children but the difference was
not significant. The associations of parity and gravid-
ity with perinatal death in MCH are consistent with
other Findings only for the higher rate of perinatal
mortality in the first pregnancy and they do not sup-
port the J-shaped relation of pregnancy order or parity
with perinatal mortality described in many perinatal
mortality surveys.13'18 Both referenced British
studies1318 had only 9% of their mothers with birth
orders of at least five, whereas more than 40% of the
mothers in the MCH were within this category.
The regression analysis showed that mothers of
Saudi and North Yamani origin had similar odds for
perinatal death but for mothers of other ethnic origin
the odds were twice as great. In Britain, whether a
mother was born in the Indian subcontinent or in
Europe has been found to be associated with major
differences in perinatal mortality rate." The dif-
ferences were related to the incidence of congenital
anomalies and difference in diet between these ethnic
groups. The MCH study confirmed the PMR dif-
ference between ethnic groups but could not address
the underlying mechanism.
Consanguinity between parents was common. This
type of marriage was most often seen in Saudi parents,
followed by North Yamanis. Harfouche16 documented
that these consanguineous marriages are associated
with an increase in infant mortality of 5% in the off-
spring because of an increased occurrence of all types
of genetic disorders. Nevertheless, in this study, con-
sanguinity was not associated with any adverse effect
on perinatal mortality. On the other hand, it was
related to birthweight in controls: consanguineous
mothers delivered infants who were 80 g lighter on
average.
Early marriage was also common in this study. The
mean age at marriage was very low (16.8 years) com-
pared to Scotland's mean of 27.3 years.10 Arab
countries as a whole are known to have high rates of
early marriage, a practice related to tradition and
religious beliefs.16
Risk Factors Related to Pregnancy and Labour
Pregnancy complications, especially bleeding and
hypertension, have been documented in many studies
89
20 21
as important risk factors for perinatal mortality. -
In this study, hypertension (>85 mmHg diastolic
pressure recorded by a doctor in the mothers'files)and
bleeding were strongly associated with perinatal death
in the univariate analysis. In the regression analysis,
the complications of pregnancy were no longer signifi-
cant due to their high correlation with the labour com-
plications. Complications during pregnancy were thus
good predictors of who was likely to have problems
during labour and indicated a need for special
monitoring of these women whose children would be
particularly at risk.
Risk Factors Related to the Child
Birthweight and gestation are known to be the major
Downloaded from http://ije.oxfordjournals.org/ at University of Ulster on January 4, 2015
factors associated with perinatal mortality and our
own findings support this. Nevertheless, after con-
trolling for other variables, length of gestation was not
significantly related to outcome when birthweight was
included in the model. This would be expected because
of high correlation between the two. Although low
values of both may be associated with poor outcome,
they are likely to be simply expressions of the result of
stillbirth or premature birth arising from other un-
measured factors.
Causes of Death
The main causes of death described in MCH were
similar to those described in a WHO report for the
Mediterranean region.13 These included low birth-
weight (due both to prematurity and small-for-dates),
birth injuries, anoxia, congenital anomalies and
neonatal infections. The proportion of lethal malfor-
mations as a cause of mortality was lower than the
Scottish figures (Table 7). This is in part due to a
dearth of post-mortem examinations of stillbirths in
the hospital. It is also due to the large numbers of
deaths due to trauma and neonatal infections in the
MCH, both of which depend heavily on obstetric and
neonatal services. Collectively pre-eclampsia, ante-
partum haemorrhage, mechanical causes and neonatal
infections caused 47.69b of all deaths in MCH com-
pared to 21.5% in Scotland for the same year, reflect-
ing Jeddah's higher incidence of the complications of
pregnancy, labour and the neonatal period.
CONCLUSION
In general, the risk factors identified in this study were
consistent with those identified for Western countries.
The main differences were in the high rates of older
age pregnancy and high parity. Excluding lethal con-
genital anomalies, most of the causes recorded for
perinatal death were related to low birthweight and
90 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
pregnancy and labour complications such as ante-
partum haemorrhage, mechanical causes, and early
neonatal problems, particularly neonatal infections.
Antenatal care delivered in MCH was not closely
controlled or standardized and there was no significant
difference between cases and controls in relation to
attendance at the antenatal clinics. Complications were
often detected only late in pregnancy or during labour
because no record was kept for mothers attending the
antenatal clinics. The records were usually given to
mothers during antenatal visits but were often for-
gotten at labour.
We would speculate that more careful and frequent
antenatal care, particularly for high-risk mothers,
might reduce complications during pregnancy. The
association between the complications of labour with
perinatal mortality suggests the need for greater atten-
tion to be paid to the monitoring of complicated
pregnancies and at-risk deliveries during labour. This
is particularly important in the light of the high
mortality rates due to mechanical causes. Although
not tested in this study, it is b'kely that improvement in
neonatal services would also contribute to a reduction
in avoidable perinatal deaths arising from neonatal in-
fection and low birthweight. This descriptive study has
served to raise a number of hypotheses to explain the
high rates of perinatal mortality in Jeddah. These
hypotheses need now to be tested in more detailed
studies.
ACKNOWLEDGEMENTS
We would like to thank all the staff at the Maternity
and Child Hospital who helped so much to make it
possible to collect the data for this study. We would
also like to thank Dr Andrew Boddy of the Social
Paediatric and Obstetric Research Unit, Glasgow,
whose help in the design of the study was invaluable.
We are also indebted to Dr David Taylor of the
Department of Obstetrics and Gynaecology, and to
Mr Simon Ogston of the Department of Epidemiology
and Public Health, Ninewells Hospital and Medical
School, who both gave repeated constructive advice
during the preparation and writing up of Dr Milaat's
PhD thesis.
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