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Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 132-137

Pregnancy-related health behavior of Saudi women and key information sources: A clinic-based study

1 Center for Computational Epidemiology and Response Plan, University of North Texas, Denton, Texas, USA
2 Department of Obstetrics and Gynecology, Maternal Fetal Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia

Date of Web Publication1-Oct-2018

Correspondence Address:
Dr. Suhasini Ramisetty-Mikler
Center for Computational Epidemiology and Response Plan, University of North Texas Discovery Park, 3940 N Elm St, Denton, Texas 76207
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_15_18

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Background: Topics concerning preconception, prenatal health, and prenatal care-seeking behavior among Arab women have not been sufficiently addressed. This study focuses on these behaviors in Saudi pregnant women as they relate to birth outcomes. Aims: The aim of the study was to characterize preconception and prenatal health behavior concerning nutrition and physical activity and to identify health information sources that may impact their health literacy. Methods: A sample of 258 pregnant Saudi women recruited from two major hospital clinics in Riyadh were interviewed. Factors affecting folic acid (FA) awareness and consumption were examined individually using logistic regression to generate crude odds ratio (OR) and adjusted OR (AOR). Results: An overwhelming majority (>90%) is aware of significance of FA, however, less than half took supplements preconceptionally or consumed foods rich in FA. Younger (<30 years) women (AOR = 0.43; 95% confidence interval [CI] = 0.19, 0.98; P < 0.05) and women with lower education level (AOR = 0.36; 95% CI = 0.15, 0.89; P < 0.05) are less likely to have heard or known about the role of FA in preventing birth defects (AOR = 0.45; 95% CI = 0.23, 0.88; P < 0.05) and less likely to have knowledge of foods rich in FA (AOR = 0.57; 95% CI = 0.32, 1.0; P < 0.05) compared to college-educated women. Conclusion: The results suggest that awareness of folate importance is high, however, the consumption or supplementation of folate is low. The study findings highlight the need for routine preventative health care and educational opportunities for couples. In particular, younger women and women with lower educational level should be targeted for interventions.

Keywords: Folic acid, health knowledge, preconception, pregnancy, Saudi Arabia

How to cite this article:
Ramisetty-Mikler S, Javed S, Alamri SS, Kalantan S, Kurdi WI. Pregnancy-related health behavior of Saudi women and key information sources: A clinic-based study. Saudi J Health Sci 2018;7:132-7

How to cite this URL:
Ramisetty-Mikler S, Javed S, Alamri SS, Kalantan S, Kurdi WI. Pregnancy-related health behavior of Saudi women and key information sources: A clinic-based study. Saudi J Health Sci [serial online] 2018 [cited 2022 Aug 19];7:132-7. Available from: https://www.saudijhealthsci.org/text.asp?2018/7/2/132/242496

  Introduction Top

Preconception care is effective in reducing maternal hyperglycemia and related congenital malformations and preterm birth.[1] Although preconception stage is considered vital, research addressing the importance of nutrition and physical activity during preconception stage is scant. A recent study[2] reported a high prevalence of neural tube defects (NTDs) and low optimal folic acid (FA) intake among Saudi pregnant women. Studies to investigate knowledge concerning nutrition, vitamin/FA requirement, and preconception lifestyle of Saudi women in the context of preventing adverse child outcomes have not been attempted.

A few studies have emerged on the health of pregnant Saudi women, but not specifically focused on maternal risk factors associated with birth outcomes. For example, second-hand smoke exposure was found to be 31% among pregnant Saudi women that linked to lower birth weight and length. Vitamin D deficiency was noted to cause poor fetal growth.[3] Recent increase of obesity in the Mideast including Saudi Arabia is of a great public health concern.[4] Consequently, the burden of Type-2 diabetes, heart diseases, and stroke is projected to escalate. Obesity among college women (48%) is on the rise and is linked to diet, consumption of aerated beverages, and unhealthy lifestyles.[5],[6] The increasing trend of obesity is also correlated with certain categories of isolated structural birth defects including the nervous system.[6] These studies underscore the need for educating women on healthy lifestyles.[7]

Periconceptional FA supplementation is effective in preventing congenital abnormalities, in particular, NTDs. A survey of women in the Middle East (UAE)[8] found that only 46% of the women heard about FA and only a few (9%) knew its role in preventing birth defects. Only one-half of the respondents took FA supplements in the first trimester.

Information from credible sources is preferable over internet sites or mass media. Health information seeking behavior of Saudi women is rarely studied.[9] This study investigates preconception and prenatal health behavior of Saudi women as it relates to birth outcomes with the following objectives: (a) lifestyle-nutrition and physical activity, (b) knowledge of FA importance and foods rich in FA, and (c) to identify health information sources (physician/nurse, mass media, family).

  Methods Top

An observational cross-sectional study using a questionnaire was performed to fulfill the purpose of this study. The study was approved by the Institutional Review Board at Alfaisal University and King Faisal Specialist Hospital Research Center in Riyadh.

Participants and data collection

Five prenatal clinics that serve native Saudi women in Riyadh, Saudi Arabia, were approached. However, we could obtain approval from two major clinics. Ultimately, our cross-sectional study used adult pregnant women (18+) recruited (2015–2016) from King Faisal Specialist Hospital and Security Forces Military Hospital in Riyadh. A total of 283 mothers were approached and 258 took part. On average, the interview took 24 min (standard deviation [SD] = 3.6; range 15–40).

Survey instrument

Hospital faculty/staff and medical students developed a series of questions to gather information on: ( a) health-care seeking behavior, (b) knowledge concerning nutrition and importance of FA, (c) consumption of foods rich in nutrients (questions adopted from a standard Food Frequency Questionnaires,[10] (d) Physical activity frequency (walking, jogging etc.), (e) health information sources, and (f) sociodemographic variables. Food frequency questions were adopted from a standard questionnaire. The survey was translated from English to Arabic back to English and pilot tested (n = 20) for consistency. Staff examined responses and recommended ways to improve reliability and validity by clarifying the wording of questions, setting recall periods, and identifying response options. Trained female medical students or residents explained the study assuring confidentiality and obtained written consent.

Variables and data analysis

Mother's knowledge on the importance of FA is the main outcome of interest in this study. Independent variables include health care-seeking behavior before and during pregnancy, frequency of food consumption, physical activity level, and demographic factors (primigravida vs. multigravida, age, education, employment status, and income).

Descriptive statistics (means and proportions) for prevalence and bivariate associations between the study variables were conducted using SPSS (IBM SPSS Statistics for Mac, Version 24.0. Armonk, NY: IBM Corp.). Based on the distribution, several variables were regrouped or made into dichotomous. Factors affecting FA awareness were examined individually by computing crude odds ratios (OR) and adjusted (AOR) for other covariates using logistic regression along with 95% confidence intervals (CI) with P = 0.05.

  Results Top


Mean age of the mothers (n = 283) was 31 years (SD = 5.7; range 18–47). All mothers were native Saudis, married (99.6%), and the majority (88%) live with their spouse.

A little over one half (53%) of mothers completed 4-year college or postgraduate and a very few (2%) have a professional degree (e.g., Medicine, engineering, law). Over one-third completed high school (20%) or diploma/certificate (17%) courses; and the rest (11%) did not complete high school. Forty percentage of the mothers were employed outside home mostly as teachers, administrative, computer, and IT jobs. The median household income is 10,000 Saudi Riyals (range 1000–95,000) (Saudi Riyal = $3.75 US).

Prenatal care

The sample constituted one-third first-time mothers. Before the current pregnancy, the majority (84%) sought care when feeling sick and only 48% of the women visited doctor for routine care before pregnancy. The majority (85%) began prenatal care during the first trimester and 15% delayed seeking care beyond the first trimester. A few mothers (17%) reported missing doctor's appointments due to transportation problems, long distance, illness, and being out of town.

Only a third of the women (35%) had routine dental checkups before pregnancy. Forty percentage of the women reported currently having dental problems including cavities, toothache (18.5%), and gum disease (10%). More than one-third (38%) suffering from dental problems did not see a dentist.

Lifestyle: Nutrition and physical activity

Although we have inquired about several food items, we only report on the consumption of foods rich in FA. Nearly 42% of the women consumed meat and seafood, 46% as lacto-ovo vegetarian, 7.2% lacto-vegetarians, and the rest are vegetarians who consume eggs only (4.6%). Nearly 70% consumed between 1 and 4 eggs per week. A great majority (90%) consumed lentils/beans 2+ times a month, green leafy vegetables (81%) and breads (92%) 5+ times a month. Since 1998 when the mandatory FA fortification of cereal grain products in the United States was mandated, NTDs decreased by 35%.[11] Saudi Arabia has no such fortification requirement.

Mothers were asked to report on the type of activity and time spent on specific activities. Before pregnancy, only 38% of the mothers exercised regularly and only a third (32%) engaged in exercise activities during pregnancy. Overall, only 5%–10% of the women reported jogging, running, pilates, and yoga at least once a week or more. Walking at least 30 min at least once a week seems to be more common (34%) compared to other activities (e.g., Pilates, Jazzercise).

Mothers knowledge and awareness of folic acid and other vitamins

Only one-half of the mothers reported taking FA/vitamin supplements (48%) before pregnancy. Mothers' knowledge regarding the importance of FA and prenatal vitamins appears to be high [Figure 1]. However, only half of the mothers tried to consume foods rich in FA and only 78% currently taking vitamin supplements. Of those who took vitamins, more than half (57%) started taking prenatal vitamins by 4th-month of pregnancy. Only a small percentage (7%) did not take vitamins.
Figure 1: Folic acid awareness among Saudi mothers (in percent)

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We also performed logistic regression to estimate odds to examine whether a woman's age (<30 years vs. older than 30 years), education level (high school vs. college education), employment (unemployed vs. employed), and income low (<10,000) versus high (10,000+) to determine their level of FA knowledge. Unadjusted and adjusted (for all four demographic variables in the model) ORs with 95% CI are presented in [Table 1].
Table 1: Socio-demographic factors associated with folic acid knowledge

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Younger women (<30) and those with lower education level are less likely to have heard about FA. Women with lower education level are less likely to know FA importance in preventing birth defects, less likely to know daily requirement, and about foods rich in FA. Women from lower income category are less likely to know about daily FA requirement, less likely attend any preconception health sessions (preconceptual counseling). Doctor or nurse is less likely to discuss about taking FA and its importance in preventing birth defects with women from lower income level.

Contrast between primigravida and multigravida

We also examined if there is a difference in the awareness of FA between first-time mothers and others. Nearly one in five (21%)first time mothers did not hear or read about FA compared to other (5%) mothers (X = 14.6, df = 1, P < 0.001). One half (51%) of the first-time mothers were not aware that some foods rich in FA compared to 38% of mothers who were pregnant before (X = 3.8, df = 1, P = 0.05).

Significantly lower percent of first-time mothers (54%) made an attempt to consume FA-rich foods compared to other (41%) mothers (X = 4.0, df = 1, P = 0.04). A significant difference was also found between the two groups of mothers (X = 5.1, df = 1, P = 0.02) with fewer.

First-time mothers (44% vs. 60%) knowing the daily FA requirement (400–600 mcg), also were not aware (59% vs. 45%) that some foods (e.g., grains, flour, cereals) are enriched with FA (X = 4.6, df = 1, P = 0.03).

A little over two-thirds of first-time mothers (68%) compared to other mothers (49%) did not attend preconception health sessions (X = 8.2, df = 1, P = 0.004).

Health information sources

For most women, physician/nurse are the main source of information concerning health, nutrition, and pregnancy/delivery. Nearly one in three women also turn to mass media and books to seek knowledge while a small percentage consulted friends and family [Figure 2].
Figure 2: Information sources for vitamins and folic acid (in percent)

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Physician, books/media, and family are also the main sources for information related to pregnancy, delivery, and nutrition.

  Discussion Top

In general, the concept of preventative care specific to gynecological health (e.g., routine physical checkups,  Pap smear More Details screening test) is not commonly practiced in Middle Eastern cultures. A major concern that the study points to is general health-care seeking behavior of Saudi women with only half of the women saw a physician for routine health care. All women in the reproductive age should be encouraged to have annual wellness checkup (Pap smear screening test and gynecological examination) which provides an ideal platform to educate women about benefits of FA and multivitamin supplementation, regardless a pregnancy is anticipated or no.[12] Dental and oral health is another area that requires attention. Only a third of the mothers reported having a routine care and visited a dentist for their current dental problems. According to the American Dental Association,[13] oral health can be affected by the hormonal changes during pregnancy. For example, pregnant women are at a higher risk of developing gingivitis, an infection of the gums that can cause swelling and tenderness. Oral screening during the prenatal stage is often overlooked, perhaps due to major misconceptions about the need for and/or the safety of dental treatment during pregnancy.[14] Prenatal oral conditions such as periodontitis have been associated with preterm birth and low birth weight, and high levels of cariogenic bacteria in mothers that can lead to increased dental caries in the infant. Education on proper oral hygiene should be a priority and women should be screened for oral risks, referred for dental treatment when necessary.[15] Pregnant women may likely to visit the dentist if they had proper knowledge on how their oral health affects their children's oral health.[16] Obstetrician and family practitioners should recommend a thorough oral examination early in pregnancy.

Overall, the level of physical activity is low as only a third of the mothers mostly engaged in walking 30 min, once a week before and during pregnancy. A few studies that measured physical inactivity among Saudi women concur with our study findings. A high level of physical inactivity is reported in various regions and population groups in Saudi Arabia.[17] Adolescent females, in particular, are at greater risk of sedentary lifestyle.[18] Al-Zalabanii et al.[19] reported that overall, 73% of Saudi women reported being physically inactive. Young college women reported spending 66% of their wake time in sedentary lifestyle.[20] Another review by Sisson and Katzmarzyk[21] reported that Saudi Arabia (2%) is one of the countries with the lowest prevalence of physical activity among women. Cultural factors prohibit girls engaging in exercise/sport activities in public schools even today. Saudi women lack opportunities and suitable places like gyms for physical activity.[22] Lack of facilities, independence, and societal and cultural norms prohibit or constrain exercise activities among Saudi women.[22],[23]

Concerning the health status of pregnant women, approximately 10%–12% of the mothers were diagnosed with anemia, overweight problem, thyroid problems, and diabetes preconceptionally. Obesity is a growing problem among pregnant Saudi women,[24],[25] which may lead to major maternal complications.[1],[26] Overweight during pregnancy has been[27] linked to preeclampsia (27% vs. 9% in controls), pregnancy-induced hypertension (24% vs. 8% in controls), and gestational diabetes (22% vs. 5% in controls). Fetal complications such as premature birth, stillbirth, and Neonatal Intensive Care Unit admissions are frequent in overweight pregnant women compared to controls.

Evidently, first-time mothers are less likely to be aware of FA, its requirements, and foods rich in FA (e.g., lentils, dark green vegetables). The study findings suggest that first-time mothers need to be educated to incorporate food options that contain FA in their daily diet. Knowledge of FA seems to be reasonably sufficient; however, health-care professionals should be involved more in educating women in general, and mothers in particular, regarding natural sources of FA. The study also revealed that demographic characteristics such as being younger, lower education level, and low-income status significantly affect awareness on the importance of FA in preventing birth defects. In contrast, a study of Saudi female college students found that the majority (88%) was unaware of the role of FA in preventing NTDs.[28] Interestingly, doctor or nurse is less likely to discuss about taking FA and its importance with women from lower income level. There is a great need to raise awareness on the importance of taking FA, nutritional education, and guidance in selecting FA-rich foods to reduce negative maternal and birth outcome.[29] Educational interventions may be implemented during visits for premarital screening and well-woman checks.[30]

The finding of lower levels of folate consumption among mothers is also supported by past research emerged from this region.[9],[31],[32],[33] Although the problem of low consumption has been noted for the past 5 years, targeted efforts to improve knowledge and consumption have not been noted. Routine wellness checkups, preconception and prenatal educational programs to increase awareness must offered as a comprehensive package with a targeted goal to prevent birth defects. Couples premarital counseling is the ideal time to incorporate educational programs on women's health, conception, childbearing, and the importance of nutrition and physical activity during preconception and prenatal stage. Further studies are needed to explore the impact of sociodemographic and cultural barriers on women's health status.

Evidently, physicians/nurses are the key informants and can influence the level of knowledge concerning healthy pregnancy. Our study underscores the importance and the need for prenatal and antenatal education programs to improve mother's knowledge. For the past decade, prenatal programs are being delivered through primary care centers in Saudi Arabia. Nonetheless, little is known about needs of pregnant Saudi women and the extent to which they have benefited from the knowledge they acquired through such programs.[34]

Our study suffers from shortcomings which are typical for cross-sectional approach and nonrepresentative populations. First, due to time constraints (10 months), the study included two clinics in the largest city that are exclusively for providing care for native Saudi women. Since the focus of the study is on native Saudi women, we have excluded other private hospital clinics that do not typically enroll native Saudi population. Therefore, the findings can only be generalized to urban native Saudi women. Second, due to the cross-sectional nature of the study, causality cannot be established. Nonetheless, our study provided insights into women's knowledge and actual intake of FA, which is continued to be lower in urban areas. This study should be replicated in small towns and rural areas which might point to even lower levels of folate consumption. Data linked to actual NTD-related birth defects will provide a vivid picture of the magnitude of the problem.

  Conclusion Top

Our findings highlight the need for routine wellness checkups, nutritional education, specifically on the importance of FA. More intensive approaches to folate supplementation must be implemented in view of the nondeclining trend of NTDs in this region.[35] Resources must be invested in educating first-time mothers and mothers from lower educational/income levels. Community nurse-family partnerships may be beneficial, particularly, for rural areas.


The authors wish to gratefully acknowledge the participation of all mothers, the clinic staff, and third-year medical students who assisted with the data collection.

Financial support and sponsorship

This study was supported by the United States Fulbright Commission under Teaching and Research Scholar award to the first author.

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1]

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