VOLUME 10 | ISSUE 5 | SEPTEMBER 1990

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Evaluation of Newborn Care in the Kingdom of Saudi Arabia: A First Step Toward Regionalization of Perinatal Care

Abdulatif Al-Faraidy, MD, Facharzt; Adekunle Dawodu, FRCP(E); Gady Magbool, MD, Facharzt; Khalid Al-Umran, CABP; Gunes Ozdural, MSC

From the Department of Paediatrics and Community Medicine, College of Medicine and Medical Sciences. King Faisal University, Dammam; Presented in part at the “International Symposium on Neonatal Intensive Care” held at Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia, January 29-30,1989.

How to cite this article:

A Al-Faraidy, A Dawodu, G Magbool, K Al-Umran, G Ozdural, Evaluation of Newborn Care in the Kingdom of Saudi Arabia: A First Step Toward Regionalization of Perinatal Care. 1990; 10(5): 558-563

DOI: 10.5144/0256-4947.1990.558

Abstract

The newborn care facilities, policies, and patient load in the perinatal care centers (PNCCs) in Saudi Arabia were assessed in 1985 as a first step toward providing data that would be needed in formulating plans for the optimal regionalization of perinatal care. A total of 110 PNCCs based in 52 towns and villages were surveyed using on-site evaluation. The Ministry of Health, with 60 (55%) of the 110 PNCCs, is the major health care provider, while 33 (30%) belong to private organizations. The Armed Forces, universities, and other government agencies account for 17 (15%). There was an annual total of 212,048 live births in the PNCCs. Except for variability in the distribution of Level III centers, there was good correlation between the number of live births per year and the number of PNCCs in the different parts of the Kingdom. Few of the Level III centers provide outreaching educational programs or assist in neonatal transportation. A shortage of medical and nursing staff for neonatal care was found. The importance of the data for regionalization of perinatal care in the Kingdom is highlighted.

Over the last two decades, the Kingdom of Saudi Arabia has experienced tremendous development in many areas, including that of health care. Perinatal and neonatal health care have been part of this general trend toward development and improvement. Optimal utilization of neonatal care resources requires appropriate coordination between the available neonatal health care facilities. The objective of such coordinated care is to provide appropriate health care for every newborn infant, according to the severity of illness, in order to reduce perinatal and neonatal morbidity and mortality. Many of the neonatal care units in the Kingdom are currently providing services ranging from Level I to Level III, without any clearly coordinated approach.¹ Thus, organized communication and back-up support between the various neonatal care units are missing in most cases. This is reflected in the wide variation of perinatal and neonatal statistics from various units in the Kingdom^2,3 and can lead to unnecessarily large numbers of neonatal deaths and neurological defects among survivors.

There is a need for a model to coordinate existing neonatal health care facilities in the Kingdom, with the objective of better utilization of available resources. Good examples of such a model are the regionalized perinatal health care services of North America and some European countries, where hospitals with perinatal care facilities in a specified region are classified into three levels, I to III, each with defined functions and responsibilities.⁴ Good communication and support between the various levels of centers, plus adequate transportation services, will assure smooth continuity of patient care and improve pregnancy outcome.⁵

Considering the geography and demography of Saudi Arabia, and the current situation of neonatal health care, development of a program of regional perinatal health care would improve the outcome of pregnancy through better utilization of available resources. The fundamental steps of a program of regionalization would include a planning phase, followed by an implementation phase.

Components of the planning phase would include: (1) regional surveys to ascertain demography, geography, climate, and the relation of obstetric and pediatric units to existing hospitals; (2) assessment of available perinatal care facilities with regard to number of beds, equipment, manpower, and physical facilities; (3) planning for the effective regional administration of perinatal care services; (4) organization of lines of communication; and (5) organization of transportation services.

The implementation phase would require specific operational objectives which should include correction of identified deficiencies to improve the quality of care, formulation of criteria for transfer within a region, and development of support systems for consultation, laboratory services, educational programs, and transportation. The implementation phase should also include continuous assessment and review of the program.

Applying this scheme for a regionalized system of perinatal care, we conducted a national survey of neonatal resources and patient loads in the Kingdom during 1985. We present some of the data from this national study which can serve as a foundation for a realistic regionalization plan for the Kingdom.

Methods

All neonatal care units in the Kingdom were surveyed as to physical facilities, equipment, staffing, policies, and other relevant variables, including hospital births, by means of an extensive questionnaire¹ with more than 600 items. This questionnaire was completed by trained surveyors onsite in each facility. Each neonatal care unit was then designated as providing one of three levels of care.⁴

Level III perinatal care facilities are referral centers, frequently teaching hospitals, that serve as back-up for linked Level I and II facilities. All pregnancy and neonatal disorders are managed in Level III facilities. These centers should therefore provide transportation for sick newborns as well as outreaching educational programs. Research and participation in regional perinatal organization are other important functions of Level III centers.

Level II centers are large community hospitals that deal with most disorders of the newborn and in some cases can manage those treated in Level III centers. The availability and geographic location of Level III centers in a region are factors that influence the resources available in Level II units.

Level I centers deal only with normal deliveries and newborns, and refer high-risk obstetric patients to Level II and III centers, but should be staffed and equipped to handle unexpected emergencies, such as immediate resuscitation.

To determine the location, administration, and type of care provided by the institutions surveyed, we assessed the distribution of hospitals by region, organization, and level of neonatal care. Similarly the regional distribution of annual hospital deliveries, manpower resources, and physical facilities was determined to assess patient loads and resources.

With the Kingdom’s estimated population of 10 million and crude birth rate of 45.9 per 1000 population,⁶ the expected number of total births for each region was calculated and the percentage of out-of-hospital births was estimated. The available manpower and physical resources found in each region were also compared with data published.⁴

Results

In the eleven regions of the Kingdom, as classified by the Ministry of Health, there were 110 hospitals or medical centers providing neonatal care in 52 towns and villages. All are well connected by modern roads and highways. Air routes also connect most of these towns and villages (Figure 1).

Sixty hospitals (55%) of the 110 neonatal care facilities are Ministry of Health hospitals. Other important health care providers in the Kingdom include the armed forces hospitals (military, National Guard, Security Forces), which account for 10% of facilities; the private sector, accounting for 30%; and universities and other government agencies, accounting for 5% (Table 1). According to the level of perinatal care provided, 16 hospitals were classified as Level III, 75 as Level II, and 19 as Level I. Only four of the 60 Ministry of Health hospitals were classified as Level III, whereas six of the eleven armed forces hospitals provide Level III care.

Survey of the regional distribution of perinatal facilities revealed that five regions lack hospitals with Level III neonatal care services, although the overall ratio of the number of such units to total hospital births in the Kingdom is satisfactory (Table 2). Important elements, including back-up support and transportation of patients from referring hospitals, outreaching educational programs, and participation in regional perinatal organization, are lacking in most of the Level III hospitals.

Table 1. Levels of neonatal care facilities organization in Saudi Arabia. *

Organization	Level I	Level II	Level III	Total
Ministry of Health	12	44	4	60
Private	7	24	2	33
Armed forces	0	5	6	11
University	0	1	3	4
Government	0	1	1	2
Total	19	75	16	110

* See text for definitions of the three levels of neonatal care facilities.

Table 2. Regional distribution of births and neonatal care facilities in Saudi Arabia.

Region	Live births	Level I	Level II	Level III	Total centers
Riyadh	55,248	8	15	4	27
Mecca	57,765	4	17	5	26
Baha	3,937	0	1	1	2
Medina	23,744	1	7	2	10
Eastern Province	32,779	2	13	2	17
Asir	11,820	0	4	2	6
Najran	2,575	0	2	0	2
Gizan	4,071	1	4	0	5
Gasim	8,063	0	4	0	4
Northern Province	9,009	3	6	0	9
Hail	3,037	0	2	0	2
Total	212,048	19	75	16	110

* See text for definitions of the three levels of neonatal care facilities.

The regional distribution of perinatal care load (population, annual hospital births, estimated total annual births) and resources (hospitals with perinatal care facilities, number of obstetric beds, neonatal special care [NNSC] beds, and number of obstetricians and pediatricians) in Saudi Arabia for the year 1985 are summarized in Table 3. There was good correlation between the population and expected number of live births per year and the distribution of perinatal care centers in different parts of the Kingdom. However, there was an uneven regional distribution of obstetric and NNSC beds. Hospital deliveries constituted only 46% of the estimated total number of deliveries in the Kingdom, with the remainder out of hospital deliveries. The regional distribution of hospital births as a percentage of the estimated total births shows wide variation, ranging from as low as 15% in the Gizan region to as much as 66% in the Riyadh region.

Table 4. Neonatal special care resources in Saudi Arabia in 1985.

Resources	Available	Expected	Percentage of cover
Beds^a	907	846*	100*
		1763†	51†
Neonatologists^b	55	75*	73*
		144†	38†
Residents^c	51	180*	28*
		350†	15†
Nurses	254	432*	58*
	(1:3.5 nurse/pt)	881†	29†
		(1:2 nurse/pt)

* For current hospital deliveries; † for estimated total deliveries.

^aEstimated as 6 NNSC beds/1000 live births; ^bone per 10 NNSC beds; ^cone per 5 NNSC beds.

NNSC = neonatal special care.

The number of NNSC beds available is sufficient for the number of hospital deliveries, but represents only 51% of the number needed for the expected total annual deliveries in the Kingdom (Table 4). The number of residents working in the various neonatal special care units represents only 28% of the number needed for NNSC beds, using the recommended ratio of one resident per five NNSC beds.⁴ Similarly, the number of nurses assigned per shift to the available NNSC beds represents only 58% of the number needed for these beds, based on a ratio of one nurse per two NNSC beds on each shift.⁴

Table 5. Space and equipment facilities in neonatal special care units in Saudi Arabia.

Facility	% Availability or level of adequacy
Phototherapy	92
Cardiopulmonary monitoring	58
Ventilators	49
Oxygen analyzer	45
Transportation equipment	32
Washbasin	60
Space requirement	35
Oxygen outlets	7
Electrical outlets	6
Suction outlets	5
Compressed air outlets	4

* Compared with published recommendations.⁴

Analysis of the space allotted to the intermediate and intensive care areas in the various Level II and Level III neonatal care units showed that only 35% of these units satisfied the space requirements of 4.5 square meters per infant and nine square meters per infant in the neonatal intermediate and intensive care areas, respectively.⁴ Most of the surveyed neonatal care units also lacked the optimum number of electrical, oxygen, compressed air, and suction outlets (Table 5). Oxygen analyzers were used in only 45% of the Level II and III neonatal care facilities.

Discussion

This report assesses the current status of newborn care facilities in Saudi Arabia, which is essential for planning regionalization of perinatal care. The survey revealed that neonatal care facilities are widely distributed throughout the Kingdom, with variable levels of care provided and rapid growth of available facilities. Since completion of our 1985 survey, the number of hospitals providing neonatal health care in Saudi Arabia has increased from 110 to 178, located in 94 (previously 52) towns and villages (Table 6). The Ministry of Health is still the major provider of neonatal health care, but most of the current Level III perinatal care centers are in armed forces and university hospitals. Thus, there is a need for upgrading some Ministry of Health hospitals in some geographical areas and for cooperation among organizations providing perinatal care. This should be part of the problem addressed during the implementation phase of regionalized care.

It is essential to correct deficiencies with respect to physical structure, equipment, and manpower resources in order to improve care and avoid over-centralization. Some of the deficiencies reflect a lack of adequate knowledge of the requirements of neonatal care. It is therefore mandatory to involve neonatologists or pediatricians with knowledge and interest in the care of newborn infants in the planning stage of care facilities, since the later correction of problems, which may require major construction, is difficult in a functioning neonatal intensive care unit.

Live-birth distribution is a fundamental consideration in predicting the volume of patients requiring various levels of care in each region.⁷ There is a relatively high percentage of out-of-hospital deliveries in many regions of the Kingdom, and this should be recognized when calculating the regional perinatal care loads. Other variables, such as low-birth-weight rates, also need to be determined, and a project to do so is in progress.

Since it is not economical or feasible for all PNCCs to provide Level III care, a regionalization plan must be developed that ensures appropriate care is provided, including adequately equipped facilities staffed by well-trained personnel. As reported by other authors,^5,8 this should contribute to a reduction in the observed high perinatal mortality rate of 30.4 per 1000 total births and the neonatal mortality rate of 22.4 per 1000 live births observed during the study period. The next step toward achieving such a goal would be the establishment of regional planning bodies that would determine regional perinatal care needs, taking into consideration the available baseline data provided and addressing some of the problems identified here. These areas for improvement include more efficient transportation and communication facilities.

Acknowledgment

We thank King Abdulaziz City for Science and Technology. Riyadh, for sponsoring this study through Grant AB-6-121.

References

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3. Dawodu AH, Al-Umran K, Al-Faraidy A. Neonatal vital statistics: a 5-year review in Saudi Arabia. Ann Trop Paediatr 1988;8:187-92.

4. Brann AW Jr, Cefalo RC, eds. Guidelines for Perinatal Care. American Academy of Pediatrics, American College of Obstetricians and Gynecologists, 1983.

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6. Demographic Year Book (1983). New York: United Nations, 1985.

7. Swyer PR. The organization of perinatal care with particular reference to the newborn. In: Avery GB, ed. Neonatology, ed 3. Philadelphia: Lippincott, 1987.

8. Pickkala P, Erkkola R, Kero P, et al. Declining perinatal mortality in a region of Finland, 1968-82. Am J Public Health 1985;75:156-60.

9. Bindagji HH. Atlas of the Kingdom of Saudi Arabia. Oxford. England: Oxford University Press, 1980.