|Year : 2007 | Volume
| Issue : 3 | Page : 103-111
Determinants of birth spacing among Saudi Women
Moataz Abdel-Fattah1, Tamer Hifnawy1, Tarek I El Said2, Maha M Moharam3, Mahmoud A Mahmoud3
1 Department of Research Unit, Preventive Medicine, Al-Hada armed forces hospital, Taif, Saudi Arabia
2 Department of Family Medicine, Al-Hada armed forces hospital, Taif, Saudi Arabia
3 Department of Obstetric & Gynaecology Departments, Al-Hada armed forces hospital, Taif, Saudi Arabia
|Date of Web Publication||28-Jun-2012|
PhD, Chief of Preventive Medicine Department, Al-Hada Armed Forces Hospital, P.O. Box 1347, Taif
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: High fertility levels are of major concern to planners and policy makers in most countries in the developing world. In Saudi Arabia, the rate of population growth is the third highest of the countries of the Eastern Mediterranean Region.
Objectives: This study aimed at identifying determinants of birth spacing and attitudes toward family planning among Saudi women.
Methods: A cross sectional survey of all women who have been married before, aged 15-49 years attending Al Hada armed forces hospital (primary health care and antenatal care clinics), was conducted between 1 st February 2005 and 31 st January 2006. Data was collected on socio-demographic, biological characteristics, beliefs, attitudes, and utilization of family planning services, pregnancy intervals and medical history
Results: For the 786 women included in the study, the mean duration of interbirth interval was 2.38±1.24 years. The multivariate Cox regression revealed that a woman's education, work status, husband's work status, a woman's history of chronic diseases, and husband's encouragement of interbirth spacing were the only significant predictors of longer interbirth intervals. Shorter interbirth intervals were independently predicted by lower family income, and presence of female offspring only or equal number of male and female offspring as opposed to presence of more males. The great majority of participating women (98%) had a positive opinion of the effect of birth spacing on the family.
Conclusion: This study showed that certain factors were significant predictors of interbirth spacing for the Saudi women. This should lead to the encouragement of longer intervals between births. However, further studies are needed to ascertain a cause-effect association..
Keywords: Saudi, Women, Birth spacing
|How to cite this article:|
Abdel-Fattah M, Hifnawy T, El Said TI, Moharam MM, Mahmoud MA. Determinants of birth spacing among Saudi Women. J Fam Community Med 2007;14:103-11
|How to cite this URL:|
Abdel-Fattah M, Hifnawy T, El Said TI, Moharam MM, Mahmoud MA. Determinants of birth spacing among Saudi Women. J Fam Community Med [serial online] 2007 [cited 2019 Nov 15];14:103-11. Available from: http://www.jfcmonline.com/text.asp?2007/14/3/103/97098
| Introduction|| |
The concept of reproductive health is relatively new, but has gained momentum since mid-1990s. While it mainly addresses issues on reproduction for both men and women, it also deals with women's health issues as a whole, since these issues are closely related to the reproductive process.  As women play an important role in caring for family members, especially children, their illness or deaths has an immediate effect on the well being of the family as a whole, and may impact the entire population. 
High fertility levels are of major concern to planners and policy makers in most countries in the developing world. In Saudi Arabia, the rate of population growth is 4.3%, the third highest among countries of the Eastern Mediterranean Region.  The analysis of birth intervals is of interest in this context since it can provide further insight into the mechanisms underlying changes in fertility.  Short birth intervals adversely affect the health of mothers and the survival of their children. The risk of the death of a child increases if the interval between the birth of the child and the previous birth is less than 24 months. , The regulation of fertility is found to be an essential factor for improving maternal health and the nutritional status of child and the reduction of child mortality rate. ,,,,
Pregnancies that occur too early or too late in a woman's reproductive life, those that are too closely spaced, those that occur in women who have already had too many births, and those which occur in women who have health problems, such as high blood pressure and diabetes that could be aggravated by pregnancy - pose health risks for mothers and/or their children. These risks to life and health summarized by "too close, too many, too old, too young" hold true for all socioeconomic groups. Clearly, general health would improve markedly if proper measures are taken to avoid high risk pregnancies and maintain healthy intervals between births. ,
Results from the 1996 Saudi Arabia Family Health Survey (SFHS-96) indicate that changes in fertility including the reduction in child mortality and the rise in age at marriage are strongly influenced by social and economic development. Through a variety of mechanisms family size that couples desire is reduced. Increasing women's control over their own reproductive lives would clearly have a major impact on their health and the growth and survival of their children. Individual choices about family size are, however, made effective through fertility regulations. ,
It is often assumed that Muslim religious leaders have more conservative attitudes than the general population on family planning, yet a review of the literature reveals no specific comparison of the two groups. It seems that the views of muslim religious leaders on family planning are often misinterpreted.  This study aimed to identify determinants of spacing births, and determine the attitude of females attending Al Hada Armed Forces Hospital primary health care clinics toward the family planning.
| Subjects and Methods|| |
A cross-sectional survey, of all women aged 15-49 years who had been married before or were still married and who attended Al Hada Armed Forces Hospital (primary health care and antenatal care clinics), was conducted. All eligible women were interviewed using a questionnaire designed to elicit details of their socio-demographic and biological characteristics, beliefs, attitude and their use of family planning services, pregnancy intervals and medical history. Crowding index was defined as the number of family members/number of rooms in dwelling. Those with a history of primary or secondary infertility were excluded from the study of determinants of pregnancy spacing (n=51), but all were included in the study to determine attitudes toward family planning. Data were collected by trained primary care physicians and nurses between 1 st February, 2005 and 31 st January, 2006.
Birth interval was defined as the interval between reported dates of birth, rather than the inter-conception intervals. The interval between marriage and the first birth was excluded from the analysis. The period of interest in this study was that between the date of the birth making the start of the interval either the date of the next conception, or the interview date (if no conception had occurred). If the interval is terminated by a conception, it is termed a closed interval (82.7 of intervals); otherwise, it is termed an open interval (17.3% of intervals). In order to avoid any selection bias, open as well as closed intervals were included in the analysis. However, including these intervals was likely to result in pregnancy rates that were biased downwards, because a pregnancy may not be recognized or reported until four or five months after conception. In other words, women may have been pregnant at the time of the survey but may not have been aware of it, and therefore would not have reported it to the interviewer. Their birth intervals would be misclassified as open, when they were really closed. The method used to avoid this problem was to artificially backdate the interview date to nine months before the actual interview date.
Regarding the beliefs and attitude towards the concept of family planning, data were collected from all participants by trained female health educators (n=837). A questionnaire with open and closed ended questions was utilized. The questions elicited information on the knowledge of family planning, sources of this information, contraceptive use, and the attitude of the participants towards the concept of family planning and its effect at both family and community levels. The study was conducted after obtaining the approval of the Research and Ethics committee of Al-Hada Armed Forces Hospital. Informed consent was obtained from all women willing to participate in the study (response rate was 93%).
Data were analyzed using SPSS version 11.0 software. Kaplan-Meier survival, univariate and multivariate Cox-regression analysis, which take into account censored events, were performed. The former is used for categorical variables, while the latter is for both continuous and categorical ones, the 5% level was chosen to judge the significance of the results obtained.
Since many intervals (all the open intervals) were censored, a hazards model was used for the analysis. A Cox proportional hazards model was used here. This choice is supported by the fact that the effect of the majority of covariates on the hazards of conception is proportional to the whole duration of the birth index.
| Results|| |
The mean age of the 786 of the women included in the study was 31.95±7.3 years ,with a minimum of 18 years and a maximum of 49 years. Nearly one third of the participants (34.7%) were illiterate or had primary school education, while university graduates constituted 20.2% of the sample. Only 16.4% were working women.
The mean age at marriage of the participating women was 19.71±3.77 with a median of 19 years while the mean age at the birth of the first child was 21.13±3.68. The mean age at marriage of their husbands was 26.90±6.45 with a median of 25 years. The number of children each woman had ranged from one to16, with an average of 4 children per woman.
Birth spacing and its determinants
The study revealed 3168 interbirth intervals among the 786 participating women. Of the 3168 interbirth intervals, 82.7 % were closed and 17.3 % were open. The mean duration of interbirth interval was 2.38±1.24 years with a median of two years.
[Table 1] represents the sociodemographic determinants of the interbirth spacing. It revealed that women who had finished high school (secondary or diploma) (22.9%) or had a university degree (20.2%) had significantly longer interbirth intervals (2.54 and 2.67 years respectively) than those who had no formal education (log rank test=22.13, p<0.0001). Interbirth intervals for women in employment were 2.73 years compared with 2.32 years for unemployed women (log rank test=15.73, p=0.0001). Also, women married to civilians, professionals or retired men had significantly longer interbirth intervals (ranging from 2.65 to 2.88 years) than those women married to military men, military officers or other military personnel (interbirth intervals ranging from 1.84 to 2.27 years and log rank test= 26.54, p=0.0001).
|Table 1 : Mean duration of birth spacing in relation to sociodemographic characteristics|
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Statistically significant differences were observed between the interbirth interval and the number of wives in the family (log rank test=5.18, p=0.0229), the family income (log rank test=11.46, p= 0.0032), as well as the crowding index (log rank test=18.03, p<0.0001). Interbirth interval was significantly shorter for families in which there were two or more wives (2.23 years), those who described their income as not enough (1.93 years) and for those whose crowding index was > two persons/room (2.02 years). On the other hand, neither the husband's level of education nor the residence was a significant predictor of the interbirth spacing.
As shown in [Table 2], the length of the interbirth interval was significantly affected by the number of living children (log rank test=26.12, P<0.0001) and their male to female ratio (log rank test=26.59, P<0.0001). The shortest interbirth intervals were observed when the woman had only one living child (2.06 years) and for those who had only female living children (1.93 years). The longest interbirth intervals were reported by women who had two to four living children (2.58 years) and those who had children of both sexes with more males (2.64 years).
|Table 2 : Mean duration of birth spacing in relation to biological and medical characteristics|
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The interbirth interval was also influenced by the mother's history of chronic diseases (log rank test=6.08, p=0.0137) and that of abnormal delivery (log rank test=7.62, p=0.0058). Significantly longer interbirth intervals were associated with a positive history of both (2.60 and 2.65 years respectively). A significantly longer interbirth interval (2.41 years) was associated with breastfeeding (log rank test=15.27, P=0.0001). The mother's biological and medical characteristics, including her age at delivery of the first child, history of having abnormal child or child death, as well as history of postpartum complications, were not related to the length of the interbirth interval. Also, a history of husband's chronic diseases was not significantly associated with the length of the interbirth interval.
Considering all significant predictors of the interbirth spacing, the multivariate Cox regression revealed that a woman with higher education, working women, a woman with a husband in the military, or a civilian, or retired, a woman with a history of chronic diseases, and the husband's encouragement of the wife to space births were the only significant predictors of longer interbirth interval. Shorter interbirth interval was independently predicted by lower family income, and presence of females only or on equal number of male and female children as opposed to more male children.
Assessment of attitudes and beliefs of family planning
Attitudes and beliefs of participating women on the concept of family planning were assessed among 765 women, representing 91.4% of the total sample. Parents and family formed the first source of knowledge, representing 67.5% (516/765) followed by media and press, friends 58% (444/765) and 57.3% (438/765) respectively. Other sources such as doctors, nurses, and teachers represented 43.9% (339/765).
Seven hundred and fifty participating women representing 98% had positive opinions of its effect on the family. However, 88.6% (678/765) of them reported a positive opinion of the effect of family planning on the community and only 10.2% reported that it had no effect on the community.
Those who never used any contraceptives represented approximately one third of the sample (34.1%). The pill was the most reported method (369 or 44.1%) followed by intrauterine devices (249 or 29.4%); safe period, condoms, injectables and others were also mentioned.
Nearly half of those who had never used any contraception were newly married. They were followed by those who wanted more children 22.1%. However, religious reasons accounted for only 2.1% of the non users [Table 3][Table 4].
|Table 3 : Multivariate cox regression of the significant predictors of birth spacing|
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|Table 4 : Attitude and beliefs of participating women regarding the concept of family planning (n=837)|
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| Discussion|| |
Family planning is an issue important for health and development, as well as a human rights. Muslim countries and societies, no different from the rest of the world, aspire to reach their development goals by improving the health of their women and children. 
Birth intervals are growing longer, yet most are still short of the healthiest interval of 3 to 5 years.  The median birth interval in developing countries is about 32 months, 4 months short of 3 years. This is based on the Population Reports analysis of 55 countries with Demographic Health Survey (DHS) data. On average, women in developing countries have much shorter birth intervals than they would prefer.  Our study showed even shorter birth intervals than have been reported by women in other developing countries. This could be explained by the fact that the majority of women in this study were relatively younger at the time of conception (97% were younger than 30 years old). This may be because this group probably thought it best to have their children quickly; other mothers had already attained already their intended family size. It was proved by data analysis of DHS of the 55 countries that the largest proportions of women with intervals shorter than 3 years tended to be in those countries with higher per capita income, as may be the case in the study in Saudi Arabia.  The explanation of short birth intervals in these countries could be that many women here want to have their children in rapid succession and then to use contraception to limit the number of children they have rather than space births. 
Expanding education and employment opportunities for women is a reason for the spacing of children. The current study as well as others have demonstrated the positive impact of women's education, particularly higher education on birth interval. ,,, In fact, women's educational attainments rather than those of their husbands have a significant impact on birth intervals. Higher educational attainment improves a woman's status and opens the door for employment, resulting in an increase in the spaces between births. , ,, The relatively longer intervals observed in relation to working women may be a reflection of their need to care for their children and the desire for self-fulfilment by being in gainful employment outside the home. The attainment of higher education has an indirect influence on spacing, in that marriage is delayed, there are changes in reproductive norms and behaviors as well as the practice and efficacy of contraception. ,, It seems then that social, economic and environmental factors influence fertility through its proximate determinants.
It has been established that breastfeeding has an influence on fertility by lengthening the period of postpartum infecundability  and through its effect on postpartum abstinence.  In our study, breastfeeding was associated with a significant fertility-inhibiting effect. The same results have been documented. ,, It is documented that the death of an infant reduces the length of the subsequent birth interval. Clearly, one possible reason for this is that the duration of breastfeeding is reduced as breastfeeding for 12 months reduced fertility by more than half by physiologically increasing the period of postpartum non-conception. , It has also been explained in terms of volitional replacement, which reflects a need to replace a lost child. 
However, in our study, we failed to prove this association. This could be attributed to the high fertility rate in our sample (four children per woman) which may mask the effect of one or two birth intervals following the death of a child. Besides, the death of a child causes a sense of increased risk of death of subsequent children. Another important explanation may be that the death of a child causes depression in the mother which then occasions vulnerability to early death of a subsequent birth.  A further detailed study focused on the effect of the death of a child on birth intervals in our community is needed.
The sex of children is an important factor that determines length of the birth interval. This is apparently observed in our community where preference for boys dominates. ,,,, Previous studies indicated that boy preference put an upward pressure on fertility as couples continued to have children until they had their desired number of boys.  In agreement with the previous studies, the current study proved that having only girls was significantly associated with the shortest interbirth interval.
In the current study, it was shown that most husbands approved of family planning (82.5%). Discussion and spousal perception of the partner's attitude towards family planning were found to be significantly associated with the use of contraceptives.  The present work revealed that mothers who reported chronic medical problems were found to have longer interbirth intervals. This finding could be explained by the fact that chronically ill women are at higher risk of prenatal, natal and postnatal complications that are more prevalent in this group of patients.
Comparison of the work/family attitudes of military couples with civilian couples showed that military couples, when viewed in light of demographic differences, were characterized as more motivated to achieve, more confident of their abilities, and more frustrated with not achieving their potential in their job.  In our study, military couples (officers or other military personnel) were associated with shorter interbirth intervals as compared to civilian employees and professionals. This could be explained by the aforementioned characteristics of military couples.
A high percent of women interviewed in our study had heard about family planning despite the low effect of programs on contraceptive methods and birth spacing implemented in Saudi Arabia. However, their main source of information was parents and family members, friends followed by media and press and finally health institutions and schools. This finding differs slightly from what was found by Tessema ZK,  in a study in Ethiopia assessing couples' knowledge of family planning. In that study, the role of the media and press was greater than that of health institutions. The reason may be that the increase in population size had not been a national concern in Saudi Arabia until recently. However, nearly 90% of the women had a positive opinion on the effect of family planning on the well-being of the family and community respectively; this was in agreement with a similar study done in Nigeria. 
Consistent with other studies, our study revealed that the oral contraceptive was the most used method followed by intrauterine devices. , Eighty percent of men, 86% of women; 82% of male religious leaders and 98% of female religious leaders believed that family planning was in keeping with in tenets of Islam.  This was obvious in our study which revealed that religion had little effect on the family planning method used.
Husband's awareness of the side-effects of contraception or their refusal to use it had no effect on the percentage of the non usage of family planning. Nonetheless, in our study the husband's encouragement for family planning had a statistically significant effect on increasing the birth intervals among participating women.
Islam should not be considered a barrier to the spacing of births. Governments and non-governmental organizations in Islamic countries as well as the international organisations should support the rational use of contraception. These efforts would help to prevent unplanned pregnancies and help families to understand the rationale behind suitable birth spacing by providing financial and political support for culturally sensitive reproductive health programs to cater for the needs of Muslim couples. 
Limitations and potential biases of this study could be summarized as follows. Our study was not population-based. It was based at a big hospital serving around 50000 persons in the western region of Saudi Arabia. However, it is unlikely for the determinants of interbirth interval to have been confounded by this since the results were similar to those of other countries in our region. ,, Also, it should be emphasized that our study is based on a population in a developing country, so its findings may not be generalized to other populations with different demographic characteristics. Among the limitations of the study, was the subjectivity of the variable related to the socio-economic level of the studied population. To conclude, an analysis of the spacing of births which effects the health of Saudi women will provide planners and policy makers with useful information to help with reforms and encourage longer intervals between births . These reforms may ultimately help families decide on appropriate interbirth intervals for their children and hopefully have beneficial effects on the population and on health status of mother and child. However, further studies using a population-based approach, and possibly, the inclusion of a proper mix of newly married women as well as those who have beeen married for some time is necessary to ascertain a cause-effect association.
| Acknowledgment|| |
The authors wish to express their gratitude to Brigadier General Dr. Saeed Al-Asmary, Program director of Al-Hada and Taif Armed Forces hospitals, Taif, Saudi Arabia. We would like to thank the Departments of Obstetrics and Gynecology and Family Medicine, Al-Hada Armed Forces hospital for their help with this study. Special thanks to Mrs. Amal Abdel-Kader, Mrs. Sahar Waif and Miss Eman Hassan for their help in data collection.
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[Table 1], [Table 2], [Table 3], [Table 4]