Eastern Mediterranean Health Journal [2017; Vol.23, Issue 10]

Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 23 / No. 10 October/Octobre 10 ددع / نوشرعلاو ثلاثلا دلجلما لولأا نيشرت/ربوتكأ2017 V olum e 23 N um ber 10 O ctober 2017 EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con‑ cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col‑ laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico‑sanitaire, aux ONG, Centres collabora‑ teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). © World Health Organization (WHO) 2017. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Disclaimer. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. If authors are staff members of the World Health Organization, the authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions, policy or views of the World Health Organization. ISSN 1020‑3397 تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا .هجراخو ميلقلإا فى ةحصلاب ينمتهلما طسوتلما قشرل ةيحصلا ةلجلما Correspondence Editor-in-chief Eastern Mediterranean Health Journal WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emrgoemhj@who.int طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . نميلا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . Yémen Subscriptions and Permissions Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: emrgoksp@who.int). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address; email: emrgoegp@who.int. Cover 23-10.indd 8-10 12/10/2017 8:37:11 AM Contents La Revue de Santé de la Méditerranée orientale Eastern Mediterranean Health Journal Vol. 23 No. 10 10 ددع نوشرعلاو ثلاثلا دلجلما• 2017 • Editorial Achieving the Sustainable Development Goal 3: challenges in HIV testing in the Eastern Mediterranean Region Joumana Hermez, Hamida Khattabi, Ahmed Sabry, Gabriele Riedner and Rana Hajjeh ............................................................................................................................................... 647 Research articles Drug utilization in primary healthcare centres in the Gaza Strip Shereen W. Ayoub, Areej H. Musalam and Ashraf A. Abu Mahadi........................................................................................................................................................................................... 649 Effect of pre-pregnancy maternal body mass index on pregnancy outcomes in nulliparous women in the Islamic Republic of Iran Marzieh Sfandiary, Shamsi Parvizi, Afshin Almasi and Frozan Sharifipour ......................................................................................................................................................................... 657 Factors associated with folic acid knowledge and intake among pregnant women in Sudan Mohamed A. Alsammani, AbdelillahKunna and Elsheikh M. Adam ...................................................................................................................................................................................... 662 Developing a socioeconomic index for health research in Iraq Wali Omer and Tariq Al-Hadithi ......................................................................................................................................................................................................................................................... 670 Toxic metals in maternal blood, Cord blood and Meconium of newborn infants from industrial areas in Pakistan Sina Aziz, Shakil Ahmed, Saadiya Aziz Karim, Subhana Tayyab and Anisa Shirazi ...................................................................................................................................................... 678 Pregnancy outcome variables and associated factors in different nationalities living in Kuwait Abdur Rahman, Haila Al-Rashidi and Saeed Akhtar .................................................................................................................................................................................................................... 688 Near-miss cases admitted to a maternal intensive care unit, Alexandria, Egypt Eman A. Sultan, Safia I. Shehata, Salwa S. Shaarawy and Mona H.H. Ashry ..................................................................................................................................................................... 694 Short communication First study in Qatar to reveal high Legionella counts in cooling towers Raed O. AbuOdeh, Hassan A. Aziz, Houda Moussa, Samah Hussien, Tameem Hadwan and Gheyath K. Nasrallah ......................................................................................... 703 Salt composition of commercial white bread in Morocco Ali Jafri, Younes El-Kardi and Abdelfettah Derouiche ..................................................................................................................................................................................................................... 708 Assessment of World Health Organization Collaborating Centres in the Eastern Mediterranean Region Ahmed Mandil, Samar ElFeky and Arash Rashidian .................................................................................................................................................................................................................... 711 WHO events addressing public health priorities National focal points for International Health Regulations ................................................................................................................................................................................... 715 Book 23-10.indb 645 12/13/2017 9:40:57 AM Mahmoud Fikri, Editor-in-chief Editorial Board Zulfiqar Bhutta Mahmoud Fahmy Fathalla Rita Giacaman Ahmed Mandil Ziad Memish Arash Rashidian Sameen Siddiqi Huda Zurayk International Advisory Panel Mansour M. Al-Nozha Fereidoun Azizi Rafik Boukhris Majid Ezzati Hans V. Hogerzeil Mohamed A. Ghoneim Alan Lopez Hossein Malekafzali El-Sheikh Mahgoub Hooman Momen Sania Nishtar Hikmat Shaarbaf Salman Rawaf Editors Phillip Dingwall Guy Penet (French) Eva Abdin, Fiona Curlet, Cathel Kerr, Marie-France Roux (Freelance) Manar Abdel-Rahman, Ahmed Bahnassy, Abbas Rahimiforoushani (Statistics) Graphics Suhaib Al Asbahi, Diana Tawadros Administration Nadia Abu-Saleh, Yasmeen Sedky, Iman Fawzy Dalya Mostafa Cover designed by Diana Tawadros Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean Book 23-10.indb 646 12/13/2017 9:40:57 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما شراعلا ددعلا 647 Editorial Achieving the Sustainable Development Goal 3: challenges in HIV testing in the Eastern Mediterranean Region Joumana Hermez 1, Hamida Khattabi 1, Ahmed Sabry 1, Gabriele Riedner 1 and Rana Hajjeh 1 In the era prior to antiretroviral therapy (ART), taking an HIV test was associ- ated with great fear, as a diagnosis of HIV infection signaled imminent death (1). As we mark World AIDS Day on 1 December 2017, it is worth reflecting on the success over the last two decades whereby treatment for HIV infection has become safer, more effective and simpler as new regimens with fixed combinations of antiretroviral drugs have become available (ARV). The use of ARVs has equally revolutionized HIV prevention beyond condom use, syringe exchange and screening of transfusion blood and transplant organs. ART sup- presses viral replication, reduces viral load and thus minimizes the possibility of HIV transmission (1). Furthermore, pre and post-exposure prophylaxis with ARVs have proven efficacy in prevent- ing infection of individuals exposed to HIV. Similarly, the advent of highly sensitive and specific rapid diagnostic tests and self-tests has improved access to quality testing services, and made it possible to return test results on the spot. Those scientific advances have put HIV testing and early diagnosis of HIV infection in a central position within the continuum of prevention, care and treatment. The global response to HIV has translated those advances into large- scale implementation of prevention, di- agnosis, care and treatment services. As a result, the Joint United Nations Pro- gramme on HIV/AIDS (UNAIDS) announced in 2015 that the world has 1 Department of Communicable Diseases Prevention and Control (DCD), WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt. achieved and exceeded Millennium Goal 6 (MDG6) (2). This has given hope to the world to “end AIDS” by 2030 – one of the Sustainable Develop- ment Goals (SDG3). However, in the Eastern Mediterra- nean Region (EMR) the HIV epidemic continues to grow. By the end of 2016, an estimated 360 000 people were liv- ing with HIV in the Region, with 37 000 new infections and 17 000 deaths oc- curring in the same year (3). Over 95% of new infections occurred among men who have sex with men, people who inject drugs, prisoners and sex workers (4). By the end of 2016, ART coverage in the EMR stood at 15%. The biggest bottleneck to accessing treatment is the low coverage of HIV testing ser- vices. Between 2013 and 2015 several countries in the Region conducted HIV test-treat-retain cascade assessments, which have confirmed the challenges that countries face in identifying people living with HIV (PLHIV) (5). Between 50% and 93% of PLHIV remain undi- agnosed and between 20% and 50% of persons diagnosed with HIV are lost-to-follow-up after diagnosis before enrolment in ART (5). The reasons for low access to HIV testing include, but are not limited to, inadequate service delivery approaches, insufficient service availability, distance to testing services, cumbersome pro- cesses to get a final test result, poor referral services, weak community sup- port, as well as long distances between testing and treatment facilities. Those challenges are exacerbated by stigma and discrimination against PLHIV and key populations – including in health care settings – punitive laws and crimi- nalization of key populations. Of special concern is the late diagnosis of HIV, which results in death before or shortly after enrollment in care. Among the countries reporting their CD4 testing data, between 25% and 60% of PLHIV have CD4 counts less than 200 cells/µl upon diagnosis, indicating late disease stage (6). In 2016, countries of the EMR reported having conducted over 6.2 million HIV tests, excluding screening for blood donation. Of those, however, around two thirds were conducted in a mandatory manner on low-risk popula- tion groups (6). Only 3% of the tests were conducted among key popula- tions, 14% in health care settings and 13% in voluntary counselling and testing facilities (6). A negligible num- ber of tests were conducted among partners of PLHIV. In contrast, 81% of PLHIV identified were from tests conducted among key populations, in health care settings and in voluntary counselling and testing facilities. This clearly demonstrates a skewed invest- ment of resources towards less efficient testing approaches, focusing on less af- fected population groups. As a result, only 30% of PLHIV know their HIV status, 54% of them (15% of the total PLHIV) are receiving treatment and an unknown number is virally suppressed (Figure 1) (6). https://doi.org/10.26719/2017.23.10.647 Book 23-10.indb 647 12/13/2017 9:40:57 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 648 References 1. Vella S, Schwartländer B, Sow S, Eholie, RL Murphy. The history of antiretroviral therapy and of its implementation in resource- limited areas of the world. AIDS. 2012;26(10):1231–1241. doi: 1097/QAD.0b013e32835521a3. 2. UNAIDS. UNAIDS announces that the goal of 15 million people on life-saving HIV treatment by 2015 has been met nine months ahead of schedule. Geneva: UNAIDS; 14 July 2015 (http:// www.unaids.org/en/resources/presscentre/pressreleasean- dstatementarchive/2015/july/20150714_PR_MDG6report, accessed 29 October 2017). 3. UNAIDS. UNAIDS data 2017. Geneva: UNAIDS; 2017 (http:// www.unaids.org/sites/default/files/media_asset/20170720_ Data_book_2017_en.pdf, accessed 29 October 2017). The missed opportunities to diag- nose more PLHIV, diagnosing them early and properly linking of them to care and treatment are compromising the gains from investments made in HIV response to date in the Region. In spite of increased efforts to scale up HIV testing, treatment and care services, the EMR is still facing significant challenges in increasing their coverage of services. Overcoming those challenges requires, among other things, openness to non- traditional approaches to HIV testing service delivery; bringing the services to the community level with involvement of the civil society; and the use of new technologies such as self-testing and diversify HIV testing service delivery approaches to meet the needs of those left behind. Furthermore, in order to optimize the benefit of testing, the Re- gion needs to invest in ensuring early diagnosis as well as efficient linkages of those diagnosed HIV positive to care and treatment. Rapidly scaling up HIV testing ser- vices remains a paramount necessity for the EMR; not just to meet the global tar- gets, but also to ensure the fundamental human right to health for PLHIV. 4. UNAIDS. Global AIDS Update 2016. Geneva: UNAIDS; 2016 (http://www.unaids.org/sites/default/files/media_asset/ global-AIDS-update-2016_en.pdf, accessed 29 October 2017). 5. WHO Regional Office for the Eastern Mediterranean (EMRO). Test-treat-retain cascade assessment reports from Sudan, Pun- jab-Pakistan, Morocco, Egypt, Lebanon and Islamic Republic of Iran. Cairo: EMRO [Unpublished]. 6. WHO Regional Office for the Eastern Mediterranean (EMRO). Regional surveillance monitoring report 2017. Cairo: EMRO [unpublished]. 30 15 NA0 20 40 60 80 100 PLHIV Diagnosed Receiving ART Virally suppressed HIV Cascade of care in the EMR % Figure 1 HIV diagnosis, care and viral suppression cascade in the EMR as of end 2017. Book 23-10.indb 648 12/13/2017 9:40:57 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 649 1Department of Pharmacology, Faculty of Human Medicine, Al-Azhar University, Gaza Strip, Palestine (Correspondence to: Shereen Ayoub: shereenayoub_2002@yahoo.de). 2General Administration of Pharmacy, Ministry of Health, Gaza Strip, Palestine. Received: 04/07/15; accepted: 27/02/17 Drug utilization in primary healthcare centres in the Gaza Strip Shereen W. Ayoub 1, Areej H. Musalam 2 and Ashraf A. Abu Mahadi 2 L’utilisation des médicaments dans les centres de soins de santé primaires de la Bande de Gaza RÉSUMÉ La présente étude a été réalisée pour analyser les pratiques de prescription de médicaments dans les centres de soins de santé primaires de la Bande de Gaza. Les chercheurs ont analysé rétrospectivement 2569 prescriptions provenant de 22 centres sur la période allant de janvier à décembre 2014. La méthode d’échantillonnage aléatoire systématique a été appliquée. L’analyse a utilisé les indicateurs fondamentaux de prescription recommandés par l’Organisation mondiale de la Santé (OMS). Dans l’ensemble, le nombre moyen de médicaments prescrits par visite était de 2 (Écart-type 0,9), le pourcentage de médicaments génériques prescrits étant de 10,1 % ; 67,5 % des prescriptions contenaient des antibiotiques suivis par des analgésiques pour 39,4 %. Des oublis majeurs ont été trouvés dans 89,5 % des prescriptions. Pour tous les médicaments prescrits, la durée, la puissance, la fréquence du traitement, la posologie et la forme galénique n’étaient pas mentionnées dans 79,3 %, 65,4 %, 30,6 %, 23,3 % et 12,5 % des prescriptions respectivement. Les abréviations officielles n'étaient pas utilisées dans 87,4 % des prescriptions. Il existe un besoin évident d’élaborer des normes pour la prescription de médicaments, des directives thérapeutiques standard sur l’utilisation des médicaments ainsi que des programmes de formation médicale continue, et de mettre en place de systèmes de suivi pour garantir l’observance thérapeutique. ةزغ عاطق في ةيلولأا ةيحصلا ةياعرلا زكارم في ةيودلأا مادختسا يدهم وبأ فشرأ ،مَّلسم جيرأ ،بويأ نييرش نوــ ثحابلا ىرــ جأ دــ قلف .ةزــ غ عاــ طق في ةــ يحصلا ةــ ياعرلا زــ كارم في ةــ يودلأا فــ صو تاــ سرامم لــ يلحتل ةــ ساردلا هذــ ه تــ يرجأ :ةــ صلالخا لىإ نياـ ثلا نوـ ناك/رياني نـ م ةرـ فلا لاـ خ ةـ يلولأا ةـ ياعرلا زـ كارم نـ م ًازـ كرم 22 نـ م ةـ يئاود ةـ فصو 2569 هـ عوممج اـ لم ًايعاجرـ سا ًاـ ييقت اـبه تـصوأ يـتلا ةـيودلأا فـصول ةيـسيئرلا تاشرؤـلما لـيلحتلا عـّبتاو .ةـمظتنم ةيئاوـشع ةـنيع تمدخُتـساو .2014 لولأا نوناك/برمـسيد مـسلااب ةـفوصولما ةـيودلأا ةبـسن تـغلبو ؛ ± 0.92 ةـلباقم لك في ةـفوصولما ةـيودلأا ددـع طـسوتم غـلب ،ماـع هـجوبو .ةـيلماعلا ةـحصلا ةـمظنم في ةيرـبك أـطخو وهـس تلااـح تلجـسو .)% 39.4( تانكـسم هـيلت يوـيح داـضم ىـع تاـفصولا نـم % 67.5 ىوـتحا اـك .% 10.1 يـملعلا في تاـعرلجا لكـشو هـتعرجو هـلوانت تارـم ددـعو هـتوقو ءاودـلا ةدـم رـكذت لم ،ةـفوصولما ةـيودلأا عـيجم فيو .تاـفصولا عـيجم نـم % 89.5 .ةيمـسر يرـغ تارـتمخ مادختـساب تاـفصولا نـم % 87.4 بـتُكو .لياوـتلا ىـع تاـفصولا نـم % 12.5و % 23.3و % 30.6و % 65.4و % 79.3 يـبطلا مـيلعتلل جـمارب مـيمصت بـناج لىإ ،جاـعلل ةيـسايق ةـيهيجوت ئداـبم دادـعإو ،ةـيودلأا فـصول يرـياعم عـضول ةـحضاو ةـجاح ةـمثو .مازـتللاا ىـع ظاـفلحا ناـضل يـحرم مـييقت مـظن ذـيفنتو رمتـسلما ABSTRACT This study was carried out to analyse drug-prescribing practices in primary healthcare centres (PHCs) in the Gaza Strip. We retrospectively evaluated 2569 prescriptions from 22 PHCs during January–December 2014. Systematic random sampling was applied. Analysis followed the World Health Organization recommended core prescribing indicators. The mean number of drugs prescribed per encounter was 2 (standard deviation 0.9); the percentage of drugs prescribed by generic name was 10.1%; and 67.5% of prescriptions contained an antibiotic followed by analgesics (39.4%). Major omission errors were found in 89.5% of all prescriptions. For all drugs prescribed, drug duration, strength, frequency, dose and dosage form were not mentioned in 79.3%, 65.4%, 30.6%, 23.3% and 12.5% of prescriptions, respectively. Nonofficial abbreviations were used to write 87.4% of prescriptions. There is a clear need to develop standards for drug prescribing, standard treatment guidelines for drug use, along with continuing medical education programmes, and the implementation of monitoring systems to ensure that they are adhered to. https://doi.org/10.26719/2017.23.10.649 Book 23-10.indb 649 12/13/2017 9:40:57 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 650 Introduction Rational prescribing and rational drug use are important goals that all healthcare systems should endeavour to achieve, irrespective of a country’s degree of development. Rational drug use means that appropriate medicines are prescribed in the correct dose and dosage form to the correct patient and at the lowest cost to the patient and the community. When one or more of these conditions is lacking, irrational use of drugs will arise (1). Worldwide, > 50% of all medicines are prescribed, dispensed or sold inappropriately, while 50% of patients fail to take them cor- rectly (1,2). Unfortunately the availabil- ity and irrational use of drugs is a major problem in current medical practice and its consequences include the de- velopment of resistance to antibiotics, ineffective treatment, adverse effects, drug dependence and an economic cost to the patient and society. Irrational or misuse of drugs refers to the distribu- tion or consumption of drugs in ways that negate or reduce their efficacy or in cases where they are unlikely to have the desired effect (1–3). To achieve optimal availability and appropriate use of drugs, a national drug policy is required to cover drug quality, safety, efficacy, availability and affordability (4,5). This drug policy should conform with the principles of primary health care (PHC), including the availability of essential drugs and the promotion of the rational distribution and utilization of drugs (6). The Palestine Ministry of Health (MoH) established the first Palestin- ian National Drug Policy in 1996. In 2000 an Essential Drug List (EDL) was developed. However, the EDL has not been updated since. Furthermore, the Gaza Strip lacks an appropriate policy, standard treatment guidelines and training programmes for health staff regarding prescribing, dispensing and use of drugs (7). Officially, the General Administra- tion of Pharmacy in the Gaza Strip is responsible for the procurement and supply of pharmaceuticals in public sec- tor facilities. The MoH buys the major- ity of medicine and medical disposables listed on the EDL through an annual tender according to the requirements of clinics and hospitals in the West Bank and Gaza Strip. Since 2007, the MoH in Ramallah has been responsible for sending regular shipments of drugs and medical disposables to the central stores in the Gaza Strip in order to provide MoH facilities with their requirements. In practice, the shipments of medicines and medical disposables are neither regular nor contain sufficient quanti- ties to meet those needs. This situation results in the steady deterioration of stocks of medicines and medical dispos- ables in MoH facilities in the Gaza Strip (7). In general practice, the MoH in the Gaza Strip acquires pharmaceuticals in 3 ways: (1) it receives a significant part of its medicines through donations; (2) it procures some badly needed items itself to compensate for the shortage; and (3) it receives official shipments from the MoH in Ramallah (8,9). Because prescribing and dispensing and the use of drugs by patients in the Gaza Strip is not well documented, the present study was conducted in PHCs to provide information about basic indicators of drug use in the context of patient treatment. These indicators are used to measure performance in 3 areas relating to the rational use of drugs in healthcare facilities: (1) prescribing indicators measure the performance of prescribers; (2) patient care indica- tors measure what patients experience in healthcare facilities; and (3) facility indicators measure whether the health personnel can function effectively (2). A detailed manual on their application is available from WHO (10). In addi- tion, in this study the number of drugs prescribed, the percentage of antibiotics and analgesics prescribed for different age groups of patients, the reasons for attending a PHC, and the prescription writing skills in PHCs were measured to obtain preliminary data for promoting rational use and prescribing patterns in the PHCs. Methods This study was carried out during the siege of the Gaza Strip in 2014, when there was a drastic shortage of MoH EDL drugs. A cross-sectional study of 1-year duration was undertaken over the course of 2014. A form was designed for data collection adapted from the WHO manual “How to investigate drug use in health facilities: selected drug use indicators”. Indicators relating to prescribing practice were selected, and the principle investigator visited govern- ment outpatient pharmacies in PHCs for data collection (10). The number of drugs prescribed per patient, the percentage of antibiotics and analgesics prescribed for different age groups, the reasons for attending a PHC, and the prescription writing skills in PHCs were documented. Prescribing errors were classified according to the following criteria: absence, vague, incomplete and/or illegibility of any component of the body of the prescription were con- sidered to be major errors of omission. Absence of any of the prescription com- ponents such as date of prescription, patient’s personal identifiers, physician’s stamp, and/or direction for use were deemed to be minor errors of omission (11–14). Sampling and data collection The sampling frame consisted of 56 PHCs in the Gaza Strip using a sys- tematic random sampling method. The sample was selected from the numbered list of all PHCs in the Gaza Strip arranged in order from north to south by using a regular interval starting from a random starting point as follows. (1) To calculate the sampling interval, we divided the size of the list by the Book 23-10.indb 650 12/13/2017 9:40:57 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 651 desired sample size, so our sampling interval was 56/22 = 2.55. (2) Choose a random number between 0 and 1 (with at least 3 digits after the decimal point, such as 0.657), then multiply this ran- dom number by the sampling interval, and round this result upward to obtain the number of the first centre (0.657 × 2.55 = 1.67535 2), so the second centre in the list was our first sample. (3) Later centres were selected by add- ing the sample interval to the previous result (1.67535), then the next centre selected would be 1.67535 + 2.55 = 4.22 5, and so on. (4) Within the PHC the sample of prescriptions was selected using randomized systematic sampling where only 10 prescriptions were se- lected from each month throughout the year. Sample size: the sample of prescrip- tions was selected by using a system- atic simple random sampling technique. Twenty-two PHCs with 115–120 patient prescriptions per centre, with an average of 10 prescriptions per month throughout 2014 were selected. Sample collection: the data were col- lected retrospectively. Two work teams, each consisting of 2 pharmacists, were trained to collect data by attending a workshop held at the General Admin- istration of Pharmacy, Palestinian Min- istry of Health, Gaza Strip. Prior to data collection, a pilot study was conducted at 2 centres to test the study design procedure and provide feedback about the positive and negative aspects of the form design. Exclusion criteria: only prescrip- tions dispensed directly to patients by pharmacists were included in the study, whereas prescriptions containing injections to be given to patients by the nursing staff in PHCs were excluded. Calculation of indicators Throughout the study we followed the methodology recommended by the WHO. Indicators were calculated in the following way: (1) average number of drugs per encounter = total number of drugs prescribed/total number of encounters surveyed; (2) percentage of drugs prescribed by generic name = (number of drugs prescribed by generic name/total number of drug prescribed) × 100; (3) percentage of encounters with an antibiotic prescribed = (number of patient encounters with an antibiotic prescribed/total number of encounters surveyed) × 100; (4) percentage of en- counters with an injection prescribed = (number of patient encounters with an injection prescribed/total number of encounters surveyed) × 100; and (5) percentage of drugs prescribed from the EDL = (number of drugs prescribed from the EDL/total number of pre- scribed drugs) × 100. Statistical analysis The data were analysed using IBM SPSS version 19, after manual verification and cleaning. Descriptive statistics [means, percentages and standard deviations (SDs)] were used to present the results. Ethical consideration Ethical approval for the study protocol was granted by the Palestinian MoH prior to commencement of the study. Results In this study, 2569 prescriptions from 22 PHCs were collected and analysed: 1226 (47.7%) of them were for male patients and 1343 (52.3%) for female patients. The mean age of the patients was 22.6 (SD 22.7) years, ranging across the PHCs from a mean of 15.4 to 33 years. Table 1 represents the results for each PHC and for all centres combined. A total of 5074 drugs were pre- scribed. The overall mean number of drugs prescribed per encounter was 2 (0.9), with a range across the 22 PHCs from 1.7 to 2.4. From the total number of prescriptions, 23.7% specified ≥ 3 drugs, and only 6.2% specified ≥ 4 drugs (Table 2). The percentage of drugs pre- scribed by generic name was 10.1% (3.2–19.1%), whereas the percentage of EDL drugs prescribed was 81% (68.6– 90.2%). The percentage of prescriptions for antibiotics was 67.5% (53.3–78.3%), for analgesics 39.4% (28.3–56.7%) and for injections 1.3% (0–4.2%) (Table 1). Studying the number of drugs pre- scribed for different age groups of pa- tients, we found that the mean number of drugs per prescription for patients ≤ 3 years of age was [2.1 (0.9)], which is similar to that for patients aged ≤ 55 years [2.1 (1.1)]. The highest percent- age of prescriptions containing 2, 3 and 4 drugs was for patients ≤ 3 years of age, followed by patients ≥ 55 years of age, whereas the highest percentage of pre- scriptions containing 4 and 5 drugs was for patients aged ≥ 55 years (Table 3). Studying the percentage of antibiot- ics and analgesics prescribed for differ- ent age groups of patients, we found that for patients ≤ 3 years of age the percent- age of prescriptions with analgesics was 43.1%, and the percentage of prescrip- tions with antibiotics was 39.9%, which is the highest percentage among all age groups (Table 4). The most common reasons for at- tending a PHC were infectious disease (51.2%), followed by chronic disease (7.9%), and other diseases (4%) includ- ing anaemia, burns, fever, constipation and psoriasis. However, 28.1% of all pre- scriptions did not contain a diagnosis and therefore the reason for attendance was not known. Infectious disease was distributed over the following categories: 28.9% respiratory tract infections (26.2% up- per and 2.7% lower respiratory tract); 22.3% other infections, including gastroenteritis (6.6%), urinary tract in- fection (3.5%), skin infection (2.9%), conjunctivitis (1.3%) and auditory tract infection (1.2%). Patients with more than 1 infection accounted for 1.5% of prescriptions. A further 3.2% accounted for other microbial infections such as Book 23-10.indb 651 12/13/2017 9:40:57 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 652 viral, fungal and other bacterial infec- tions such as appendicitis, folliculitis, mastitis, pulpitis and stomatitis. In our sample, 5074 drugs were prescribed, among which antibiotics were the most commonly prescribed (40.9%), followed by analgesics (20.8%), dermatological preparations (5.6%) and antihistamines (4.5%) (Fig- ure 1). Regarding prescription writing skills in PHCs, 89.5% of prescriptions con- tained major omission errors: the length of treatment was omitted in 79.3%, the strength of medications was omitted in 65.4% of prescriptions, the dosing frequency was omitted in 30.6%, the dose was not specified in 23.3% and the dosage form was not specified in 12.5%. Nonofficial abbreviations were used in writing 87.4% of all prescriptions, while 18.7% were written in illegible handwrit- ing. There were minor omission errors such as the absence of a physician’s sig- nature, date of prescription and patient’s age, but the number of such cases was insignificant in comparison. Discussion Our study is an attempt to investigate current drug use patterns in PHC facili- ties in the Gaza Strip. Data for this study, 2569 prescriptions from 22 PHCs in the Gaza Strip, were collected and ana- lysed retrospectively according to the recommended WHO core indicators (10). The mean age of patients identi- fied in this study was 22.6 (22.7) years. The WHO standard values for the average number of drugs per encounter Table 1 Prescribing indicators in 22 primary health care centres in Gaza Strip Governorates Centre No. Patients’ age (yr) No. of drugs per encounter No. of drugs in prescriptions % of encounter with % of drugs prescribed in Mean (SD) Mean (SD) AB AN INJ GN EDL 1 15.4 (19.4) 2.0 (0.9) 235 71.4 33.6 0.8 19.2 83.4 2 18.7 (21.7) 1.8 (0.8) 221 63.3 35.8 0.8 12.2 87.8 3 23.8 (23.0) 1.9 (0.9) 223 60.0 36.7 0.8 18.8 87.0 4 20.3 (24.0) 1.8 (0.8) 221 67.5 38.3 0.8 3.2 85.5 5 22.3 (22.2) 2.0 (1.0) 236 64.2 35.8 0.0 14.8 77.5 6 27.0 (23.8) 2.0 (0.9) 237 60.8 42.5 0.0 5.9 78.9 7 19.5 (20.2) 2.1 (1.0) 251 78.3 36.7 0.0 7.6 85.7 8 24.9 (22.8) 2.1 (1.0) 256 59.2 56.7 3.3 10.2 84.4 9 22.3 (21.7) 1.7 (0.8) 206 75.8 33.3 1.7 9.2 89.3 10 25.4 (24.2) 1.9 (1.0) 228 61.7 41.7 2.5 12.3 81.6 11 20.5 (20.1) 1.9 (0.8) 223 71.7 41.7 0.0 9.9 77.1 12 22.1 (22.6) 2.0 (0.9) 236 75.8 35.8 0.8 6.8 68.6 13 15.4 (19.1) 2.1 (0.9) 254 78.3 52.5 0.0 9.8 70.9 14 31.2 (23.3) 2.0 (0.9) 239 53.3 28.3 4.2 4.6 78.7 15 18.5 (20.5) 2.0 (0.9) 215 70.9 35.5 0.0 7.0 73.5 16 24.1 (23.3) 2.0 (1.0) 245 67.5 28.3 3.3 5.3 78.8 17 25.6 (24.2) 2.3 (1.0) 276 73.3 48.3 2.5 7.3 77.2 18 25.3 (24.7) 2.4 (1.0) 286 71.7 43.3 2.5 17.5 83.6 19 19.6 (22.8) 1.7 (0.7) 204 62.5 40.8 1.7 10.3 90.2 20 16.9 (20.1) 1.9 (0.7) 111 71.7 41.7 3.3 15.3 82.0 21 22.0 (21.5) 1.8 (1.0) 214 66.7 34.2 0.0 11.2 77.1 22 33.0 (24.5) 2.1 (1.0) 257 61.7 45.8 0.0 10.9 83.3 Total 22.6 (22.7) 2.0 (0.9) 5074 67.5 39.4 1.3 10.1 81.0 AB = antibiotics; AN = analgesics; EDL = essential drug list; GN = generic name; INJ = injections; SD = standard deviation. Table 2 Percentage of prescriptions according to number of drugs per prescription No. of drugs per prescription (%) 1 33.9 2 42.5 3 17.5 4 4.9 > 4 1.3 Book 23-10.indb 652 12/13/2017 9:40:57 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 653 is 1.6–1.8 (15), whereas in our study the mean number of drugs prescribed per encounter was 2 (0.9). This value falls near the midpoint of results reported by investigators from Sudan (1.4) (16), Zimbabwe (1.3) (17), Saudi Arabia (1.4) (18), Yemen (1.5) (10), Lebanon (1.6) (19), Jordan (2.3) (20), Bahrain (3.3) (21) and Nigeria (3.8) (10). In this study, polypharmacy (≥ 3 drugs) was observed in only 23.7% of prescriptions, with only 6.2% of them specifying ≥ 4 drugs. This may be an ap- parent value and not a real value in the Gaza Strip. This low number of drugs per encounter may be related to drug shortage or the fact that some drugs are not actually prescribed because they are not on the EDL. In the latter case the patient may nevertheless be advised by the physician in the PHC to buy them directly from a community pharmacy. The overall percentage of drugs prescribed by generic name was 10.1%, which is similar to that of Bah- rain (10.2%) (21). Drugs prescribed by generic name vary widely between countries. In some it is high: Niger (100%) (22), Zimbabwe (94%) (17) and Tanzania (82%) (17). In others it is low, but still higher than in our study, as in Bangladesh (78%) (23), Sudan (19.5%) (16) and Saudi Arabia (15.1%) (24); whereas Jordan (5.1%) (20) and Lebanon (2.9%) (19) are even lower than in our study. In practice, physicians in PHC fa- cilities in the Gaza Strip almost always use trade names in prescribing. This explains the low percentage of drugs prescribed by generic name, which can be attributed to the influence of the marketing strategy of pharmaceutical sales representatives. Palestinian MoH guidelines are re- quired to enforce prescribing by generic name; particularly in the public sector. In this study, antibiotics accounted for 40.9% of the total of medication expenditure, followed by analgesics (20.8%). The prescribing of antibiotics accounted for 67.5% of all prescrip- tions, ranging from 53.3 to 78.3%. This value is high, as the WHO expectation is 15–25% in most countries where infec- tious disease is more prevalent (10, 25). In comparison, this value (67.5%) is slightly higher than for Jordan (60.9%) (20) and Yemen (46.5%) (10) but it is extremely high when compared to that of Lebanon (17.5%) (19). The misapplication of antibiotics in clini- cal medicine is a global phenomenon and this misuse is sometimes related to underdosing, short duration and/or use for nonbacterial infections. This has led to the emergence of bacterial resistance. In the Gaza Strip the excessive use of antibiotics is due to the lack of an appro- priate policy, the absence of standard treatment guidelines and the lack of physician training regarding antibiotic use. Moreover, patients can obtain an- tibiotics from a community pharmacy without a prescription even when un- necessary or inappropriate. Further- more, patients believe that antibiotic use is helpful in rapid amelioration of their symptoms. In our study the percentage of prescribed injections was low (1.3%), compared with both the international average of 17% and that of other de- veloping countries such as Nepal (5%) (17), Zimbabwe (11%) (17) and Bah- rain (9.3%) (21), but similar to that for Jordan (1.2%) (20). This low percent- age of prescribed injections in our study may have been due to the fact that the cost of injection therapy is higher than oral dosage form. Patients requiring Table 3 Relationship between patient age and number of drugs per prescription No. of drugs per prescription 2 3 4 5 6 Age interval (yr) (%) (%) (%) (%) (%) ≤ 3 36.1 44 35.2 34.6 0 4–15 19.4 13.8 7.2 7.7 0 16–25 10.3 10 7.2 0.0 14.3 26–35 10.6 7.8 9.6 0.0 0 36–45 7.9 7.3 11.2 7.7 14.3 46–55 6.0 6.2 8.8 7.7 42.9 > 55 9.6 10.9 20.8 42.3 28.6 Table 4 Relationship between patient age and percentage of antibiotics and analgesics prescribed Age interval (yr) % of prescriptions with analgesics % of prescriptions with antibiotics ≤ 3 43.1 39.9 4–15 16.5 21.1 16–25 9.3 10.7 26–35 9.1 9.5 36–45 7.0 8.1 46–55 5.7 5.2 > 55 9.3 5.5 Book 23-10.indb 653 12/13/2017 9:40:57 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 654 parenteral therapy (except for insulin and emergency situations) should be referred to a hospital and prescriptions for injections administered in the PHC are not available in pharmacies. In this study 81% of prescribed drugs were EDL drugs while the remaining 19% were non-EDL drugs. In general, non-EDL drugs are not allowed to be prescribed within PHC facilities. In real- ity, patients are advised to buy them directly from a community pharmacy, as it is still possible in the Gaza Strip to obtain prescription-only medication without prescription (verbally or by il- legal prescription). The non-EDL drugs illicitly prescribed by PHC facilities (19%) came from donations. Dona- tions are not always well coordinated with the MoH and some donated items are not on the EDL. Because of the retrospective nature of our study it is difficult to determine the actual number of non-EDL drugs prescribed. Studying the relationship between age and number of drugs per prescrip- tion, we found a clear tendency toward prescribing a greater number of drugs in the age group ≤ 3 years, with a mean number of drugs per prescription of 2.1 (0.9), which is similar to that for patients in the age group ≥ 55 years [2.1 (1.1)] The highest percentages of antibiot- ics and analgesics were prescribed for patients aged ≤ 3 years. Multiple drug prescriptions for older patients can be explained by patients taking 1 or more prescription drugs plus several over- the-counter drugs, such as antacids and analgesics, whereas the high use of multiple drug prescriptions for patients in the age group ≤ 3 years is unclear. The latter may be due to the co-payment differences among different age groups. An insured patient has to pay 0.3 US$ for 2 medicines for children aged ≤ 3 years and 0.3 US$ for each extra medi- cine, but 0.8 US$ for each unit medicine for patients aged > 3 years. As a conse- quence, 1 or more drugs prescribed for patients aged ≤ 3 years may be intended for other family members (26). A prescription is a legal document that may be used either for or against both physician and pharmacist in cases related to prescribing or dispensing errors. Prescribing errors may have serious consequences, therefore, all pre- scription components have to be clearly written, free of any nonofficial abbrevia- tions, and fulfil the legal requirements. Incorrectly written components of the body of the prescription are considered an error of commission (27–29). Er- rors of integration or knowledge-based errors in prescribing include potential drug–drug interactions or drug allergies that may reflect a failure of the prescrib- er to integrate information about the patient or drug history. Other prescrip- tion errors include prescriptions with illegible handwriting or with nonofficial abbreviations (30). One of the aims of our study was to recognize deficiencies in prescrib- ing and to investigate the prescription writing skills of physicians, regardless of the nature of patients’ conditions. We found that the prescription writing skills in PHCs were suboptimal. Even though diagnosis is 1 of the main components 45 40 35 30 25 20 15 10 5 0 % The prescriped group of medication A nt ib io ti c A na lg es ic D er m at ol og ic al A nt ih is ta m in A nt ih yp er te ns io n V ita m in s A nt ia st hm at ic C ar di ov as cu la r A nt ifu ng al A nt id ia be ti cs A nt iu lc er A nt ih el im en ti cs C or ti co st er oi ds A nt itu ss iv e O pt ha lm ic D iu re ti cs A nt id ia rr ho ea A nt ia ci ds A nt is pa sm od ic s O th er s U ri na ry A nt is ep ti cs A nt ie m et ic s La xa ti ve s H or m on e Figure 1 Classification of drugs prescribed by PHCs Book 23-10.indb 654 12/13/2017 9:40:57 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 655 of the PHC prescription form, assist- ing the pharmacist to ensure that the prescribed drugs are suitable for the patients’ conditions, the diagnosis was omitted in 28.1% of all prescriptions. It is worth mentioning that the shortage of MoH EDL drugs may have affected the results of this study. Had more EDL drugs been available, per- haps more drugs and more antibiotics would have been prescribed. Our results illustrate the urgent need for extensive improvement in prescribing practice as a considerable proportion of prescrip- tions lacked essential information. Conclusion and Recommendations Our study of drug-prescribing patterns in PHCs in the Gaza Strip clearly dem- onstrates that there is an irrational use of drugs. It is our opinion that there is a need to develop standards for drug prescription as well as standard treat- ment guidelines for drug use and for supervision and monitoring systems to ensure that they are adhered to. Further- more, continuing medical education programmes are required to develop awareness about polypharmacy, irra- tional drug use, good prescribing and the necessity of an auditing system. Finally, this study needs to be extended and repeated over time to assess the im- provement in drug prescribing and use. Acknowledgements We are grateful to our colleague Dr. Nedaa Hijazy from the Planning and Drug Information Department of the General Administration of Pharmacy in the MoH for her contribution in collect- ing the data for this study. Furthermore, we are grateful to Mr. Struan Robertson and Ms. Karin Guth for their help in editing this paper. Funding: None. Competing interests: None declared. References 1. WHO policy perspectives on medicines: promoting rational use of medicines: core components. Geneva: World Health Organization; 2002 (http://apps.who.int/medicinedocs/ pdf/h3011e/h3011e.pdf, accessed 15 March 2017). 2. Hogerzeil HV. Promoting rational prescribing: an interna- tional perspective. Br J Clin Pharmacol. 1995 Jan;39(1):1–6. PMID:7756093 3. Trostle J. Inappropriate distribution of medicines by pro- fessionals in developing countries. Soc Sci Med. 1996 Apr;42(8):1117–20. PMID:8737428 4. Palestinian Ministry of Health. Palestinian national drug policy. 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Errors in prescribing, preparing, and giving medicines: definition, classification, and prevention. In: Aronson JK, editor. Side effects of drugs. Annual 22. Amster- dam: Elsevier; 1999:xxiii–xxxvi. 30. Al Khaja KA, Sequeira RP, Al-Ansari TM, Damanhori AH. Prescription writing skills of residents in a family practice residency programme in Bahrain Postgrad Med. J. 2008 Apr;84(990):198–204. PMID:18424577 Book 23-10.indb 656 12/13/2017 9:40:57 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما شراعلا ددعلا 657 1Department of Midwifery, Nursing and Midwifery Faculty, Kermanshah University of Medical Sciences, Kermanshah, Islamic Republic of Iran (Correspondence to: Shamsi Parvizi: shamsiparvizik@gmail.com). 2Department of Biostatistics and Epidemiology, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Islamic Republic of Iran. Received: 29/01/16; accepted: 30/11/16 Effect of pre-pregnancy maternal body mass index on pregnancy outcomes in nulliparous women in the Islamic Republic of Iran Marzieh Sfandiary 1, Shamsi Parvizi 1, Afshin Almasi 2 and Frozan Sharifipour 1 Impact de l’indice de masse corporelle maternel pré-gravidique sur les issues de grossesse parmi les femmes nullipares en République islamique d’Iran. RÉSUMÉ La présente étude a été menée pour évaluer l’impact de l’IMC maternel pré-gravidique sur les issues de grossesse. L’IMC a été calculé pour 360 femmes nullipares. En fonction de l’IMC, les femmes enceintes ont été réparties en trois groupes : groupe I (poids maigre IMC ≤ 19,8), groupe II (poids normal IMC = 19,9- 24,9), et le groupe III (obésité IMC ≥ 25). L’analyse des données a été réalisée à l’aide de la version 16.0 du logiciel SPSS. La durée moyenne des deux premières phases du travail était significativement différente entre ces trois groupes (p < 0,001). Le taux de césarienne dans le groupe I était inférieur à celui du groupe II (OR = 0,15 ; p = 0,013). Le taux d’accouchement avec assistance instrumentale dans le groupe III était plus élevé que dans le groupe II (OR=4,6 ; p = 0,002). Le risque lié à l’absence ou la diminution des mouvements lors du test de réactivité foetale était significativement différent entre les groupes II et III (OR = 5,7 ; p = 0,009). Le taux d’induction du travail dans le groupe I était inférieur à celui du groupe II (OR=0,4 3 ; p = 0,002). L’écart de l’IMC par rapport au poids normal est associé aux issues défavorables de la grossesse et de l’accouchement. ةيملاسلإا ناريإ ةيروهجم في ءاسنلا في لملحا جئاتن لىع لملحا لبق ام ةلحرم في ملأل مسلجا ةلتك سايقم رثأ روپ یفيشر نازورف ،سيالما ينشفأ ،يزيورپ سيمش ،يرايدنفسا هيضرم في ساـ يقلما بـ ستحاو .لـ ملحا جـ ئاتن ىـ ع لـ ملحا لـ بق اـ م ةـ لحرم في مـ سلجا ةـ لتك ساـ يقم رـ ثأ مـ ييقتل ةـ ساردلا هذـ ه تـ يرجأ :ةـ صلالخا ةـفيفخ ةـعوممج( لىولأا ةـعومجلما :مـسلجا ةـلتك ساـيقلم ًاـقفو تاـعوممج ثاـث لىإ لـماولحا ءاـسنلا تـفنصو .ةدلاوـلا ةـميدع ةأرـما 360 ةــ عومجلماو ،)24.9 -19.9 = مــ سلجا ةــ لتك ساــ يقم ،يــ عيبطلا نزوــ لا ةــ عوممج( ةــ يناثلا ةــ عومجلماو ،)19.8 ≤ مــ سلجا ةــ لتك ساــ يقم ،نزوــ لا ينـتلحرلما ةدـم طـسوتم نـيابتو .SPSS 16 جـمانرب مادختـساب تاـنايبلا لـيلتح مـتو .)25 ≥ مـسلجا ةـلتك ساـيقم ،ةـنيدبلا ةـعومجلما( ةـثلاثلا لــ قأ لىولأا ةــ عومجلما في ةــ يريقلا ةدلاوــ لا لدــ عم ءاــ جو )p<0.001( ثاــ ثلا تاــ عومجلما ينــ ب ةــ للاد اذ ًاــ نيابت لــ محلل ةــ يناثلاو لىولأا ةــ يناثلا ةــ عومجلما في هــ نم ىــ عأ ةــ ثلاثلا ةــ عومجلما في ةــ يعيبطلا يرــ غ ةدلاوــ لا لدــ عم ءاــ جو .)OR=0.15; p=0.013( ةــ يناثلا ةــ عومجلما نــ م ةــثلاثلاو ةــيناثلا ينــتعومجلما ينــب ةــللاد اذ ًاــنيابت ةــلعافتلما يرــغ ةدــشالا تاــصوحف رــطامخ تــنيابتو .)OR=4.6;p=0.002( ساـيقم فارـحنا نإ .)OR=0.43; p=0.002( ةـيناثلا ةـعومجلما نـم لـقأ لىولأا ةـعومجلما في ضـيرحتلا ةبـسن تءاـجو .)OR=5.7;p=0.009( .ةدلاوـلاو لـمحلل ةيبلـسلا جـئاتنلاب طـبترم يـعيبطلا ىوتـسلما نـع مـسلجا ةـلتك ABSTRACT This study was conducted to evaluate the effect of pre-pregnancy BMI on pregnancy outcomes. BMI was calculated measured in 360 nulliparous women. According to BMI, pregnant women were placed into three groups: group I (lean group BMI ≤ 19.8), group II (normal weight group BMI = 19.9–24.9), and group III (obese group BMI ≥ 25). Data were analyzed using SPSS 16. The mean duration of the first and the second stage of labour were significantly different between three groups (P < 0.001). Cesarean section ratio in group I was lower than group II (OR = 0.15; P = 0.013). Instrumental delivery in group III was more than group II (OR=4.6; P = 0.002). Risk of nonreactive non-stress test (NST) was significantly different between groups II and III (OR = 5.7; P = 0.009). Induction ratio in group I was lower than group II (OR=0.43; P = 0.002). Deviation of BMI from the normal level is associated with adverse outcomes of pregnancy and delivery. https://doi.org/10.26719/2017.23.10.657 Book 23-10.indb 657 12/13/2017 9:40:58 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 658 Introduction Improving maternal and fetal health is a key public health objective. In recent years, the body mass index (BMI) of women of reproductive age has risen in developed countries (1). Higher ma- ternal BMI at the start of pregnancy or before pregnancy has been reported to increase physical and intellectual prob- lems in neonates (e.g. cerebral palsy, hydrocephalus, seizures, vision, hearing and behavioural problems) (2). Overweight and obese women are at increased risk of gestational diabetes, pre-eclampsia, instrumental delivery and caesarean section and their children are at higher risk of macrosomia, birth defects, low Apgar scores and neonatal complications (1,3,4). Obese women have been reported to have longer la- bour due to insufficient contractions during the first stage of labour, therefore, the induction and augmentation rate is higher in this group. Obese women also have a longer second stage of labour, hence, they may need more stimulation by oxytocin. In addition, newborns of obese mothers have lower Apgar scores which increases the risk of fetal distress and prolonged hospitalization of the new born (2). The financial cost of the equipment used for caring for low-birth- weight neonates as a result of preterm labour places a considerable burden on health services (3). Most of these data are from studies conducted in developed countries. In developing countries, where poverty and malnutrition are higher, there is in- adequate information about maternal BMI and its effects on pregnancy. Therefore, this study was conducted with the aim of evaluating the effect of BMI on pregnancy outcomes in nullipa- rous women in Kermanshah, Islamic Republic of Iran. Methods Study design and setting We conducted a prospective study at Hazrat Masomeh Hospital in Kerman- shah from October 2014 until Sep- tember 2015. This is a general hospital affiliated to the Social Security Organiza- tion and has about 6000 births annually Study sample The sample was drawn from nulliparous women who intended to be pregnant and attended the hospital pregnancy clinic before pregnancy. Many women attend the clinic for routine preconcep- tion counselling. BMI of the women was measured before pregnancy. Then in the first trimester, BMI was measured again. Women who were in the BMI group as before pregnancy and had a singleton pregnancy without any systemic disease, such as hypertension, diabetes and kid- ney disease that can affect pregnancy outcomes, were enrolled in the study and followed until delivery. The sample size needed for the over- weight/obese group was 130. Sampling was sequential until 130 obese/over- weight women were found. Thus, 1000 nulliparous women who attended the clinic were assessed of which, 130 were overweight/obese. Then, 130 women each for the underweight and normal weight groups were randomly selected who were in the same BMI group before pregnancy and in the first trimester. In the overweight/obese group, 10 women left the study (did not deliver in the hospital), 8 women in the underweight group were omitted (6 did not consent to continue in the study and 2 did not deliver in the hospital) and 2 women in the normal weight group did not deliver in the hospital. Therefore, the final sam- ple with the 3 groups was: 122 women in group I (thin group BMI ≤ 19.8 kg/m2), 128 in group II (normal weight BMI = 19.9–24.9 kg/m2) and 120 in group Ш (overweight/obese group BMI ≥ 25 kg/m2. Data collection Data were collected in a form designed by researchers. The form had two parts. The first part recorded demographic characteristics of the women: age, education, residence and BMI. The second recorded information about pregnancy outcomes: labour induction and augmentation, mode of delivery, duration of the first and second stages of labour (first stage: cervical dilation from 3–10 cm; second stage: from full dilation until complete expulsion of the baby), neonate weight, history of moth- er’s hospitalization during pregnancy, gestational age at delivery, gestational hypertension, fetal movement reduc- tion and nonreactive non stress test. Ethical considerations Institutional review board approval was needed as this was not a clinical trial. All the women gave their consent to be included in the study. Statistical analysis Data were analysed using SPSS, version 16. Depending on the variable, chi- squared, multinomial and binary logis- tic regression analyses were performed. P < 0.05 was considered statistically significant. Results The sociodemographic characteristics of the women are shown in Table 1. Their mean age was 24.1 (SD 4.7) years, range 24.4–25.4 years. The mean ages in groups Ι, Π and Ш were 24.6 (SD 4.5), 24.4 (SD 4.5) and 25.4 (SD 4.8) years respectively, with no statisti- cally significant differences (P > 0.05). The majority of the women in all BMI groups were urban residents and were housewives. There was no significant dif- ference between the groups with regard to residence (urban/rural) (P = 0.1) and employment status (employed/ unemployed) (P = 0.3). Based on the chi-squared test, there was a significant Book 23-10.indb 658 12/13/2017 9:40:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما شراعلا ددعلا 659 difference between BMI and level of education (P < 0.001): 21.9% of women in Group II and 20.0% of women in Group III had a university degree com- pared with 8.2% in Group I. Based on multinomial logistic re- gression, BMI did differ significantly with main outcomes: delivery mode (P = 0.407), duration of the first and the second stages of labour (P = 0.579 and P = 0.144 respectively) and neonatal weight (P = 0.271). Table 2 shows the obstetric char- acteristics of the nulliparous women by BMI. Maternal hospitalization his- tory (e.g. for diabetes, urinary tract infec- tions, hypertension and intrauterine growth restriction during pregnancy) was not significantly associated with BMI (P = 0.46). Among the 3 groups, 8 (6.6%) women in group Ι, 10 (7.8%) in group Π and 13 (10.8%) in group Ш had been hospitalized. With regard to gestational age, 10 women (8.2%) in group Ι, 9 (7%) in group Π and 14 (11.7%) in group Ш delivered pre-term (< 38 weeks). Regarding fetal move- ment reduction during pregnancy and labour, 63 women (17%) had fetal movement reduction during pregnan- cy: 28 in group Π (21.9%), 20 in group Ш (16.7%) and 15 in group Ι (12.3%). However, based on chi-squared analysis the differences were not statistically sig- nificant (P = 0.13). Table 3 shows the delivery charac- teristics and neonate weight among the nulliparous women by BMI. The mean duration of the first stage of labour was 196.8 (SD 113.1) minutes in group Ι, 231.7 (SD 99.4) minutes in group Π and 267.1 (SD 112.6) minutes in group Ш. The mean duration of the second stage of labour was 65.7 (SD 37.7) minutes in group Ш, 51.8 (SD 34.4) minutes in group Π and 41 (SD 35.6) minutes in group Ι. The mean weight of the newborns delivered to the women was 3140.1 (SD 385.3) g in group Ι, 3246.8 (SD 449.01) g in group Π and 3332.4 (SD 528.6) g in group Ш. Table 4 shows the logistic regres- sion analysis assessing the effect of BMI on pregnancy and obstetric outcomes. There was no significant difference in caesarean delivery compared with vaginal delivery between groups Π and Ш (OR = 1.9; 95% CI: 0.94–4.16, P = 0.072); however, there was a significant difference between group Ι and group Π (OR = 0.15; 95% CI: 0.03–0.68, P = 0.013). There were significantly more in- strumental deliveries than vaginal deliv- eries in group Ш compared with group Π (OR = 4.6; 95% CI: 1.77–12.03, P = 0.002), but not between groups Ι and Π (OR = 2.4 95% CI: 0.901–6.61, P = 0.078). There was no significant rela- tionship between BMI and gestational age (term, preterm, post-term) in the 3 groups (P = 0.42). According to the logistic regression results, the likelihood of gestational hypertension was significantly lower in group Ι than group Π (OR = 0.01; 95% CI: 0.01–0.23, P = 0.024), but there was no significant difference between groups Ш and Π (OR = 0.96; 95% CI: 0.34–2.44, P = 0.92). The likelihood of a nonreactive nonstress test was significantly higher in group III than group II (OR = 5.7; 95% CI: 1.40–17.06, P = 0.009), but there was no significant difference between groups IΙ and I (OR = 1.66; 95% CI: 0.412–6.69, P = 0.47). The likelihood of induction was not significantly different between groups Π and Ш (OR = 1.4; 95% CI: 0.82–2.45, P = 0.2), but the likelihood induction was significantly lower in group Ι than group Π (OR = 0.43; 95% CI: 0.26–0.73, P = 0.002). The likelihood of augmentation was not significantly different between groups Π and Ш (OR = 1.6; 95% CI: 0.60–4.69, P = 0.32) or groups Ι and Π (OR = 0.5; 95% CI: 0.16–1.54, P = 0.23). Table 1 Sociodemographic characteristics of the nulliparous women by body mass index (BMI) Sociodemographic characteristic Group I BMI ≥ 19.8 kg/m2 (n = 122) Group II BMI 19.9-24.9 kg/m2 (n = 128) Group Ш BMI ≤ 25 kg/m2 (n = 120) P-value1 No. (%) No. (%) No. (%) Education < 0.001 Secondary 60 (49.2) 51 (39.8) 43 (35.8) Diploma 52 (42.6) 49 (38.3) 53 (44.2) University 10 (8.2) 28 (21.9) 24 (20.0) Residence 0.1 Urban 87 (71.3) 101 (78.9) 99 (82.5) Rural 35 (28.7) 27 (21.1) 21 (17.5) Employment 0.3 Employed 4 (3.3) 4 (3.1) 8 (6.7) Unemployed 118 (96.7) 124 (96.9) 112 (93.3) 1Chi-squared test. Book 23-10.indb 659 12/13/2017 9:40:58 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 660 Discussion Our results show that the mean dura- tion of the first stage of labour in the obese/overweight group was sig- nificantly longer than that of the normal weight and thin groups. In addition, women in the thin group had a shorter first stage of labour than the normal weight group. Furthermore, the mean duration of the second stage of labour in obese/overweight group was longer than the normal weight and thin groups and again women in the thin group had a shorter second stage than the normal weight group. These results are similar to those obtained in other studies in the Islamic Republic of Iran (3) and in the United States of America (5,6). However, an Australian study reported no relationship between the duration of the first, second and third stages of labour and BMI (7). In our study, there was no significant difference between the obese/over- weight and normal weight groups in the frequency of caesarean section com- pared with vaginal delivery. However, instrumental delivery was significantly more frequent in the obese/overweight group than the normal weight group; there was no significant difference between the thin and normal weight groups. This might be because of efforts to extend vaginal delivery and reduce caesarean sections. Therefore, the rate of instrumental delivery, such as vacuum- assisted vaginal delivery, has increased to avoid unnecessary caesarean sec- tions. Several studies show an increase in the rate of instrumental delivery in obese women, who in the past would have delivered by caesarean section. In addition, studies in the Islamic Republic of Iran and India have shown a high correlation between maternal obesity and caesarean section and instrumental delivery (2–4,8–10). In our study, the mean weight of neonates in both the obese/overweight and normal weight groups was greater Table 2 Pregnancy and delivery characteristics among the nulliparous women by body mass index (BMI) Variable Group I: BMI ≥ 19.8 kg/m2 (n = 122) Group II: BMI 19.9−24.9 kg/m2 (n = 128) Group Ш: BMI ≤ 25 kg/m2 (n = 120) P-value No. (%) No. (%) No. (%) Maternal hospitalization1 0.46 Yes 8 (6.6) 10 (7.8) 13 (10.8) No 114 (93.4) 118 (92.2) 107 (89.2) Gestational hypertension 0.024 Yes 1 (0.8) 10 (7.8) 9 (7.5) No 121 (99.2) 118 (92.2) 111 (92.5) Fetal movement reduction 0.13 Yes 20 (16.4) 28 (21.9) 20 (16.7) No 102 (83.6) 100 (78.1) 100 (83.3) Nonreactive nonstress test2 0.032 Reactive (normal) 11 (68.8) 22 (78.6) 9 (42.9) Non-reactive (abnormal) 5 (31.2) 6 (21.4) 12 (57.1) Gestational age at delivery3 0.416 Pre-term (< 38 weeks) 10 (8.2) 9 (7.0) 14 (11.7) Term 112 (91.8) 119 (93.0) 106 (88.3) Post-term (≥ 42 weeks) 0 (0) 0(0) 0(0) Labour intervention < 0.001 Induction 45 (36.9) 70 (54.7) 75 (62.5) Augmentation 6 (4.9) 8 (6.2) 10 (8.3) None 71 (58.2) 50 (39.1) 35 (29.2) Delivery mode4 < 0.001 Normal vaginal delivery 103 (86.6) 108 (84.4) 78 (66.1) Caesarean section 2 (1.7) 14 (10.9) 20 (16.9) Instrumental delivery 14 (11.8) 6 (4.7) 20 (16.9) 1For diabetes, urinary tract infections, hypertension and intrauterine growth restriction during pregnancy. 2Includes only the women who had the stress test. 3None of the women was delivered post-term (≥ 42 weeks). 4Data were missing for 3 women in Group I and 2 women in Group III. Book 23-10.indb 660 12/13/2017 9:40:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما شراعلا ددعلا 661 than the thin group, however, there was no significant difference between the obese/overweight group and nor- mal weight group. Other studies have shown a significant association between increased neonatal birth weight and maternal obesity (2,4,8–12). To conclude, our study showed sev- eral pregnancy complications related to higher maternal BMI: increased likeli- hood of longer labour, instrumental delivery and larger babies. Women of childbearing age should be encouraged to maintain a normal BMI. In addition, for both underweight and overweigh/ obese women, pre-pregnancy counsel- ling, health programmes and appro- priate multidisciplinary management should be offered. We categorized the women into 3 groups; in order to de- termine the effect of BMI on pregnancy outcomes more clearly, studies with 4 groups (in which the overweight and obese groups are separated) and larger sample sizes are recommended. Funding: None. Competing interests: None declared. Table 3 Delivery duration and newborn weight among the nulliparous women by body mass index (BMI) Variable Group I BMI ≥ 19.8 kg/m2 Group II BMI 19.9-24.9 kg/m2 Group Ш BMI ≤ 25 kg/m2 P-value1 Mean (SD) Mean (SD) Mean (SD) Duration of the first stage of labour 196.8 (113.1) 231.7 (99.4) 267.1 (112.6) < 0.001 Duration of the second stage of labour 4 (35.6) 51.8 (34.4) 65.7 (37.7) < 0.001 Newborn weight (g) 3140.1 (385.3) 3246.8 (449.01) 3332.4 (528.6) 0.003 1ANOVA. SD = standard deviation. Table 4 Logistic regression analysis of the association between BMI and pregnancy and delivery variables Variable Gp I vs Gp II Gp III vs Gp II OR (95% CI) P-value OR (95% CI) P-value C-section vs normal vaginal 0.15 (0.03−0.68) 0.013 1.9 (0.94−4.16) 0.072 Instrumental vs normal vaginal 2.4 (0.901−6.61) 0.078 4.6 (1.77−12.03) 0.002 Induction 0.43 (0.26−0.73) 0.002 1.4 (0.82−2.45) 0.2 Augmentation 0.5 (0.16−1.54) 0.23 1.6 (0.60−4.69 0.32 Gestational hypertension 0.01 (0.01−0.23) 0.028 0.96 (0.34−2.44) 0.92 Nonreactive nonstress test 1.66 (0.41−6.69) 0.47 5.7 (1.40−17.06) 0.009 References 1. Li N, Liu E, Guo J, Pan L, Li B, Wang P, et al. Maternal prepreg- nancy body mass index and gestational weight gain on preg- nancy outcomes. PLoS One. 2013 Dec 20;8(12):e82310. 2. Moghadami N, Aminikhah B, Davari Tanha F. The effect of maternal body mass index on spontaneous versus induced preterm birth: a prospective study. Tehran Univ Med J. 2009 Jun;67(3):221–5. 3. Dadras A, Ahmadi Z, Danesh-Kojuri M, Hosseini F. Relation- ship between pre-pregnancy body mass index and childbirth outcomes in primiparous women. Iran Journal of Nursing. 2010;22(62):56–64. 4. Sahu MT, Agarwal A, Das V, Pandey A. Impact of maternal body mass index on obstetric outcome. J Obstet Gynaecol Res. 2007 October;33(5):655–9. 5. Kabiru W, Raynor D. Obstetric outcomes associated with increase in BMI category during pregnancy. Am J Obstet Gy- necol. 2004;191:928–32. 6. Baksh L, Bloebaum L, Barley J, Streeter N, Carapezza D, Crow- ley P, et al. Maternal pre-pregnancy body mass index and pregnancy outcomes in Utah. A pregnancy risk assessment monitoring system report; 2005. Salt Lake City (UT): Reproduc- tive Health Program, Utah Department of Health; 2005 (http:// digitallibrary.utah.gov/awweb/awarchive?item=11646, ac- cessed 6June 2017). 7. Doherty DA, Magann EF, Francis JC, Newnham JP. Pre-preg- nancy body mass index and pregnancy outcomes. Int J Gynae- col Obstet. 2006;95:242–7. 8. Pakniat H, Mohammadi F, Ranjkesh F. The impact of body mass index on pregnancy outcome. J Midwifery Reprod Health. 2015;3(2):361–7. 9. Najafi SA. Nomali M, Goudarzi Z, Maslahati A, Mobasheri E. Relationship between body mass index of third trimester of pregnancy and type of delivery. Tehran Univ Med J. 2015 March;72(12):831–7. 10. Behrashi M, Nasr Esfahani T, Behnamfar F, Nikzad H, Mousavi G. Maternal body mass index and complications of pregnancy and labor. Feyz (Journal of Kashan University of Medical Sci- ences). 2000;4(2):18–27. 11. Baeten JM, Bukusi EA, Lambe M. Pregnancy complications and outcomes among overweight and obese nulliparous women. Am J Public Health. 2001 March;91(3):436–40. 12. Nohr EA, Vaeth M, Baker JL, Sørensen TIA, Olsen J, Rasmussen KM. Combined associations of prepregnancy body mass index and gestational weight gain with the outcome of pregnancy. Am J Clin Nutr. 2008;87:1750–9. Book 23-10.indb 661 12/13/2017 9:40:58 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 662 1Department of Obstetrics and Gynaecology, College of Medicine, Qassim University, Al-Mulida, Saudi Arabia (Correspondence to: Mohamed A. Alsammani: m_sammani@yahoo.com). 2Department of Obstetrics and Gynaecology, College of Medicine, University of Bahri, Khartoum, Sudan. 3Department of Obstetrics and Gynaecology, Omdurman Maternity Hospital, Omdurman, Sudan. Received: 13/10/15; accepted: 15/01/17 Factors associated with folic acid knowledge and intake among pregnant women in Sudan Mohamed A. Alsammani 1,2, Abdelillah Kunna 2 and Elsheikh M. Adam 3 Facteurs associés aux connaissances et déterminants concernant l’apport en acide folique parmi les femmes en âge de procréer au Soudan RÉSUMÉ La consommation d’acide folique avant la conception est connue pour avoir un effet protecteur contre les anomalies du tube neural (ATD). La présente étude avait pour objectif d’évaluer les connaissances et déterminants de la sensibilisation à la consommation d’acide folique parmi les femmes enceintes à la maternité de l’hôpital d’Omdourman au Soudan en 2014. Un questionnaire, standardisé et anonyme, a été utilisé pour collecter des données. Près de 80 % des répondants avaient déjà entendu parler de l’acide folique. Les femmes ayant reçu une éducation universitaire (92,2 %) en savaient plus sur l’acide folique et en consommaient davantage souvent durant la période préconceptionnelle (8,3 %). Les médecins étaient la source d’information la plus courante sur l’acide folique (62 %). Un nombre inférieur de sujets (8,9 %) étaient conscients que l’acide folique permet de prévenir les malformations congénitales et 33,8 % des sujets savaient que les légumes vert à feuilles constituent une source d’acide folique. Parmi tous les sujets, seulement 3,2 % en consommaient avant la conception. La supplémentation préconceptionnelle en acide folique doit être prise en compte afin de réduire la forte incidence des ATD constatées au Soudan. نادوسلا ،نامرد مأ في لماولحا ءاسنلا ينب كيلوفلا ضحم لوانت تاددمحو تامولعم مدآ دممح خيشلا ،هنك هللإا دبع ،ىناسلا متالخا دممح ةـساردلا هذـه تدـمع دـقو .يـبصعلا بوـبنلأا بوـيع دـض يـئاقو رـثأ هـل لـملحا لـبق كـيلوفلا ضـحم مادختـسا نأ فورـعلما نـم :ةـصلالخا نادوـسلا في ناـمرد مأـب ةدلاوـلا ىفـشتسم في لـماولحا ءاـسنلا فوـفص في كـيلوفلا ضـحم مادختـساب يـعولا تاددـمحو تاـمولعم مـييقت لىإ نـع نعمـس دـق تابيجتـسلما نـم % 80 وـحن نأ ينـبتو .تاـنايبلا عـجم لـجأ نـم ءاـسلأا لـّهمج دـحوم نايبتـسا مدخُتـساو .2014 ماـع لاـخ ةـلحرم في نـهيرغ نـم رـثكأ هنمدختـسا اـك كـيلوفلا ضـمحب ىـعأ ةـفرعم )% 92.2( تاـيعمالجا ءاـسنلا تلجـسو .لـبق نـم كـيلوفلا ضـحم نـم لـقأ ددـع نأ ينـبتو .)% 62( كـيلوفلا ضـمحب ةـقلعتلما تاـمولعملل اعويـش رداـصلما رـثكأ ءاـبطلأا لكـشو .)% 8.3( لـملحا لـبق اـم ةـفرعم ىـع نـك تاكراـشلما % 33.8 نأو ،ةـيدلاو بوـيع ثودـح نود لوـيح كـيلوفلا ضـحم نأـب ةـفرعم ىـع نـك )% 8.9( ةـساردلا دارـفأ ىوتـسم طـبتراو .لـملحا لـبق اـم ةـلحرم في هنمدختـست طـقف % 3.2 نأو .كـيلوفلا ضـحم رداـصم نـم ًاردـصم لـثتم ةـيقرولا تاورـلخا نأـب مادختـسا في رـظنلا بـيجو .)P<0.05( ةدلاوـلا لـبق اـم ةـياعر ىـع لوـصلحاو ،مـيلعتلا ىوتـسم عاـفتراو ،ةـيرلحا قـطانلما في شـيعلاب يـعولا .نادوـسلا في يـبصعلا بوـبنلأا بوـيعب ةـباصلإا لدـعم ضـفخ لـجأ نـم ةدلاوـلا لـبق اـم ةـلحرم في كـيلوفلا ضـحم تاـمكم ABSTRACT Preconceptual folic acid use is known to have a protective effect against neural tube defects (NTDs). This study assessed knowledge and determinants of awareness on folic acid use among pregnant women at Omdurman Maternity Hospital, Sudan during 2014. The standardized, anonymous questionnaire was used to collect data. Almost 80% of respondents had heard of folic acid. College-educated women (92.2%) knew more about folic acid and used it more often in the pre-conceptual period (8.3%). Doctors were the commonest source of information on folic acid (62%). Fewer subjects (8.9%) knew that it prevented birth defects, and 33.8% of subjects knew that green leafy vegetables are a source of folic acid. Of all subjects, only 3.2% use it pre- conceptually. Supplementation of folic acid preconceptually needs to be addressed in order to reduce the rate of NTDs found in Sudan. https://doi.org/10.26719/2017.23.10.662 Book 23-10.indb 662 12/13/2017 9:40:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 663 Introduction Many studies have shown associations between neural tube defects and in- adequate maternal intake of folic acid before or during pregnancy and that folic acid supplementation could reduce neural tube defects (1–4). It has been recommended that during routine gynaecological visits women of reproductive age should be counselled to adjust their daily folic acid intake (5). It has been reported that more than 300 000 cases of neural tube defects oc- cur worldwide each year, and many are in low-income countries (6). While the incidence of neural tube defects is falling in the United States of America (USA) and Western Europe, these congeni- tal abnormalities remain a significant health problem in Africa (6). In the United Kingdom, the birth prevalence of neural tube defects per 1000 births decreased by 93%, from 3.6 in 1964 to 0.3 in 2004; this decline was due to the adequate intake of folic acid (7). A study in Omdurman Maternity Hospital, Sudan in 2003/2004reported an incidence of neural tube defects of 3.5 per 1000 deliveries (8). None of moth- ers of babies with neural tube defects or the control mothers had received preconception folate supplements. This high incidence of neural tube defects may indicates a lack of knowledge and adequate intake of folic acid among pregnant women in Omdurman Ma- ternity Hospital. All women receiving antenatal care at Omdurman Maternity Hospital are advised to take folic acid tablets during pregnancy. No previous study has been con- ducted among Sudanese women of reproductive age about their awareness and intake of folic acid. The aim of the present study therefore was to deter- mine knowledge of folic acid and the determinants of folic acid use among pregnant women attending Omdur- man Maternity Hospital. Methods Study design This was a cross-sectional study con- ducted at Omdurman Maternity Hospi- tal, Sudan from August 2014 to January 2015. The population of Omdurman city was 2 395 159 in 2008.Founded in 1957, Omdurman Maternity Hospital is the largest tertiary maternity hospital in Sudan with 25 000–30 000 births a year. In addition to the city population, the hospital serves a large non-urban area. Study sample and sample size The study sample was drawn from women who were visiting the antenatal clinics of Omdurman Maternity Hospi- tal for routine antenatal care during the study period, August 2014 to January 2015. All women attending the antena- tal clinic who were willing to participate were included in the study. In estimating the prevalence of folic acid awareness, it was assumed that the results for Sudan would be similar to that of Nigeria at 64% (9). With an er- ror rate of 2.5%, a level of significance (type 1 error) of 1%, and 99% confi- dence interval (CI), a sample size of 1048 women was needed to achieve the objective of our study assuming10% nonresponse. Data collection Data were collected using a question- naire administered to each woman by a senior registrar in obstetrics and gy- naecology. The questionnaire consisted of data on the knowledge and use of folic acid, sources of knowledge, period folic acid was taken, and knowledge of the potential benefits of taking folic acid supplements. In addition, selected sociodemographic and obstetric data were gathered: age, education, occupa- tion, residence, parity, prior abortions, booking status (i.e. early 1st trimester antenatal visit with booking to deliver in the hospital), antenatal care use and trimester when antenatal care was started. The questionnaire contained cri- teria for folic acid intake and knowl- edge related to trimester of pregnancy. Questions used to assess knowledge were whether respondents had ever heard about folic acid (yes/no) and whether they knew the appropriate time to take folic acid (preconception, first trimester, throughout pregnancy or never). Furthermore, participants were asked if they knew the beneficial effects of folic acid (protection against neural tube defects) and the sources of food containing folic acid (green veg- etables). Preconception intake of folic acid is considered effective use based on WHO recommendations (10) and green vegetables were considered an appropriate source of folic acid Statistical analysis SPSS, version 15.0 was used to record and analyse the data. Descriptive analyses were used: proportions were compared between women who had heard of folic acid and those who had not. Bivariate and multivariable analyses were performed, one with awareness of folic acid as the dependent variable, and the other with preconception intake of folic acidas the dependent variable. The independent variables included in the analyses were: age (<18, 18–30, 31–40, ≥ 41 years), residence (urban, rural), education (illiterate, primary, second- ary, higher secondary, university and above), occupation (housewife, self- employed business woman, employee, labourer), parity (0, 1–4, ≥ 5), prior abortion (yes, no), antenatal care – at least one visit (yes/no), first entry into antenatal care (1st, 2nd, 3rd trimes- ter) and booking status(booked, not booked). Adjusted odds ratios (OR) and 95% CIs were estimated. A P-value < 0.05 was considered statistically sig- nificant. Book 23-10.indb 663 12/13/2017 9:40:58 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 664 Ethical considerations The study was approved by the ethics committees of the Sudanese specializa- tion board and the Omdurman Mater- nity Hospital. Informed verbal consent to participate in the study was obtained from each women. Results A total of 1 300 women were ap- proached and 1 150 aged 18–45 years agreed to participate and were inter- viewed; of these, 1 000 (86.9%) women were included in the study, while 150 were excluded because of incomplete information (declined to give informa- tion). Table 1 shows the characteristics of the women and their knowledge and intake of folic acid. Of the 1 000 women included in the study, 813 (81.3%) had heard of folic acid. Of those who had heard of folic acid, the highest propor- tion (85.7%) was in the age group < 18 years and the lowest was the 41 years and older age group (72.4%). Aware- ness was highest among multiparous women (parity 1–4) (85.1%) and women who had a university degree or higher (88.8%). With regard to folic acid intake, few women (< 4%) took it during the preconception period but more women who had a university de- gree or higher used it in the first trimes- ter (66.3%) than less educated women. The majority of the women (91.2%) had attended at least one antenatal care visit, 72.9% of whom were booked. The majority of the women 61.3 % (n = 613) had started their antenatal care in the first trimester. Table 2 shows the participants’ knowledge about folic acid. With regard to sources of information on the benefits of folic acid, 62% of the women got their information from doctors, followed by newspapers at 21%; the least mentioned source of information was family mem- bers, 3%. The greatest proportion of the women (24.7%) stated that folic acid prevents anaemia; few women (8.9%) knew that it prevents birth defects. In addition, only 3.8% of the women were aware that green leafy vegetables were rich in folic acid. Table 3 show the multivariable lo- gistic regression analysis of the factors associated with ever having heard about folic acid. The variables significantly as- sociated with awareness of folic acid were living in urban areas (OR = 2.17, 95% CI: 1.51–3.21, P < 0.001), and attending antenatal care (OR = 2.2, 95% CI: 1.27–3.96, P = 0.005). Maternal age, occupation, parity, the time of starting antenatal care, prior abortion and being booked were not associated with folic acid awareness. Multivariable logistic regression analysis of the association between soci- odemographic and obstetric character- istics and preconception use of folic acid is shown in Table 4. Preconception use of folic acid was significantly associated with living in urban areas (OR = 1.80, 95% CI: 1.35–2.40, P < 0.001), past history of abortion (OR = 1.42, 95% CI: 1.05–1.92, P = 0.022), being booked (OR = 1.60, 95% CI: 1.16–2.25, P = 0.005) and first trimester enrollment in antenatal care (OR = 1.70, 95% CI: 1.07–2.73, P = 0.024). Discussion In the present study, about 80% of the women had heard about folic acid, but only 8.9% knew that folic acid prevents birth defects and 3.2% used it during the preconception period, while 55.2% used it during the first trimester. In- formation about folic acid was mostly from physicians (62%) and 33.8% of the participants knew that green leafy vegetables are rich in folic acid. A higher level of education, living in an urban area and attending antenatal care were significantly associated with awareness of folic acid. In addition, higher level of education, living in an urban area, first trimester enrollment in antenatal care and being booked were significantly associated with preconception use of folic acid. The level of awareness of folic acid in the present study (80%) is higher than that reported in Egypt (62.4%) (11), Lebanon (60%) (12) and Nigeria (37%) (13), but lower than the preva- lence reported from Jordon (93.4%) (14) and Saudi Arabia (88.4%) (15) (Table 5). In our study, a large propor- tion of the women aged18–30 years (82.9%) had heard of folic acid, which is in agreement with previously published data (16). A possible reason for this awareness is that women in this age group are just starting their reproduc- tive lives and may be more receptive to information compared with older mothers. Almost half of all birth defects are of unknown causes. For neural tube de- fects, folate deficiency is considered the most important nutritional risk factor, and supplementation with preconcep- tion folic acid has been associated with a reduced risk of neural tube defects (17,18). The World Health Organiza- tion recommends that all women when first trying to conceive should take a daily supplementation of 400 μg of fo- lic acid and continue until 12 weeks of gestation (19).According to our study, despite the high level of awareness of folic acid, only 3.2% of the women used it before conception, which is lower than in other Middle East countries including Lebanon (6.2%) (12), Egypt (8.8%) (11), Jordon (16.9%) (14) and Israel (17.6%) (1) (Table 5). This dif- ference in preconception use can be explained by differences in educational levels between countries. The most common source of in- formation on folic acid in the present study was doctors (62%), followed by newspapers (21%); this result is in accordance with previously regional data (11,12,14,18). However, the fact that most women knew about folic acid but so few used it before conception Book 23-10.indb 664 12/13/2017 9:40:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 665 indicates that there is a real need for a regional campaign to motivate women to take folic acid supplements as recom- mended. Furthermore, folic acid intake can be improved by administration of folic acid during premarital health eval- uation for genetic abnormalities and serology screening as done in China, and by educating couples about the role of folic acid in preventing neural tube defects. In China, premarital health examination increased adequate use by 20% (20).The United States Food and Drug Administration started the policy of folic acid fortification of grain Table 1 Sociodemographic characteristics of the women according to awareness and intake of folic acid Characteristic Total (n = 1000) Ever heard of folic acid Time of folic acid intake Any time after first trimester Preconception First trimester No. (%) No. (%) No. (%) No. (%) No. (%) Age (years) < 18 14 (1.4) 12 (85.7) 3 (21.4) 1 (7.1) 7 (50.0) 18- 636 (63.6) 527 (82.9) 130 (20.4) 23 (3.6) 361 (56.8) 31- 292 (29.2) 232 (79.5) 69 (23.6) 8 (2.7) 152 (52.1) ≥ 41 58 (5.8) 42 (72.4) 12 (20.7) 0 (0) 27 (46.6) Residence Urban 628 (62.8) 539 (85.8) 123 (19.6) 21 (3.3) 385 (61.3) Rural 372 (37.2) 274 (73.7) 93 (25.0) 11 (3.0) 167 (44.9) Education Illiterate 209 (20.9) 163 (78.0) 41 (19.6) 3 (1.4) 112 (53.6) Primary 258 (25.8) 197 (76.4) 52 (20.2) 10 (3.9) 134 (51.9) Secondary 284 (28.4) 239 (84.2) 66 (23.2) 9 (3.2) 158 (55.6) Higher secondary 160 (16.0) 135 (84.4) 41 (25.6) 7 (4.4) 86 (53.8) University and above 89 (8.9) 79 (88.8) 16 (18.0) 3 (3.4) 59 (66.3) Occupation Housewife 874 (87.4) 700 (80.1) 201 (23.0) 15 (1.7) 475 (54.3) Employee 81 (8.1) 75 (92.6) 7 (8.6) 17 (21.0) 51 (63.0) Labourer 35 (3.5) 29 (82.9) 6 (17.1) 0 (0) 19 (54.3) Self-employed business woman 10 (1.0) 9 (90.0) 2 (20.0) 0 (0) 7 (70.0) Parity 0 666 (66.6) 545 (81.8) 139 (20.9) 25 (3.8) 378 (56.8) 1- 175 (17.5) 149 (85.1) 33 (18.9) 4 (2.3) 104 (59.4) ≥5 159 (15.9) 119 (74.8 44 (27.7) 3 (1.9) 70 (44.0) Prior abortion Yes 271 (27.1) 221 (81.5) 65 (24.0) 3 (1.1) 137 (50.6) No 729 (72.9) 592 (81.2) 151 (20.7) 29 (4.0) 409 (56.1) Antenatal care (at least one visit) Yes 912 (91.2) 754 (82.7) 201 (22.0) 31 (3.4) 513 (56.3) No 88 (8.8) 59 (67.0) 15 (17.0) 1 (1.1) 39 (44.3) Antenatal care entry 1st trimester 613 (61.3) 534 (81.7) 105 (17.1) 24 (3.9) 386 (63.0) 2nd trimester 192 (19.2) 138 (71.9) 62 (32.3) 3 (1.6) 71 (37.0) 3rd trimester 92 (9.2) 64 (69.2) 23 (25.0) 2 (2.2) 37 (40.2) Booking Booked 742 (74.2) 615 (82.9) 158 (21.3) 24 (3.2) 430 (58.0) Not booked 258 (25.8) 198 (76.7) 58 (22.5) 8 (3.1) 106 (41.1) Book 23-10.indb 665 12/13/2017 9:40:58 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 666 products to increase the intake of wom- en during their reproductive years by a daily dose of 100 μg (21). This policy resulted in a decline in the prevalence of spina bifida by 31% and neural tube defects by 6% (22). Of the women surveyed, only 8.9% knew that folic acid prevents birth de- fects. This percentage is comparable to the rate in Qatar (8.7%) (23), but lower than rates in Saudi Arabia (15) and the United Arab Emirates (24), 11.2% and 14% respectively. In our study, lack of knowledge and less preconception use of folic acid may explain the high rate of neural tube defects prevalence (12.5/10 000 births) in our setting (25),com- pared with rates of 2/10 000, 3.3/10 000, and 0.4/10 000 births reported from Egypt, Nigeria and Saudi Arabia respectively (25). The present study demonstrated the association between awareness of folic acid and living in urban areas, higher- level of education and antenatal care attendance. This finding is consistent with previous studies which concluded that women with higher education knew more about folic acid and were more likely to use it (2,20). Women living in rural areas and having a lower education level knew less about folic acid and were less likely to use it (9). Also, our study showed a significant association between preconception use of folic acid and living in urban areas, being booked, a higher level of educa- tion and antenatal care attendance. On the other hand, some studies failed to demonstrate any association between sociodemographic characteristics and folic acid use (25). As our study was in only one hospi- tal in Sudan rather than a multicentre study, our sample may not be repre- sentative of the population so the results cannot be generalized to wider popu- lation. Further studies in other parts of Sudan would be useful to provide information on folic acid use for the whole country. Conclusion Our study has shown that the pre- conception use of folic acid among women in Omdurman is inadequate. Women who had higher education, lived in urban areas, were booked, and had attended antenatal care knew more about preconception use of folic acid and used it significantly more. Doctors were the main source of information on folic acid. Given the low rates of use of fo- lic acid found in our study and the high prevalence of neural tube defects in Su- dan, programmes to promote folic acid use and supplementation with folic acid at the time of premarital examination until the end of the first trimester are warranted. Funding: None. Competing interests: None declared. Table 2 Knowledge on folic acid among studied women Knowledge questiona No. (%) Sources of information on folic acid Doctor 620 (62.0) Newspaper 210 (21.0) Nurse 121 (12.1) Pharmacist 150 (15.0) Family member 30 (3.0) Television 118 (11.8) Effect of folic acid intake before and during pregnancy Prevents birth defects 89 (8.9) Good for body 77 (7.7) Prevents anaemia 247 (24.7) Good for bones 76 (7.6) Helps growth and development 102 (10.2) Good for pregnant women 71 (7.1) Not sure 89 (8.9) Pre-conception use 32 (3.2) Foods rich in folic acid Green leafy vegetables 338 (33.8) Fish 174 (17.4) Fruits 250 (25.0) Liver 206 (20.6) Milk 372 (37.2) Do not know 284 (28.4) Type of vitamin tablets taken Folic acid 192 (19.2) Iron 163 (16.3) Multivitamins 134 (13.4) Calcium 61 (6.1) None 450 (45.0) aMultiple responses were permitted (percentages do not add to 100%). Book 23-10.indb 666 12/13/2017 9:40:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 667 Table 3 Association of awareness of folic acid with selected demographic and obstetric characteristics Variable Bivariate analysis Multivariable analysis OR (95%CI) P-value OR (95%CI) P-value Age (years) < 18a 18− 1.24 (0.27–5.62) 0.779 0.45 (0.08–2.44) 0.35 31− 1.55 (0.34–7.12) 0.572 0.85 (0.41–1.77) 0.66 ≥ 41 2.29 (0.46–11.36) 0.312 0.97 (0.47–1.99) 0.93 Residence Rurala Urban 2.17 (1.57–2.99) < 0.001 2.17 (1.51–3.21) < 0.001 Education Illiteratea Primary 1.097 (0.71–1.7) 0.676 1.9 (0.89–4.08) 0.096 Secondary 0.667 (0.42–1.05) 0.082 1.8 (0.87–3.84) 0.113 Higher secondary 0.656 (0.38–1.12) 0.125 1.1 (0.54–2.44) 0.725 University and above 0.45 (0.22–0.94) 0.032 1.1 (0.49–2.48) 0.806 Occupation Employeea Housewife 0.32 (0.14–0.75) 0.009 1.61 (0.20–13.22) 0.660 Labourer 0.83 (0.34–2.04) 0.688 0.71 (0.07–6.85) 0.768 Self-employed business woman 0.45 (0.06–0.55) 0.446 1.23 (0.12–12.40) 0.862 Parity 1a 1− 0.79 (0.50–1.25) 0.306 0.88 (0.53–1.45) 0.609 ≥5 1.51 (1.01–2.28) 0.047 0.63 (0.34–1.17) 0.142 Prior abortion Yesa No 1.02 (0.71–1.46) 0.902 1.01(0.69–0.49) 0.951 Antenatal care (at least one visit) Noa Yes 2.30 (1.46–3.78) < 0.001 2.20 (1.27–3.96) 0.005 Antenatal care entry Not useda 1sttrimester 0.44 (0.27–0.73) 0.001 0.58 (33–1.02) 0.059 2nd trimester 1.16 (0.67–2.00) 0.596 1.35 (0.73–2.49) 0.341 3rd trimester 1.32 (0.70–2.47) 0.392 1.75 (0.88–3.48) 0.114 Booked Yesa No 1.50 (1.04–2.08) 0.030 0.85 (0.56–1.29) 0.449 aReference category. OR = odd ratios; CI = confidence interval. Book 23-10.indb 667 12/13/2017 9:40:58 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 668 Table 4 Association of preconception intake of folic acid with selected demographic and obstetric characteristics Variable Bivariate analysis Multivariable analysis OR (95%CI) P-value OR(95%CI) P-value Age (years) < 18a 18- 1.7 (0.57–4.88) 0.345 0.84 (0.23–3.07) 0.789 31- 1.4 (0.47–4.1) 0.552 0.87 (0.46–1.65) 0.676 ≥ 41 1.0 (0.31–3.29) 0.987 0.88 (0.47–1.67) 0.706 Residence Rurala Urban 2.1 (1.58–2.67) < 0.001 1.80 (1.35–2.40) < 0.001 Education Illiteratea Primary 0.91 (0.63–1.32) 0.630 1.02 (0.69–1.51) 0.917 Secondary 1.02 (0.71–1.46) 0.906 1.04 (0.71–1.52) 0.842 Higher secondary 0.95 (0.63–1.43) 0.792 0.99 (0.64–1.54) 0.967 University and above 1.96 (1.162–3.30) 0.012 1.70 (0.98–2.97) 0.059 Occupation Employeea Housewife 0.96 (0.49–1.88) 0.899 1.15 (0.21–6.34) 0.194 Self-employed business woman 2.10 (0.54–8.21) 0.282 1.10 (0.55–2.18) 0.747 Labourer 1.10 (0.91–2.33) 0.114 0.55 (0.11–2.70) 0.462 Parity 0a 1- 1.12 (0.80–1.58) 0.495 1.23 (0.85–1.76) 0.27 ≥5 0.523 (0.37–0.75) < 0.001 0.67 (0.45–1.05) 0.08 Prior abortion Yesa No 0.76 (0.57–1.00) 0.051 1.42 (1.05–1.92) 0.022 Antenatal care (at least one visit) Noa Yes 1.90 (1.23–3.02) 0.004 1.45 (0.87–2.4) 0.154 Antenatal care entry Not useda 1st trimester 1.80 (1.18–2.73) 0.006 1.70 (1.07–2.73) 0.024 2nd trimester 0.66 (0.40–1.07) 0.091 0.70 (0.41–1.20) 0.194 3rd trimester 0.98 (0.56–1.73) 0.950 0.90 (0.49–1.66) 0.747 Booking Noa Yes 2.20 (1.67–2.98) < 0.001 1.60 (1.16–2.25) 0.005 aReference category. OR = odds ratio; CI = confidence interval. Book 23-10.indb 668 12/13/2017 9:40:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 669 References 1. Amitai Y, Fisher N, Haringman M, Meiraz H, Baram N, Lev- enthal A. Increased awareness, knowledge and utilization of preconceptional folic acid in Israel following a national cam- paign. Prev Med. 2004 Oct;39(4):731–7. PMID:15351539 2. Abdulrazzaq YM, Al-Gazali LI, Bener A, Hossein M, Verghese M, Dawodu A, et al. Folic acid awareness and intake survey in the United Arab Emirates. Reprod Toxicol. 2003 Mar- Apr;17(2):171–6. PMID:12642149 3. de Walle HE, de Jong-van den Berg LT. Insufficient folic acid intake in the Netherlands: what about the future? Teratology. 2002 Jul;66(1):40–3. PMID:12115779 4. Group MVSR; MRC Vitamin Study Research Group. Preven- tion of neural tube defects: results of the Medical Research Council Vitamin Study. Lancet. 1991 Jul 20;338(8760):131–7. PMID:1677062 5. Cleves MA, Hobbs CA, Collins HB, Andrews N, Smith LN, Robbins JM. Folic acid use by women receiving routine gy- necologic care. Obstet Gynecol. 2004 Apr;103(4):746–53. PMID:15051568 6. Fonseca EB, Raskin S, Zugaib M. Folic acid for the preven- tion of neural tube defects. Rev Bras Ginecol Obstet. 2013 Jul;35(7):287–9. PMID:24080839 7. Morris JK, Wald NJ. Prevalence of neural tube defect pregnan- cies in England and Wales from 1964 to 2004. J Med Screen. 2007;14(2):55–9. PMID:17626701 8. Elsheikh G, Ibrahim SA, Mahgoub F, Thorne J, Lewis M. Deliv- eries of babies with neural tube defects in Omdurman, Sudan. Cerebrospinal Fluid Res. 2004;1(1):1. PMID:15679934 9. Anzaku AS. Assessing folic acid awareness and its usage for the prevention of neural tube defects among pregnant women in Jos, Nigeria. J Basic Clin Reprod Sci. 2013;2(1):13–7. 10. World Health Organization, Department of Nutrition for Health and Development, Evidence and Programme Guid- ance Unit. Periconceptional daily folic acid (400 µg) supple- mentation for prevention of neural tube defects. (www.who. int/selection_medicines/committees/expert/20/applica- tions/Folic_acid.pdf?ua=1, accessed 2 October 2017). 11. Al-Darzi W, Al-Mudares F, Farah A, Ali A, Marzouk D. Knowl- edge of periconceptional folic acid use among pregnant women at Ain Shams University Hospital, Cairo, Egypt. East Mediterr Health J. 2014 10 12;20(9):561–8. PMID:25343469 12. Nasr Hage C, Jalloul M, Sabbah M, Adib SM. Awareness and intake of folic acid for the prevention of neural tube defects among Lebanese women of childbearing age. Matern Child Health J. 2012 Jan;16(1):258–65. PMID:21210201 13. Lawal TA1, Adeleye AO. Determinants of folic acid intake during preconception and in early pregnancy by mothers in Ibadan, Nigeria. Pan Afr Med J. 2014 Oct 1;19:113. PMID:25722786 14. Alebous HD, Ma’aita ME, Alkhazaleh FA. Folic acid and neural tube defects: are Jordanian pregnant women aware? Clin Exp Obstet Gynecol. 2014;41(6):647–53. PMID:25551956 15. Al-Akhfash AA, Abdulla AM, Osman AM, Abdulgafar JI, Almesned AA. Maternal knowledge and use of folic acid among Saudi females. Saudi Med J. 2013 Nov;34(11):1173–8. PMID:24252897 16. Wu DY, Brat G, Milla G, Kim J. Knowledge and use of folic acid for prevention of birth defects amongst Honduran women. Reprod Toxicol. 2007 Jun;23(4):600–6. Epub2007Feb12. PMID:17398068 17. Wolff T, Witkop CT, Miller T, Syed SB; U.S. Preventive Services Task Force. Folic acid supplementation for the prevention of neural tube defects: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2009 May 5;150(9):632–9. PMID:19414843 18. Fernández-Gaxiola AC, De-Regil LM. Intermittent iron sup- plementation for reducing anaemia and its associated impair- ments in menstruating women. Cochrane Database Syst Rev. 2011 12 7; (12):CD009218. PMID:22161448 19. World Health Organization. Standards for maternal and neonatal care. Prevention of neural tube defects. 2007 (www. who.int/reproductivehealth/publications/maternal_perina- tal_health/neural_tube_defects.pdf?ua=1, accessed 2 June 2017). 20. Ren A, Zhang L, Li Z, Hao L, Tian Y, Li Z. Awareness and use of folic acid, and blood folate concentrations among pregnant women in northern China–an area with a high prevalence of neural tube defects. Reprod Toxicol. 2006 Oct;22(3):431–6. PMID:16549319 21. Erickson JD. Folic acid and prevention of spina bifida and an- encephaly. 10 years after the U.S. Public Health Service recom- mendation. MMWR Recomm Rep. 2002 Sep 13;51 RR-13:1–3. PMID:12353506 22. Williams LJ, Mai CT, Edmonds LD, Shaw GM, Kirby RS, Hobbs CA, et al. Prevalence of spina bifida and anencephaly during the transition to mandatory folic acid fortification in the United States. Teratology. 2002 Jul;66(1):33–9. PMID:12115778 23. Bener A, Al Maadid MG, Al-Bast DA, Al-Marri S. Maternal knowledge, attitude and practice on folic acid intake among Arabian Qatari women. Reprod Toxicol. 2006 Jan;21(1):21–5. PMID:16112540 24. Kari JA, Bardisi ES, Baitalmal RM, Ageely GA. Folic acid awareness among female college students: neural tube de- fects prevention. Saudi Med J. 2008 Dec;29(12):1749–51. PMID:19082226 25. Zaganjor I, Sekkarie A, Tsang BL, Williams J, Razzaghi H, Mulin- are J, et al. Describing the prevalence of neural tube defects worldwide: a systematic literature review. PLoS One. 2016 Apr 11;11(4):e0151586. PMID: 27064786 Table 5 Folic acid awareness and preconception among women of child-bearing age in some countries County (reference) Year Sample size City Awareness of folic acid (%) Pre-conception use (%) Sudan (present study) 2015 1 000 Omdurman 80.0 3.2 Egypt (10) 2102 660 Cairo 62.4 8.8 Jordon (14) 2014 1 000 Amman 93.4 16.9 Lebanon(12) 2012 600 Lebanon 60.0 6.2 Israel (1) 2008 1 860 Israel 90.3 17.6 Qatar (19) 2006 1 800 All Qatar 53.7 - Saudi Arabia (13) 2012 1 000 Qassim 88.4 4.4 Nigeria (11) 2014 602 Ibadan 37.0 2.5 Book 23-10.indb 669 12/13/2017 9:40:58 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 670 1Department of Community Medicine, College of Medicine, Hawler Medical University, Erbil, Iraq (Correspondence to: Wali Omer: waliomer@ yahoo.com; wali.omer@hmu.edu.iq). Received: 11/05/16; accepted: 23/01/17 Developing a socioeconomic index for health research in Iraq Wali Omer 1 and Tariq Al-Hadithi 1 Élaboration d’un indice socioéconomique pour la recherche en santé en Iraq RÉSUMÉ Bien que le statut socioéconomique soit l’un des facteurs essentiels dans la plupart des recherches en santé, celui-ci reste une des notions les plus difficiles à cerner. La présente étude vise à proposer une méthode relativement précise et facile afin d’évaluer ce statut socioéconomique pour les recherches en santé en Iraq, ainsi que dans les pays au profil similaire dans le monde en développement. Après avoir passé en revue diverses méthodes de calcul du statut socioéconomique, une nouvelle méthode basée sur trois variables dominantes est suggérée : le niveau d’éducation, l’activité professionnelle et le capital/revenu. Une amélioration supplémentaire est obtenue en prenant en considération l’expérience et le statut professionnel. La validité du contenu a été calculée en s’appuyant sur les avis d’experts et la fiabilité test-retest. En se fondant sur les avis d’experts, il a été constaté que le ratio de validité de contenu calculé pour l’indice socioéconomique était relativement élevé et la fiabilité du coefficient de corrélation pour les six variables (niveau d’éducation, activité professionnelle, revenu, capital, expérience et statut professionnel) était très élevée. Ainsi, la méthode suggérée est raisonnablement valable, fiable ainsi que facile à calculer. قارعلا في ةيحصلا ثوحبلل يداصتقاو يعماتجا سايقم دادعإ يثيدلحا قراط ،رمع ليو لا وــ هف ،ةــ يحصلا ثوــ حبلا نــ م يرــ ثك في ةــ يرهولجا لــ ماوعلا دــ حأ لــ ثمي يداــ صتقلااو يــ عاتجلاا عــ ضولا نأ نــ م مــ غرلا ىــ ع :ةــ صلالخا يـعاتجلاا عـضولا باـستحلا ابهاـسح لهـسيو ًايبـسن ةـقيقد ةـقيرط ةـساردلا هذـه حرـقتو .ًءاصعتـسا روـملأا رـثكأ نـم ةدـحاو لكـشي لازـي ةـفلتخلما بيلاـسلأا ضارعتـسا دـعبو .يـمانلا لماـعلا في ةـلثاتلما تاـسترلما تاذ نادـلبلا بـناج لىإ ،قارـعلا في ةـيحصلا ثوـحبلل يداـصتقلاا /ةورـثلاو ةـفيظولاو مـيلعتلا :يـهو ةدئاـس تايرـغتم 3 لىإ دنتـست ةدـيدج ةـقيرط داـتعا حرـقُي ،يداـصتقلاا يـعاتجلاا عـضولا باـستحلا ءابرــ لخا ءارآ قــ يرط نــ ع ىوــ تحلما ةــ يحاص تبــ سُتحاو .يــ فيظولا عــ ضولاو تابرــ لخا ةاــ عارم قــ يرط نــ ع فياــ ضإ ينــ ستح ىرــ يجو .لــ خدلا سايقلم بـستحلما ىوتحلما ةـيحاص لدـعم نأ ينـبت ،ءابرـلخا ءارآ لىإ ًادانتـساو .راـبتخلاا ةداـعإ/رابتخلاا ةـقيرط مادختـساب ةـيقوثولما تبـستحاو لـ خدلاو ةـ فيظولاو مـ يلعتلا( تايرـ غتم ةتـ سل طاـ بترلاا لـ ماعم ةـ يقوثوم تلجـ س اـ ك ًايبـ سن ًاـ عفترم ناك يداـ صتقلااو يـ عاتجلاا عـ ضولا .ابهاـستحا لهـسي اـك ةـقوثومو ةـلحاص ةـحرقلما ةـقيرطلا دـعت ،لياـتلابو .ةـياغلل ًاـعفترم ىوتـسم )يـفيظولا عـضولاو ةبرـلخاو ةورـثلاو ABSTRACT Although socioeconomic status is one of the essential factors in much health research, it is one of the most difficult constructs to measure. The aim of this study was to develop a relatively accurate, easy-to-calculate method to estimate socioeconomic status (SES) for health research in Iraq as well as similar profile countries in the developing world. After reviewing various methods of calculating SES, a new method is proposed based on the 3 main variables: education, occupation and wealth/income. Additional refinement was done based on experience and job status. Content validity was calculated through experts’ opinions and reliability through test/retest. Based on experts’ opinions, it was found that the calculated content validity ratio for the SES index was relatively high and the correlation coefficient reliability for the six variables (education, occupation, income, wealth, experience and job status) was very high. Thus, the suggested method is reasonably valid, reliable as well as easy to calculate. https://doi.org/10.26719/2017.23.10.670 Book 23-10.indb 670 12/13/2017 9:40:58 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 671 Introduction Socioeconomic status (SES) has been shown by many studies to be related to almost all health conditions as well as their risk factors. These include but are not limited to: overall mortality, child mortality, maternal mortality, chronic diseases, communicable diseases, health behaviour and use of health services (1-4). Health researchers are usually required to analyse their finding accord- ing to SES. Outside the health field, studies have also shown that SES is related to many important aspects of life including language development, political participation, vulnerability and crime rates (5). SES can be defined as “one’s access to financial, social, cultural, and human capital resources” (6). It has also been defined as “the relative position of an individual or family within a hierarchical social structure, based on their access to, or control over, wealth, prestige, and power” (7). Although SES is one of the essen- tial factors in the majority of health research, it is still one of the most dif- ficult constructs to capture. The dif- ficulty arises from the fact that SES is not a single variable like height or weight that can be easily measured. SES is the result of the interaction of many variables, which are themselves difficult to measure, such as income, wealth and occupation (6,8–11). This is especially problematic for health researchers who are not specialized in social sciences and just want a relatively accurate yet easy- to-calculate method to measure SES in their study (12). The “big 3” variables of SES are edu- cation, occupation and income and/ or wealth (6,13–15). When examining these 3 variables, we can see that they have 2 dimensions: the first is resource- fulness (education/culture) and the second is resources (income/wealth). Occupation can be viewed as an inter- mediate variable that can affect and be affected by both other variables (16): Education/culture ⇄ Occupation ⇄ Income/wealth. In most cases, these 2 dimensions go together, therefore people with high education are more likely to have higher income and vice versa. But in some cases, they may depart from one another; for example, someone with only primary level education may have a successful private business and amass a great amount of wealth. On the other end of the spectrum, a newly graduated medical doctor may only have negative wealth (debts). Although we have 2 distinct dimen- sions in the SES construct, we usually need to reduce it to one number to as- sign people into socioeconomic classes or levels. This number will be even more useful if it is on a numerical scale; then it would be more amenable to robust statistical analysis (6,8,9,11). Almost all researchers agree that the 3 variables play a major role in defining a person’s SES but the way they use these variables differs to a great extent. Health researchers have used different meth- ods, from assigning a linear number for each variable to the use of regression analysis, and more recently, principal component analysis to calculate the index (9,17). Up to now, there has been no rea- sonably accurate and easy-to-calculate method to measure SES in Iraq that can help health researchers calculate SES for their studies. The aim of this study therefore was to develop such a method for Iraq and possibly for neighbouring and other developing countries. Methods We reviewed the currently used meth- ods for calculating SES index from which we developed a new, relatively ac- curate and easy-to-calculate SES index for health research in Iraq and estimated its validity and reliability. Development of SES equation Based on the aforementioned concept of SES (6,13-16), we can create a simple equation that will calculate the SES as follows: SES = Education + Occupation + Wealth/income The above variables need to be converted into numbers. The coding of education levels in this study was based on the UNESCO 2011 international standard classification of education (18). Education levels are divided into 8 levels. The lowest is illiterate which has the value of zero and the highest is doctoral degree (PhD) or equivalent and is given the value of 7 (Table 1). For occupation, we assigned scores to the most common job titles avail- able in Iraq and neighbouring countries based on the international standard clas- sification of occupations (19). Jobs were classified into 6 categories and a score assigned to each (Table 2). The basic scores were adopted from other studies Table 1 Scores assigned for educational level Educational level Score Illiterate 0 Primary school (or can read and write) 1 Intermediate school 2 High school or vocational 3 Diploma (institute) 4 Bachelor degree (college) 5 Master degree or equivalent, e.g. higher diploma 6 PhD or equivalent 7 Book 23-10.indb 671 12/13/2017 9:40:58 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 672 (20–22) but modified according to the relative importance and prestige of each occupation in Iraq. Modification of the scores was done according to the list of colleges/departments ranked by the required high school score for the academic year 2014-2015 (i.e. mini- mum grades required for admission to colleges/departments in the Kurd- istan Region of Iraq). Every year tens of thousands of students together with their families decide on which occupa- tion/subject to choose. It represents a community’s view of the relative value of each occupation/subject. In case of the wife and students, the occupation of the head of the household is used in calculations. Although education and occupa- tion account for most of the SES score, the equation was made more sensitive by adding wealth and income. The 2 variables to reflect wealth and income were house and car ownership respec- tively. However, car and house own- ership do not have equal weights and their weights are also much lower than those assigned for education and oc- cupation. Thus house ownership was given a weight of 0.5 and car ownership a weight of 0.1. Hence our equation became: SES = Education + Occupation + House ownership * 0.5 + Car ownership * 0.1 To further refine our equation, we added another variable for age (which can represent experience and can affect income/wealth). For ease of data col- lection and calculation, we deducted 20 from the current age and divide by 100 to produce a reasonable weight. The next version of the equation was therefore: SES = Education + Occupation + House ownership * 0.5 + Car ownership * 0.1 + (age-20)/100 To accommodate special cases (re- tired/unemployed people/deceased head of household), we assigned a weight for previous job by deducting 1 unit. Our final equation was therefore: SES = Education + Occupation + House ownership * 0.5 + Car ownership * 0.1 + (age-20)/100 - Retired/unemployed/ deceased Validation To validate the proposed SES method, we tried a number of scenarios to dem- onstrate the limits of each variable, i.e. different education levels, different oc- cupations, house and car ownership, age and employment status. Validity To estimate the content validity of this new method, a modified Lawshe con- tent validity ratio (CVR) (23) was used. CVR = (ne - N2)/N2 where ne denotes number of expert panellists indicating an “essential” com- ponent and N2 denotes total number of experts. The new method was given to 12 experts in the field of public health during a workshop that was held to es- timate its content validity. They were asked whether any of the 6 components of the equation (education, occupa- tion, income, wealth, experience and job status whether retired, unemployed or deceased) were: not needed, needed but not essential or essential. Addition- ally, their opinion was sought about the weights assigned to each component: whether the weights were underesti- mated, overestimated or appropriate. If underestimated or overestimated, they were asked to provide their estimate. Their feedback was analysed using the above formula and their recommenda- tions were taken into consideration. Reliability To estimate reliability, a specially de- signed questionnaire (Figure 1) was ad- ministered twice to the same sample of 54 individuals, selected from employees of the College of Medicine and Nursing at Halwer Medical University in Erbil, and considered to be representative of different SES levels with different values for the 6 variables. Correlation coefficients were calculated for the 6 variable of SES. Data were collected by face-to-face interview. Ethical considerations The study was approved by the research ethics committee of the College of Medicine, Hawler Medical University. Informed oral consent was obtained from each participant in the reliability analysis. Results Our final equation to calculate SES was: SES = Education + Occupation + House ownership * 0.5 + Car ownership * 0.1 + (age-20)/100 – Retired/unemployed/ deceased The minimum score would be 0 for an unemployed, illiterate, young manual labourer with no house and car, and the maximum 14.05 for a medical doctor of 65 years (which is the usual age of retirement in Iraq) who has a car and a house. The calculated SES score can either be divided into equal parts (3: high, middle and low socioeconomic levels, or 5: very low, low, middle, high, very high SES), or the distribution of scores in the sample can be checked and a decision made accordingly. The distribution will likely be skewed to the left, i.e. the majority will be in the lower SES level. Validity Table 3 shows the different scenarios using the SES equation with different socioeconomic indices. For example, the SES of case number 4 in Table 3 is calculated as follows: Education: 5 (col- lege); Occupation: 6 (medical doctor); House: 0 (No); Car: 1 (Yes); Age: 25 years. Therefore: SES = 5 + 6 + (0*0.05) + (1*0.1) + (25- 20)/100 - 0 = 11.15. Content validity Based on the opinion of the experts, the CVR for the SES index was 0.72. Book 23-10.indb 672 12/13/2017 9:40:59 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 673 Reliability The correlation coefficients for the 6 components of SES were 0.99 for education, 0.95 for occupation, 0.99 for income, 0.95 for wealth, 0.98 for experience and 0.99 for job status, with an average of 0.98. Discussion Health researchers have used a variety of approaches to measure SES. 1. Direct question about SES: this is one of the least accurate methods to measure SES because of social desir- ability bias. Usually the questionnaire includes a questions like “What is your SES?” with 3, or less frequently 5, options to select from, such as high, moderate and low. The problem with this method is that people at either ex- treme of SES tend to report their SES as moderate because of the sensitivity of the issue (14,24). 2. Using a single variable as a proxy for SES: this has the advantage of sim- plicity but ignores the fact that SES is a multidimensional construct. There are several commonly used single proxy variables. a. Education: this is easy to measure but represents only 1 dimension of the SES construct. In addition, people with the same education may have very different SES (14). b. Occupation: this is probably the best candidate but the problem is usually with how to capture and code it. One difficulty in capturing occupation is that many people, especially those who work in the public sector, supplement their income with a second job. c. Income: this is a relatively good indicator of SES but the problem is its sensitivity. People do not like to disclose their income, especial- ly when they are above the me- dian, or have in-kind or multiple sources of income. Wealth is even more problematic to capture than income. An alternative but less direct method is to ask if income is sufficient. The options usually listed include: not enough, mar- ginally enough, enough and more than enough. The problem with this approach is that it is very sub- jective and is a measure of a per- son’s contentedness with material wealth rather than its value. d. Residence: where people live is strongly related to their SES. When people achieve a higher SES, they usually choose another area to live in. The problem with using residence as a proxy for SES is twofold. First, each neigh- bourhood of the city needs to be ranked according to a scale, usually the value of one square metre of land. Second, using resi- dence is not externally valid, i.e. it is not generalizable and cannot be used for other areas even in the same country. Therefore we need to have specific values for each neighbourhood for all the cities (10,12). e. Crowding index: although this could serve as a rough indicator of socioeconomic index, it does not always reflect SES. For example, many old people live alone in a big house but they do not have a high SES. Another example, in rural areas having more children is regarded an asset as they repre- sent free unpaid workers and this may not necessarily translate into more room (25). f. In addition to the variables men- tioned above, there are many oth- ers that can be used in specific cases to refine SES, for example number of languages spoken and the proficiency level, and com- puter skills. 3. Creating an index from a combina- tion of variables, more commonly a combination of education, occupa- tion and income/wealth, to represent different aspects of the SES construct. Researchers have used a variety of methods for assigning weights to each variable. The accuracy of these methods depends on how the weight is assigned and how the data are cap- tured. a. Using linear weight: here an ar- bitrary weight is given for each variable. The problem with such a method is the relative weight given to each component (26). b. Regression analysis: to be able to assign weights based on regres- sion, a nationally representative, comprehensive and accurate data set is needed and this may not be available. Another problem with using regression is confounding between the variables leading to over-representation of one di- mension of SES or another (17). c. Principal component analysis: this is a relatively new and promis- ing method of assigning weight to different components of the SES construct but like regression, a na- tionally representative, accurate and detailed data set is needed (9,17,27). One of the most frequently used methods for calculating SES in the Middle East is the method developed by El-Gilany and colleagues (26). Us- ing their method, the researcher has to ask more than 36 questions to cal- culate SES, which could be a major distraction from the main topic of the study. In addition, they give 3 times the weight to education compared to occupation, with unemployed/retired having a value of zero. Although they assigned weight for the occupation of the wife, they assigned a value of zero for housewife. Thus a doctor whose wife is a primary school teacher will have much lower SES than one whose wife is a doc- tor, and a civil engineer who has been unemployed for the past 3 months will have a much lower SES compared with his employed civil engineer colleagues. They also assigned equal weights to a television and computer among many other household possessions. However, Book 23-10.indb 673 12/13/2017 9:40:59 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 674 a computer is a much better indicator for SES than a television or even a car, not because of its monetary value but because it is a proxy for more education (12). Another issue with their method is that they include data about health in their SES calculation, which may not be necessary. We used a combination of variables to develop our index and assigned rela- tive weights to each component vari- able. Strengths of the proposed index 1. Small number of variables: we used only 6 variables to calculate SES and most of them are already collected for other purposes, e.g. age, educa- tion and occupation. This has the ad- vantage of a shorter interview time. According to Ganzeboom and col- leagues (20), education and occupa- tion account for more than 90% of the SES weight. That is why we only needed 2 more variables to represent income/wealth, the third big con- tributor to SES. 2. Easy to measure variables: the vari- ables used in our method are easy to measure. 3. No sensitive questions: the questions used for data collection are not sensi- tive and people are not asked about income or wealth. 4. Content validity: based on expert opinion, the CRS for the SES index was 0.72 which is relatively high; it is much higher than the critical value suggested by Lawshe (23) for 12 ex- perts, which is 0.56. This indicates that our method of calculating the proposed index sufficiently covered all of the dimensions of the SES. 5. External validity: the variables used are not specific to one area and are generalizable so can be used in differ- ent governorates of Iraq, and prob- ably other countries in the Middle East and other developing countries with a similar socioeconomic profile. In addition, it can be used to com- pare SES between different societies because the measure is absolute and not relative. 6. Time sensitivity: some variable can have a very strong relation with SES but their effect changes with time. For example, a few years ago, only people with high SES had a mobile phone but today almost everyone has one. Our proposed index avoids such time-sensitive variables. 7. Reliability: with an average correla- tion coefficient of 0.98, our index is fairly reliable because of the nature of the variables selected and the method used to measure them. The high reli- ability score could be attributed to the fact that data collection involved only 6 variables that are easy to collect, non-sensitive and unambiguous. The Cronbach alpha could not be used to estimate reliability in our method because it assumes unidimension, which does not apply to our case as SES is a multidimensional construct (28–30). 8. List of common occupations: provid- ing this list ensures that data about occupation are collected in an accu- rate and detailed way, avoiding vague terms such as “kasb” (meaning bread- winner or earner). This is a common response when the field of occupa- tion is left blank to be filled by the respondent (12). 9. Reasonable weights for each compo- nent: education and occupation have most of the weight when calculating SES because the third component of the big 3, i.e. wealth/income, is closely related to them, and these 2 compo- nents have almost equal weights (8). We included house and car owner- ship as proxies for wealth and income respectively. House is probably the most single expensive item a person can own. While a car is typically much less expensive than a house, what is important about car is the cost to run it and its daily maintenance. A person may be able to buy a car but they may not be able to afford the daily expenditure to run it. Nevertheless, home possessions do not make a big difference and cannot move some- one from one occupation category to another. For example, a medical doctor who does not have a house will not have a much lower SES than a colleague who does. In addition, we took years of experience into consid- eration, calculated from age, which can affect wealth/income. However Table 2 Scores assigned for occupational categories based on the relative importance and prestige of each occupation in Iraq Occupational category Score Unskilled manual occupations (e.g. cleaner, gardener, housekeeper, labourer, shoe mender, street vender) 1 Semi-skilled manual occupations (e.g. baker, barber, blacksmith, builder, butcher, carpenter, cook, driver, farmer, fitter, goldsmith, midwife, plumber, policeman, soldier, shop owner, tailor) 2 Skilled manual and non-manual occupations (e.g. clerk, customer services employee, nurse, technician − electrical or mechanical technician) 3 Associate professional occupations (e.g. accountant, actor, athlete, commissioned military and police officer, journalist, medical assistant, cleric, teacher, translator) 4 Skilled professional or senior managerial occupations (e.g. company manager, dentist, engineer, high-level administrative official, IT professional, judge, lawyer, pharmacist, university lecturer, veterinarian) 5 Highly skilled professional occupations (e.g. medical doctors, university professors) 6 Book 23-10.indb 674 12/13/2017 9:40:59 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 675 we deducted 20 from the current age of the individual as this is the average age at which people start a job. 10. Including special cases: many of the already used methods of calculating SES usually assign a value of zero for retired, unemployed, student and housewife (26). Accordingly, an en- gineer who has been unemployed for the past few months may end up with a lower SES than a manual labourer. This pitfall is avoided by deducting one unit from the SES level of the respondent’s previous job in case of unemployment or being retired. This is based on the fact that a retired/ unemployed person does not lose all the prestige of the previous job but the weight of the previous occupa- tion will be reduced by 1 job category level. On the other hand, for the wife and student, the occupation of the head of the household is used for the calculation. Historically, as well as at present, the position of women in society is often defined by the head of household’s socioeconomic char- acteristics rather than their own (31). Limitations of the proposed index Like any method used for calculating SES, this method also has its own weak- nesses. The most obvious is the fact that we are reducing a complex multi- dimensional construct to one number. Another issue is change over time; the value of education and a degree can change over time and depends on the literacy rate. The same is true for occupation; although relatively stable, some occupation titles have been in- troduced in the past few years, such as those related to computers, while other occupations may die out. That is why SES needs to be updated from time to time (16,22,32,33). The proposed equation is thought to be reasonably accurate for most health studies but if the researcher is interested in even more detail, then the education and occupation of the wife should also be taken into consideration. The same equation can be used for calculating the SES of the wife and then the results added together. Conclusion Currently, most health research in Iraq uses unreliable and/or invalid methods for calculating SES. Our study aimed to fill this gap by proposing a new method which is valid, reliable and easy to cal- culate. Acknowledgements The authors would like to acknowledge the valuables remarks of Professor Jamal Ameen on a previous version of this manuscript and the faculty members of the Department of Community Medi- cine, College of Medicine at Hawler Medical University for their valuable feedback. Funding: None. Competing interests: None declared. Table 3 Case scenarios showing different socioeconomic (SES) indexes No. Education Job Age Car House Unemployed/ retired/deceased SES index Description 1 7 6 60 1 1 14 Specialized medical doctor, house and car 2 7 6 40 1 1 13.8 Medical doctor with PhD or equivalent degree, house and car 3 7 6 60 1 1 1 13 Retired medical doctor with PhD or equivalent degree, house and car 4 5 6 25 1 0 11.15 Medical doctor, car 5 6 5 30 1 0 1 10.2 Master in literature, unemployed 6 5 5 40 1 1 10.8 Manager of small company with college education, house and car 7 4 4 40 1 1 8.8 Primary school teacher graduated from institute, house and car 8 3 3 40 1 1 6.8 Clerk with high school education, house and car 9 2 2 50 1 1 4.9 Shop owner with intermediate schooling, house and car 10 1 2 50 1 1 3.9 Farmer with primary schooling, house and car 11 1 2 30 1 1 3.7 Fitter with primary schooling, house and car 12 0 1 30 0 0 1.1 Illiterate manual labourer 13 0 1 20 0 0 1 Illiterate manual labourer 14 0 1 20 0 0 1 0 Illiterate manual labourer, unemployed Book 23-10.indb 675 12/13/2017 9:40:59 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 676 Figure 1 Questionnaire used to capture socioeconomic data for self-administered interviews. For face-to-face interview, delete the list of job categories in question 4 to avoid confusion 1. Year of birth ___________ 2. Education 0) Illiterate 1) Primary (or read and write) 2) Intermediate 3) High school or vocational 4) Institute (2 years) 5) College (Bachelor degree) 6) College (Master degree) 7) PhD or equivalent 3. Current occupation status 1) Government employee: next select your occupation. 2) Private sector employee: next select your occupation. 3) Self-employed: next select your occupation. 4) Housewife: next select your husband’s occupation. 5) Student: next select your father’s occupation. 6) Retired: next select your previous occupation. 7) Unemployed: next select your previous occupation. 8) Deceased: next select your father’s occupation 4. Occupation 4 Accountant 4 Actor 4 Athlete 2 Baker 2 Barber 2 Blacksmith 2 Builder 2 Butcher 2 Carpenter 1 Cleaner 3 Clerk (employee) 4 Commissioned military or police officer 5 Company manager 5 Computer engineer 2 Cook 3 Customer services 5 Dentist 2 Driver 5 Engineer 2 Farmer 2 Fitter 1 Gardener 2 Goldsmith 5 Government official (director- general & above) 4 Journalist 1 Labourer 5 Lawyer 4 Medical assistant 6 Medical doctor 2 Midwife 3 Nurse 5 Pharmacist 2 Plumber 2 Policeman 4 Cleric 1 Shoe mender 2 Small business (shop owner) 2 Enlisted soldier 1 Street vendor 2 Tailor 4 Teacher 3 Technician 4 Translator 5 University lecturer 5 Veterinarian Other Occupation groups 1) Unskilled manual occupation 2) Semi-skilled manual occupation 3) Skilled manual and non-manual occupation 4) Associate professional 5) Skilled professional or senior manager 6) Highly skilled professional 5. Do the family have a private car? 0) No 1) Yes 6. Do the family own a house? 0) No 1) Yes Book 23-10.indb 676 12/13/2017 9:40:59 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 677 References 1. Ahmed SM, Adams AM, Chowdhury M, Bhuiya A. Gender, so- cioeconomic development and health-seeking behaviour in Bangladesh. Soc Sci Med. 2000;51(3):361-71. PMID:10855923 2. Amin R, Shah NM, Becker S. Socioeconomic factors differ- entiating maternal and child health-seeking behavior in rural Bangladesh: A cross-sectional analysis. Int J Equity Health. 2010;9(1):9. PMID:20361875 3. SozmenK, UnalB. Socioeconomic inequalities in non-commu- nicable diseases and self assessed health in Turkey.Iran J Public Health. 2014Jun;43(6):736-48. PMID:26110144 4. Lalloué B, Monnez JM, Padilla C, Kihal W, Le Meur N, Zmirou- Navier D, et al. A statistical procedure to create a neighbor- hood socioeconomic index for health inequalities analysis. Int J Equity Health. 2013;12(1):21. PMID:23537275 5. WHO Commission on Social Determinants of Health. 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European Health Psychologist. 2014;16(2):56-69. 31. Saegert SC, Adler NE, Bullock HE, Cauce AM, Liu WM, Wyche KF. Report of the APA task force on socioeconomic status. Washington (DC): American Psychological Association; 2007. 32. Blishen BR. A socio-economic index for occupations in Cana- da. Can Rev Sociol. 1967;4(1):41-53. 33. Hauser RM, Warren JR. Socioeconomic indexes for occu- pations: A review, update, and critique. Sociol Methodol. 1997;27(1):177-298. Book 23-10.indb 677 12/13/2017 9:40:59 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 678 1Dow University of Health Science, Dow Medical College, Karachi, Pakistan (Correspondence to: Sina Aziz: sigma_98@hotmail.com). 2International Center for Chemical and Biological Sciences, University of Karachi, Karachi, Pakistan. 3Abbasi Shaheed Hospital, Karachi Medical Dental College, Karachi, Pakistan. Received: 27/03/16; accepted 23/01/17 Toxic metals in maternal blood, cord blood and meconium of newborn infants in Pakistan Sina Aziz 1, Shakil Ahmed 2, Saadiya Aziz Karim 3, Subhana Tayyab 1 and Anisa Shirazi 2 Taux de métaux toxiques et d’éléments traces dans le sang maternel, le sang cordonal et le méconium des nouveau-nés au Pakistan RÉSUMÉ Les métaux toxiques et la carence ou l’excès en éléments traces peuvent avoir des effets nocifs sur la santé. La présente étude avait pour objectif de quantifier les taux de métaux toxiques (plomb, cadmium) et d’éléments traces (zinc, cuivre, aluminium et fer) contenus dans le sang des femmes enceintes, le sang cordonal, et le méconium des nouveau-nés dans des zones industrielles de Karachi (Pakistan). Une recherche analytique a été menée en 2011 et 2012 sur des femmes enceintes et des nouveau-nés au niveau socioéconomique faible dans vingt villes proches des zones industrielles de Sindh, de Federal B et de Korangi à Karachi, où une pollution environnementale avait été anticipée. Les échantillons de sang des femmes enceintes (n = 416), de sang cordonal (n = 309) et de méconium (n = 309) ont fait l'objet d'une analyse quantitative à la recherche de métaux et d’éléments traces. Les résultats ont indiqué que les mères résidant dans des villes sidérurgiques présentaient les taux de plomb les plus élevés. Le méconium contenait des concentrations élevées de métaux lourds toxiques et d’éléments traces par rapport au sang cordonal et au sang maternel. Les métaux toxiques contenus dans le sang maternel étaient présents en grandes quantités. Par conséquent, des mesures de sécurité devraient être prises lorsque les déchets industriels sont éliminés afin de prévenir la contamination de la population. ناتسكاب في ةدلاولا يثيدح يّقعو يسرلا لبلحا مدو تاهملأا مد في ةحيحشلا صرانعلاو ةِّيمسلا نداعلما تايوتسم يزايرش هسينأ ،بيط هناحبس ،ميرك زيزع هيدعس ،دحمأ ليكش ،زيزع انيس في ةـساردلا هذـه نـم فدـلها لـثتمو .ةـحصلا ىـع ةيبلـس راـثآ ةحيحـشلا صراـنعلا ةداـيز/صقنو ةيمـسلا نداـعملل نوـكي نأ نـكمي :ةـصلالخا في )دـيدلحاو موـينيموللأاو ساـحنلاو كـنزلا لـثم( ةحيحـشلا صراـنعلا كـلذكو موـيمداكلاو صاـصرلا لـثم ةيمـسلا داوـلما تايوتـسم دـيدتح ةرفلا في ةـيليلتح ثوـحب تيرجأو .ناتـسكاب ،يـتارك في ةيعانصلا قـطانلما في ةدلاوـلا يـثيدح دـيلاولما يـّقعو يرـلا لـبلحا مدو ،لـماولحا ءاـسنلا في ةـيعانصلا ةراـجتلا قـطانم برـق ةدـلب 20 في ضـفخنم يداـصتقاو يـعاتجا ىوتـسم نـم عـضرلا لاـفطلأاو تاـهملأا فوـفص في 2012-2011 ىرجو .اـهيف يـئيب ثوـلت ثودـح عـقوتي يـتلا ،يـتارك ةـنيدمب ،ةـيعانصلا يـجناروك قـطانمو ،ءاـب ةـيلارديفلا ةـيعانصلا ةـقطنلماو ،دنـسلا مـيلقإ ًاـيلتح )309 = ةـنيعلا مـجح( يـّقعلاو )309 = ةـنيعلا مـجح( يرـلا لـبلحا مدو ،)416 = ةـنيعلا مـجح( لـماولحا تاـهملأل مدـلا تاـنيع لـيلتح يّقعلا ىوـتحاو .صاـصرلا بـسن ىعأ نـلمتح بـلُصلا ندـم في تاـيقلما تاـهملأا نأ لىإ جـئاتنلا تراـشأو .ةحيحـشلا صراـنعلاو نداـعملل ًاـيمك نداـعلما نـم ةيرـبك تاـيمك دوـجو ينـبتو .ملأا مدو يرـلا لـبلحا مدـب ةـنراقم ةحيحـشلا صراـنعلاو ةّيمـسلا ةـليقثلا نداـعملل بـسن ىـعأ ىـع .ناكـسلل مّمـست ثودـح نود ةـلوليحلل ةـيعانصلا تاـيافنلا نـم صـّلختلا دـنع ةماـسلا يرـبادت ذاـتخا يـغبني ،مـث نـمو .تاـهملأا مد في ةّيمـسلا ABSTRACT Toxic metals and deficiency/excess of trace elements can have adverse effects on health. The aim of this study was to quantify toxic metals lead, cadmium and trace elements zinc, copper, aluminium (Al) and Iron (Fe) levels in pregnant women, cord blood and meconium of new-born infants from industrial zones of Karachi, Pakistan. Analytical research was performed from 2011–2012 in low socio-economic pregnant mothers and newborn infants from 20 towns near Sindh Industrial Trading Estates, Federal B industrial area and Korangi industrial areas, Karachi, where environmental pollution was anticipated. Blood samples of pregnant women (n = 416), cord blood (n = 309) and meconium (n = 309) were analyzed quantitatively for metals and trace elements. Results indicated that mothers residing in steel towns were found to have the highest levels of lead. Meconium contained high levels of toxic heavy metals and trace elements compared to cord blood and maternal blood. Maternal blood toxic metals were present in high quantities. Therefore, safety measures should be taken when industrial waste is disposed of in order to prevent population contamination. https://doi.org/10.26719/2017.23.10.678 Book 23-10.indb 678 12/13/2017 9:40:59 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 679 Introduction Toxic metals are found in excess in industrial waste (1). Individuals living in industrial areas or in the vicinity of industrial areas are exposed to trace elements and heavy metals. This results in an adverse effect on their health and life in general (2–6). Pregnant women exposed to these metals and elements are at greater risk as both the fetus and mother will be affected (1, 2). Various studies have been done to determine toxic metals and trace ele- ments in the blood of individuals (3). Animal studies indicate toxic levels of lead in the gestational rat and its pup (4). However, few studies have been done to determine the levels of toxic metals in pregnant women and the new-born (5). Toxic levels of lead occur in children ei- ther due to their exposure to high levels of lead in the maternal blood or from the environment in which they are born. Most crucial time in children when they are prone to toxicity is the first two years of life (6). However, some heavy metals, e.g. lead, may be toxic to a child during the growth period, the effects of which may be seen in adulthood. High levels of lead may be due to air emissions, house dust, soil, water and consumer products (7). Similarly other heavy and light met- als and trace elements can also be toxic to humans (8). Pakistan is a low socio- economic country with the majority of the population residing in industrial cities such as Karachi, with an estimated population of over 23.5 million (9), and exposure to toxic metals may be at the maximum due to industrial waste. Studies have been done on the coastal areas of Karachi, which have shown toxic levels of metals, such as lead (Pb), cadmium (Cd), light metal alu- minium (Al) and trace elements [Zinc (Zn), Copper (Cu), and Iron (Fe)]. Data on these toxic metals and trace elements is lacking from the industrial areas of Karachi, and no published data is available from Pakistan on the level of toxic metals and trace elements in the meconium of babies born to mothers residing in industrial areas of Karachi. Individuals residing in these areas are subjected to a high quantity of these tox- ic metals and with a deficiency or excess of trace elements. These individuals can have neuropsychological deficits that include cognitive and functional com- promise in the affected individual. The abnormalities may be subtle in nature. Pregnant women residing in industrial areas may be subjected to even greater risk, due to dual involvement of both mother and fetus. This is an important study as en- vironmental pollution is a worldwide problem, especially so in the developing world, where proper precautions, rules and regulations for disposal of industrial waste may not be followed. Toxic met- als such as lead have already been found in the blood of adults residing in the city of Karachi (3). However, this study is important as it emphasizes that the toxic metals may be present in the mother and the new-born. Thus, residing in industrial areas of Karachi indicate that the unborn child may also be exposed to the toxic metals. This study aimed to determine the levels of toxic heavy metals [(lead (Pb), cadmium (Cd)], light metal aluminium (Al) and trace elements [Zinc (Zn), Copper (Cu) and Iron (Fe)] in preg- nant women residing in these areas and their new-born. Information on toxic metals and trace elements in maternal blood, cord blood and meconium of the new-born gives an estimate of the levels of toxic metals and a deficiency or excess of trace elements, if any, in the samples of the pregnant women and their new-born. The null Hypothesis proposed that toxic heavy metals and trace elements are normal in pregnant maternal blood, cord blood and meco- nium of the new-born from industrial zones of Karachi, whereas the alternate hypothesis was that toxic metals and light metal aluminium, and trace ele- ments are deficient in pregnant mater- nal blood, cord blood and meconium of the new-born from industrial zones of Karachi. Methods This analytical cross-sectional study was conducted from November 2011 to October 2012 in mothers and their new-born at two obstetric units of tertiary care government hospitals in Karachi, serving pregnant women from low socio-economic classes and residing in industrial areas of Karachi. These industrial areas are the Sindh Industrial Trading Estate (S.I.T.E.) area, F.B. (Federal B) Industrial area and Korangi industrial area. A detailed performa with maternal information along with information of the new-born was recorded. Those patients residing near Sindh Industrial Trading Estate (S.I.T.E.) area, F.B. (Federal B) Indus- trial area and Korangi industrial area Karachi were included. Sampling technique Patients were selected from each hospi- tal by simple random sampling. Patients coming to civil hospitals residing in industrial areas in Korangi, Shershah, and Sind Industrial Trading Estate were included. This was based on preliminary information collected from the patients by the investigators. The calculated sam- ple size (95% CI) and margin of error (53% ± 2.5) was 1531 pregnant women. At Abbasi Shaheed hospital and Civil hospital, samples from the mother and cord blood were taken at the time of delivery of the baby. Only mothers residing in the industrial areas were in- cluded. Three samples were taken from each study subject (6–8 ml maternal blood sample, 6–8 ml of umbilical cord blood and first meconium passed by the respective mother’s new-born) (Figure 1). The blood samples and meconium were transported to Industrial Analyti- cal Centre (IAC) at Hussain Ebrahim Jamal (H.E.J.) Research Institute of Chemistry, Karachi. The blood samples Book 23-10.indb 679 12/13/2017 9:40:59 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 680 were centrifuged and serum stored at –86°C at IAC. Meconium obtained from each new-born’s diaper, when first passed, was scraped into a sterile container and transferred along with remaining samples to IAC and stored at –86°C temperature. Actual quantitative weight of meconium was also done at the laboratory. The average baby passes the meconium in first 24 to 48 hours of birth (10–12). Hence, the baby had to be followed carefully till the meconium was passed and collected in an appropri- ate container. The toxic heavy metals [(Lead (Pb), Cadmium (Cd)], light metal alumini- um (Al) and trace elements [Zinc (Zn), Copper (Cu) and Iron (Fe)] in the blood of the mother, cord blood and the meconium of the new-born were determined. Methodology for the initial preparation of meconium for analysis was problematic as it is a thick viscous material (10,13). Quantitative analy- sis of heavy metals was done by flame atomic absorption spectrophotometer for meconium, at IAC, including the quantitative analysis performed by In- ductive Coupled Plasma-Optical Emis- sion Technique (ICP-OES) (14–16). Ethical approval Pregnant women were informed of the nature of study and consent taken from them either by thumb impression or sig- nature prior to sample collection. The written form contained information for the mother in 3 languages (English, Urdu and Sindhi). The mother was informed that all information given remained confidential and anonymous. Also if levels of toxic metals were high or the levels of trace elements were ab- normal in the mother or the new-born, then the paediatrician and obstetrician would provide health education and treatment. If a mother refused to be involved in the study, she was excluded. The quantitative and qualitative in- formation about a sample was obtained from the light and a radiation emitted by the exited atoms and ions. The actual detection of light was carried out a using Charge Coupled Detector (CCD). The concentration of the elements could be extracted from the intensities of emis- sion lines of the elements. This was ac- complished by using plots of emission intensity vs. concentrations. Calibration curves were established by analysing solutions with known concentrations and obtaining their emission intensities for each element. A Perkin Elmer Op- tima 2000 DV equipped with WinLab 32 software and equipped with a Ryton Scott-type spray chamber was used. Samples for the analysis were in aqueous form and were filtered. Conductivity of the samples was within range i.e. 10 000 µs. The elements in the blood and meconium samples were analysed by ICP-OES. Conditions of the ICP-OES 2000 DV for the analysis included a radio frequency (RF) power at 1300 W, nebulizer flow at 0.8 L/min, auxiliary flow at 0.2 L/min, plasma flow of 20 L/min, pump flow of 0.8mL/ min, plasma viewing was dual view, torch position at –2.5 and sensitivity of 0.001ppm. The values obtained of the metals analysed in the study sam- ples were based on the reference values in published articles (8,15,17,18), as shown in the Table 1. All the following values are expressed in (ppm). For toxic metals Lead (Pb) minimal and maximal detectable limits were 0.1–16.3, 0.1–12, and 0.2–65.4, for maternal blood, cord blood and meconium respectively. For cadmium (Cd) minimal and maximal detectable limits were in the range 0.1–8.5, 0.1–3.2 and 0.3–122.2 for maternal blood, cord blood and meconium respectively. While in case of aluminium (Al) mini- mal and maximal detectable limits were 0.1–358.8, 0.1–385.2 and 0.1–465.3 respectively. In trace element Zinc (Zn) mini- mal and maximal detectable limits were 0.1–529, 0.25–251.25 and 0.36–538.4 for maternal blood, cord blood and Unpaired* (n=428) Mother Cord Blood Meconium Mother Cord Blood Meconium (n=214) (n=107) (n=107) (n=202) (n=202) (n=202) Paired (n=606) *Unpaired sample of maternal blood and cord blood or mother or meconium. Sample lost or mother left the postnatal ward without giving the meconium of her new- born. Figure 1 Sample collected (N =n1034) from pregnant women, cord blood and meconium of the new-born from Civil Hospital and Abbasi Shaheed Hospital, Karachi, Pakistan Book 23-10.indb 680 12/13/2017 9:40:59 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 681 meconium respectively. In case of cop- per (Cu) minimal and maximal detect- able limits were 0.12–18.6, 0.1–18 and 0.4–193.7 for maternal blood, cord blood and meconium respectively. For Iron (Fe) minimal and maximal detect- able limits were 0.1–529, 0.3–251.3 and 0.4–538.4 for maternal blood, cord blood and meconium respectively. Statistical analysis We applied Pearson’s correlation test in our analysis to see the relationship be- tween the three parameters, i.e. mater- nal blood, cord blood and meconium. However, there was no significant relationship, so this analysis was not in- cluded. SPSS 17.0 for Windows (SPSS, Inc., Chicago, IL, USA) and Microsoft® Office Excel® 2007 (12.04518.1014) for Windows 7 Professional was used to perform statistical analysis. Values were expressed as (mean ± standard deviation) and (max-–min). To see the relationship among the variables, Karl Pearson’s correlation technique was used. The significance of the difference among mean values was calculated us- ing one-way ANOVA. Multiple com- parison technique used was Scheffee and included location (residence of the mothers) for each element – lead (Pb), cadmium (Cd), aluminium (Al), zinc (Zn), copper (Cu), and iron (Fe) – between the three groups (meconium, cord blood and maternal Table 1 Normal range of metals (Cd, Pb, Zn, Cu) in maternal and cord blood (20,21,22,23) Maternal blood (ppm) Cord blood (ppm) Heavy toxic metals Cd 0.00089 0.00032 Pb 0.0088 0.0097 Trace elements Cu 1.003 ± 0.159 0.0951 Zn 0.883 ± 0.070 4.738 *Fe 1.272 ± 0.340 *Fe in normal female blood 0.3–1.6 ppm. Table 2 Descriptive statistics of zinc present in maternal blood (n = 416), cord blood (n = 309) and meconium (n =3 09) of different Karachi areas Location Maternal blood (n = 416) Mean ± SD Cord blood (n = 309) Mean ± SD Meconium (n = 309) Mean ± SD P Baldia Town 3.6 ± 4.6 6 ± 12 80.7 ± 148.2 0.7132 Gadap Town 4.7 ± 11.7 6.4 ± 10.7 78.4 ± 117.4 0.9698 Gulbarg Town 4.3 ± 10.4 9.1 ± 26.5 75.7 ± 119.7 0.025^ Gulshan-e-Iqbal Town 9.6 ± 15.5 1.7 ± 1.8 25.3 ± 21.5 0.2391 Hyderabad 268.1 ± 369 49.5 ± 41.1 43.1 ± 18.7 0.5583 Jamshed Town 1.4 ± 2.4 1.5 ± 1.7 21.8 ± 33.4 0.388 Khairpur Town 0 ± 0 0 ± 0 0 ± 0 – Korangi Town 17.4 ± 12 18.2 ± 18.6 35.3 ± 40.8 0.3864 Landhi Town 10.5 ± 12.3 10.6 ± 8.0 18.2 ± 18.1 0.4316 Liaquatabad Town 12.3 ± 26.9 8.0 ± 12.8 38.6 ± 57.7 0.0018^ Lyari Town 17 ± 14.9 24.7 ± 20.8 18.8 ± 28.4 0.7256 Malir town 6.6 ± 6.1 33.6 ± 58.6 75.7 ± 1508 0.2105 New Karachi Town 7.8 ± 12.7 15.3 ± 14.9 160.3 ± 218.4 0.1421 North Nazimabad 11.3 ± 17.3 23.3 ± 51.8 35.1 ± 95.5 0.2323 Not Mentioned 17.3 ± 4.7 7.4 ± 6.1 49.5 ± 40.3 0.0776 Orangi Town 23.2 ± 37.4 24 ± 35 30.5 ± 57.8 0.8115 Saddar Town 3.9 ± 0 0 ± 0 30.8 ± 0 <0.0001^ Shah Faisal Town 15.8 ± 23.1 9.2 ± 11 58.7 ± 152.2 0.2801 Site Town 24.7 ± 9.4 23.8 ± 12 9.5 ± 7.8 0.3592 Levels higher than the normal are indicated by: maternal blood ppm, Zn = 0.883 ± 0.070 and cord blood ppm, Zn = 4.738 (20,21) while in meconium >100μ/g dry wt was toxic (13). ^P-value shows that in Gulbarg town, Liaquatabad town, Saddar and Steel Town are significantly different by location. P-value indicates that the observed result would be highly unlikely under the null hypothesis. No detectable zinc was present in samples from Khairpur. Book 23-10.indb 681 12/13/2017 9:40:59 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 682 blood). P-value < 0.05 was considered statistically significant. Descriptive sta- tistics were calculated for birth outcome characteristics and for toxic metals and trace elements. Results A total of 1034 samples were collected (meconium, maternal blood and cord blood). Of these, 606 were paired sam- ples (meconium n = 202, cord blood n = 202, and maternal blood n = 202). The remaining 428 were unpaired (maternal blood n = 214, meconium n = 107 and cord blood n = 107). The unpaired samples were either due to the mother leaving the hospital before the baby passed meconium or the sample of meconium was misplaced by the mother or thrown away; this was an expected mishap, despite counselling the mother repeatedly (Figure 1). In the paired samples (n = 606) response rate was 100% of participants, with mother (n = 202), cord blood (n = 202) and meconium (n = 202). In the unpaired group (n = 428) response rate was 66.7%, with mother (n = 214), cord blood (n = 107) and meconium (n = 107). Overall response rate was 83%. The results of 1034 samples of cord blood, maternal blood and meconium are shown in Tables 2–7. The meco- nium contained higher quantities of Pb, Cd, Al, Cu, Fe and Zn compared to cord blood and maternal blood, while Pb was present in cord blood in small amounts. All the samples of meconium tested positive for toxic metals. Quantitative results (mean ± SD) and frequency (%) of towns with results of the metals in maternal blood, cord blood and meco- nium with respect to area of residence are shown in Tables 2–8. Of all residen- tial areas, the steel mill area showed the highest levels of toxic metals, especially lead. The reference values have been mentioned in the legend for maternal blood, cord blood and meconium for each toxic metal and trace element mentioned in the tables. Lead (Table 3 and Table 8): It was clearly shown that a large amount of lead was seen in the meconium in the new-born from all areas except Steel Town. Overall, in all areas where cord blood was studied, the amount of lead was very little or absent. In maternal blood the maximum amount of lead was seen in those mothers residing in Steel Town, Sadder Town and New Karachi Town. Overall, the number of towns with levels greater than 0.0088 (maternal blood) (14), 0.00032 (cord blood) (14) and meconium 12 ± 14.9 (18) was 11/20, i.e. 55% in each sample tested. Table 3 Descriptive statistics of lead present in maternal blood (n = 416), cord blood (n = 309) and meconium (n = 309) for different Karachi areas Location Maternal blood (n = 416) Mean ± SD Cord blood (ppm) (n = 309) Mean ± SD Meconium (ppm) (n = 309) Mean ± SD P Baldia Town 0.1 ± 0.3 0.4 ± 0.8 4.9 ± 8.3 0.197 Gadap Town 0.1 ± 0.1 0.4 ± 0.6 13.6 ± 11.8 0.0848 Gulbarg Town 1.2 ± 2.4 1.5 ± 2.7 9.4 ± 10.9 <0.0001^ Gulshan-e-Iqbal Town 0.2 ± 0.2 0.1 ± 0.1 11.6 ± 15.0 0.2484 Hyderabad 1.2 ± 1.7 0 ± 0 7 ± 10.0 0.5161 Jamshed Town 0 ± 0 0.1 ± 0.2 2.2 ± 3.9 0.4423 Khairpur Town 0 ± 0 0 ± 0 0 ± 0 – Korangi Town 2.1 ± 4.4 3.2 ± 4.6 7.7 ± 7.5 0.1696 Landhi Town 0.5 ± 0.7 0.1 ± 0.2 2.3 ± 6.0 0.5638 Liaquatabad Town 1.2 ± 2.7 1.3 ± 2.8 6.5 ± 7.9 <0.0001^ Lyari Town 0.1 ± 0.4 0 ± 0 10.0 ± 9.4 0.0002^ Malir town 4.1 ± 5.3 0.3 ± 0.6 9.3 ± 10.5 0.0139^ New Karachi Town 2.4 ± 3.1 0.6 ± 0.4 3.4 ± 7.3 0.634 North Nazimabad 1.3 ± 3.3 0.7 ± 2.0 7.2 ± 9.8 <0.0001^ Not Mentioned 6.1 ± 7.7 2.0 ± 1.7 0 ± 0 0.2115 Orangi Town 1.2 ± 3.0 0.7 ± 2.4 11.0 ± 21.4 0.0053^ Saddar Town 1.6 ± 0 0.3 ± 0 1.2 ± 0 <0.0001^ Shah Faisal Town 3.1 ± 4.9 2.6 ± 4.5 14.4 ± 16.9 0.0102^ Site Town 0 ± 0 0 ± 0 9.3 ± 1.6 0.003^ Pb levels higher than the normal: maternal blood ppm, Pb = 0.0088 and cord blood ppm, Pb = 0.0097 (20,2) while in meconium >12 ± 14.9 μ/g dry wt was toxic (24). ^P-value shows that in Gulbarg town, Khairpur town, Liaquatabad town, Lyari, Malir, North Nazimabad, Orangi town, Saddar, Shah Faisal, Site town and Steel Town are significantly different by location. P-value indicates that the observed result would be highly unlikely under the null hypothesis. Book 23-10.indb 682 12/13/2017 9:40:59 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 683 Cadmium (Table 6 and Table 8): It was seen that Site Town and Baldia Town were highly affected, i.e. cadmium was present in the cord blood, followed by Jamshed Town and New Karachi, which were somewhat less affected. Meconium contained high quantities of cadmium in Landhi, Malir, Shah Faisal, Lyari, Gadap and Liaquatabad Town. In Hyderabad, maternal blood contained cadmium, while surprisingly it was ab- sent in the cord blood and meconium of the new-born. Overall, the percentage of towns with level greater than 0.0089 (maternal blood) (14), 0.00032 (cord blood) (14) and meconium 3.0 ± 7.44 (4) was 20%, 5% and 20% respectively, in each sample tested. Zinc (Table 2 and Table 8): Zinc was present in large amount in the meconium in all areas except Hy- derabad. In Steel Town area, zinc was absent in maternal blood and cord blood. In Korangi, Landhi, Lyari, Ma- lir, North Nazimabad, Orangi and Site Town areas, zinc was present in the same amount both in cord blood and maternal blood. Overall, the percentage of towns with level greater than 0.883 ± 0.070 (maternal blood) (15), 4.738 (cord blood) (14) and meconium >100μg/g (8) was 90%, 75% and 55% respectively, in each sample tested. Iron (Table 4 and Table 8): Signifi- cant amount of iron was present in the meconium of the new-born from all the areas included in the study. However, the maximum amount of iron was seen in the meconium of the Steel Town area. In maternal blood and cord blood, the amount of iron was very little, except in Hyderabad area where the maternal blood contained significant amount of iron. Overall, percentage of towns with levels greater than 1.272 ± 0.340 (maternal blood) (15), and meconium >100μg/g (8) were 90% and 20% re- spectively. Copper (Table 5 and Table 8): Copper was present in the meconium in all areas except Site Town, Khair- pur Town and Gulshan-e-Iqbal Areas, where copper was not detected in the meconium. Overall, in cord blood the amount of copper present was negli- gible. Copper was detected in all the samples of maternal blood with the maximum being from those residing in Gulshan-e-Iqbal area. Overall, percent- age of towns with copper levels greater than 1.003 ± 0.159 (mother’s blood) (15), 0.0951 (cord blood) (14) was 80% and 70% respectively, and in meco- nium (8) copper values >100μg/g were not detected. Table 4 Descriptive statistics of iron present in maternal blood (n = 416), cord blood (n = 309) and meconium (n = 309) for different Karachi areas Location Maternal blood (n = 416) Mean ± SD Cord Blood (ppm) (n=309) Mean ± SD Meconium (ppm) (n = 309) Mean ± SD P Baldia Town 7.2 ± 4.1 14 ± 20.1 11.7 ± 14 0.7132 Gadap Town 20.3 ± 18.4 18.4 ± 16.7 16.9 ± 15.2 0.9698 Gulbarg Town 10.3 ± 13.4 19.2 ± 26 38 ± 61.9 0.025^ Gulshan-e-Iqbal Town 9.6 ± 15.5 1.7 ± 1.8 25.3 ± 21.5 0.2391 Hyderabad 268.1 ± 369 49.5 ± 41.1 43.1 ± 18.7 0.5583 Jamshed Town 1.4 ± 2.4 1.5 ± 1.7 21.8 ± 33.4 0.388 Khairpur Town 0 ± 0 0 ± 0 0 ± 0 – Korangi Town 17.4 ± 12 18.2 ± 18.6 35.3 ± 40.8 0.3864 Landhi Town 10.5 ± 12.3 10.6 ± 8.0 18.2 ± 18.1 0.4316 Liaquatabad Town 12.3 ± 26.9 8.0 ± 12.8 38.6 ± 57.7 0.0025^ Lyari Town 17.0 ± 14.9 24.7 ± 20.8 18.8 ± 28.4 0.7256 Malir town 6.6 ± 6.1 33.6 ± 58.6 75.7 ± 150.8 0.2105 New Karachi Town 7.8 ± 12.7 15.3 ± 14.9 160.3 ± 218.4 0.1421 North Nazimabad 11.3 ± 17.3 23.3 ± 51.8 35.1 ± 95.5 0.2323 Not Mentioned 17.3 ± 4.7 7.4 ± 6.1 49.5 ± 40.3 0.0776 Orangi Town 23.2 ± 37.4 24 ± 35 30.5 ± 57.8 0.8115 Saddar Town 3.9 ± 0 0 ± 0 30.8 ± 0 <0.0001^ Shah Faisal Town 15.8 ± 23.1 9.2 ± 11 58.7 ± 152.2 0.2801 Site Town 24.7 ± 9.4 23.8 ± 12 9.5 ± 7.8 0.3592 Steel Town 0 ± 0 0 ± 0 109 ± 0 <0.0001^ Levels higher than the normal were indicated by: maternal blood ppm, Fe=1.272 ± 0.0340 (21), while in meconium >100μ/g dry wt was toxic (13). ^P-value shows that in Gulbarg town, Khairpur town, Liaquatabad town, Saddar and Steel Town are significantly different by location wise. P-value indicates that the observed result would be highly unlikely under the null hypothesis. In Khairpur, Sadder and Steel Town Fe was not detected. Book 23-10.indb 683 12/13/2017 9:40:59 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 684 Table 6 Descriptive statistics of cadmium present in maternal blood (n = 416), cord blood (n = 309) and meconium (n = 309) for different Karachi areas Location Maternal blood (n = 416) Mean ± SD Cord blood (ppm) (n = 309) Mean ± SD Meconium (ppm) (n = 309) Mean ± SD P Baldia Town 0 ± 0.1 0.6 ± 1.3 0 ± 0 0.3587 Gadap Town 0 ± 0 0 ± 0.1 0.7 ± 0.7 0.1435 Gulbarg Town 0 ± 0.1 0.1 ± 0.3 0.3 ± 0.7 0.0317^ Gulshan-e-Iqbal Town 0 ± 0 0 ± 0 0 ± 0 – Hyderabad 0 ± 0 0 ± 0 0 ± 0 – Jamshed Town 0 ± 0 0 ± 0 0 ± 0 – Khairpur Town 0 ± 0 0 ± 0 0 ± 0 – Korangi Town 1.2 ± 3.2 0 ± 0 3.4 ± 8.1 0.2059 Landhi Town 0 ± 0 0 ± 0.1 1.9 ± 5 0.4562 Liaquatabad Town 0 ± 0.1 0.1 ± 0.2 1.3 ± 4.9 0.1359 Lyari Town 0 ± 0 0 ± 0 4.3 ± 9.8 0.1571 Malir town 0 ± 0 0 ± 0.1 0.6 ± 1.1 0.0832 New Karachi Town 0.1 ± 0.1 0.1 ± 0.2 0 ± 0 0.1633 North Nazimabad 0.1 ± 0.3 0 ± 0 0.1 ± 0.4 0.2034 Not Mentioned 0.3 ± 0.5 0.6 ± 0.9 6.6 ± 13.4 0.4511 Orangi Town 0 ± 0 0 ±0.1 0.1 ± 0.4 0.1747 Saddar Town 0.1 ± 0 0.1 ± 0 1.7 ± 0 <0.0001^ Shah Faisal Town 0 ± 0.1 0 ± 0.1 8.1 ± 31.6 0.3909 Site Town 0 ± 0 0.1 ± 0.1 0 ± 0 0.4648 Steel Town 0 ± 0 0 ± 0 0 ± 0 – Level higher than the normal Cd levels: maternal blood ppm, Cd = 0.00089 and cord blood ppm, Cd = 0.00032 (20,21) while in meconium >3± 7.44 μ/g dry wt was toxic (24). ^P-value shows that in Gulbarg town, Khairpur town, Saddar and Steel Town are significantly different by location. P-value indicates that the observed result would be highly unlikely under the null hypothesis. Table 5 Descriptive statistics of copper present in maternal blood (n = 416), cord blood (n = 309) and meconium (n = 309) for different Karachi areas Location Maternal blood (n = 416) Mean ± SD Cord blood (ppm) (n = 309) Mean ± SD Meconium (ppm) (n = 309) Mean ± SD P Baldia Town 1.2 ± 0.5 1.7 ± 2.8 5.1 ± 5.6 0.1633 Gadap Town 3.8 ± 5.5 1 ± 1.5 2.1 ± 3.7 0.7026 Gulbarg Town 2.3 ± 2.7 1.4 ± 2.4 5.6 ± 8.8 0.0106^ Gulshan-e-Iqbal Town 3.8 ± 2.1 0.9 ± 1.1 0 ± 0 0.0328^ Hyderabad 6 ± 5.8 3.5 ± 4.2 28.7 ± 33 0.4602 Jamshed Town 0.7 ± 0.6 0 ± 0.1 1.6 ± 2.8 0.5411 Khairpur Town 0 ± 0 0 ± 0 0 ± 0 ----- Korangi Town 6.2 ± 6.0 5.2 ± 3.8 26.3 ± 39.2 0.1825 Landhi Town 1.7 ± 1.7 5.9 ± 8.7 4.9 ± 5.4 0.4074 Liaquatabad Town 2.7 ± 2.3 1.5 ± 2.4 8.4 ± 15.3 0.0067^ Lyari Town 6.6 ± 4.6 2.8 ± 3.7 3.9 ± 7.0 0.2566 Malir town 2.7 ± 2.9 4.3 ± 5.8 10.4 ± 23.3 0.3758 New Karachi Town 4.5 ± 7.7 1.8 ± 2.6 5.8 ± 6.0 0.5491 North Nazimabad 2.3 ± 2.9 1.5 ± 2.4 5.3 ± 12.4 0.0488^ Not Mentioned 5.6 ± 2.9 2.6 ± 2.9 19.7 ± 23.2 0.2199 Orangi Town 2.7 ± 3.0 1.7 ± 3.1 16.4 ± 41 0.0522 Saddar Town 1.6 ± 0 0.5 ± 0 5 ± 0 <0.0001^ Site Town 7 ± 0.3 8.7 ± 5.4 0 ± 0 0.1298 Steel Town 0.8 ± 0 0.1 ± 0 13.9 ± 0 <0.0001^ Levels were higher than the normal are indicated by: maternal blood ppm, Cu=1.003 ± 0.159 and cord blood ppm, Cu = 0.0951 (20,21) while in meconium >100μ/g dry wt was toxic (13). ^P-value shows that in Gulbarg town, Gulshan-e-Iqbal Town, Khairpur town, Liaquatabad town, North Nazimabad, Saddar and Steel Town are significantly different by location. P-value indicates that the observed result would be highly unlikely under the null hypothesis. Book 23-10.indb 684 12/13/2017 9:41:00 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 685 Aluminium (Table 7 and Table 8): Aluminium was present in meco- nium in all areas studied. However, the concentration of aluminium was low in maternal blood in Jamshed Town, Khairpur town, Saddar Town, Site Town and Steel Town Areas. Refer- ence values for aluminium could not be found in the biological samples ana- lysed. Discussion The objective of our project was to determine toxic metal levels and trace elements in maternal blood, cord blood and meconium of the new-born. The levels identified will inform medical workers, industrialists and environmen- talists about the toxic effects and levels of these metals and trace elements in pregnant women and their new-born. This project can have an influence on the social sector and indirectly on the economy. The human fetus, child and adult may experience adverse health outcomes from parental or childhood exposures to environmental toxicants. The fetus and infant are especially vulnerable to toxicants that disrupt developmental processes during the limited period of pregnancy. The ad- verse health effects linked to exposure of toxic metals – e.g. lead and cadmium and trace elements such as zinc, copper and iron – include fetal death, birth de- fects, Small for Gestational age (SGA), pre-term birth, clinically overt cognitive, neurologic and behavioural abnormali- ties, subtle neurophysiologic defects, childhood cancer, asthma, and other respiratory diseases. Environmental tox- icants, especially lead, produce adverse effects at low exposure levels during fetal or developmental time periods (7). Limited numbers of studies have been conducted on specific exposure during pregnancy. Although sample analysis of met- als such as lead has been undertaken previously (3-5,8,19), this is the first study done on pregnant mothers and their new-born via cord blood and meconium. Animal studies have already been undertaken (5) where the effects of lead intoxication during pregnancy and lactation was studied in the hepatic system of rats, which indicated adverse neonatal liver function. Based on this study and previous studies (3-5,8,19), we expected high levels of lead in the samples of maternal blood, cord blood and meconium from industrial areas of Karachi. In this study the presence of lead in the fetus occurred due to the free passage of lead from the mother to the fetus, which is of clinical relevance since Table 7 Descriptive statistics of aluminium present in maternal blood (n = 416), cord blood (n = 309) and meconium (n = 309) for different Karachi areas Location Maternal blood (n = 416) Mean ± SD Cord blood (ppm) (n = 309) Mean ± SD Meconium (ppm) (n = 309) Mean ± SD P Baldia Town 11.4 ± 19.3 18.8 ± 25 95.6 ± 84 0.0776 Gadap Town 23.2 ± 27.4 36.9 ± 8 144.2 ± 98.4 0.0872 Gulbarg Town 11.8 ± 12.5 20.8 ± 27.6 141.2 ± 119.2 <0.0001^ Gulshan-e-Iqbal Town 120.7 ± 206.2 7.3 ± 7.5 190.6 ± 147.1 0.3646 Hyderabad 38.2 ± 32.5 3.8 ± 1.0 218.1 ± 42.3 0.0115^ Jamshed Town 0.7 ± 1.2 0.8 ± 0.8 81.8 ± 115.7 0.3019 Khairpur Town 0 ± 0 0 ± 0 0 ± 0 – Korangi Town 8.1 ± 7 6.1 ± 5.4 84.6 ± 65 0.0013^ Landhi Town 13.5 ± 17 12 ± 15.4 130.1 ± 97.2 0.0036^ Liaquatabad Town 5.3 ± 8.7 6.5 ± 8.8 109.9 ± 94.7 <0.0001^ Lyari Town 7.7 ± 10.9 13.4 ± 13.2 45.5 ± 64.6 0.0723 Malir town 13.8 ± 20.5 32.1 ± 63 119 ± 95.2 0.0012^ New Karachi Town 15.8 ± 21.8 20.4 ± 32.8 193.1 ± 113.7 0.0022^ North Nazimabad 9.3 ± 17.9 31.9 ± 81.5 146.3 ± 121.2 <0.0001^ Not mentioned 22.5 ± 20.7 8.1 ± 10.4 86.6 ± 42.8 0.0076^ Orangi Town 16.4 ± 22.6 25.8 ± 32.7 102.9 ± 101.4 <0.0001^ Saddar Town 6.2 ± 0 4.6 ± 0 210.7 ± 0 <0.0001^ Shah Faisal Town 12.9 ± 19.4 9.0 ± 13.6 141.6 ± 125.2 <0.0001^ Site Town 1.6 ± 2.3 11.0 ± 10.4 218.3 ± 97.5 0.0513 Steel Town 0.2 ± 0 0 ± 0 11.3 ± 0 <0.0001^ ^P-value shown for Gulbarg town, HyderabadKhairpur town, Korangi, Landhi, Liaquatabad,Malir, New Karachi, North Nazimabad, Others, Orangi, Saddar, Shah Faisal town and Steel Town are significantly different by location. P-value indicates that the observed result would be highly unlikely under the null hypothesis. Book 23-10.indb 685 12/13/2017 9:41:00 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 686 lead is always toxic, irrespective of its concentration (20). Few studies have been conducted on cadmium levels. When we com- pared our results with previous studies (8,14), we found the levels to be higher in pregnant women and the cord blood of the study group. Presence of these toxic metals in the meconium may in- dicate the excretion of the metals by the baby in utero. Hence, the meconium passed by the baby after birth contains a high quantity of the metals. All our meconium samples tested positive for toxic metals and trace elements. Meconium reflects fetal exposure to toxic metals and mineral content, from mother to the fetus via blood circulation and excessive levels of toxins and certain toxic metals which harm the fetus. The levels of toxic metals and trace elements in cord blood may not reflect the extent of fetal exposure to toxic metals or the actual degree of excess or deficiency of trace elements. The reason is that the substances pro- cessed by the fetus accumulate in the fetal intestine, thus meconium analysis can be used to assess levels of fetal expo- sure to toxic metals and mineral content and indirectly of the mother and the environment in which she and her fam- ily resides. This may explain the higher quantities of lead, cadmium, copper, iron and zinc in the meconium of the new-born than in the cord blood and maternal blood (8,14,15). In this study the percentage of zinc and iron in meconium >100μg/g dry weight was seen in 55% and 20% of the industrial towns of Karachi; the study conducted by Türker et al. (8) showed 90% and 53% respectively, possibly due to the population studied which was in very close proximity (within a 20 km radius) of the petroleum refinery and dye industries. While 100% of the meconium samples tested for copper <100μg/g, in the Türker study 100% of the samples tested >100μg/g. This vari- ation could be due to interference with the rates of placental transport of trace element. This observation needs further research as some of the minerals, e.g. zinc, are transported across the placenta against a concentration gradients (21). This study, on the other hand, has shown higher levels when compared to previous studies done by Cibele et al. (14) on toxic and essential elements in maternal and cord blood. Certain industrial areas, e.g. S.I.T.E and Steel town area, showed much higher levels. Iron levels were low compared to in- ternational data, due to micronutrient deficiency in the mothers and hence in the new-born and even the meconium. Overall, this indicates iron deficiency in women in the area, which is supported by other studies from the region (22). Comments on aluminium could not be made since this is the first time maternal, cord and meconium samples have been collected for analysis. How- ever, this analysis may give an insight as a standard for further studies, especially from low socio-economic areas. This study included only pregnant women residing in industrial areas. Therefore, further work should be done with a larger sample size to include individuals not residing in the industrial areas in order to avoid bias. A limitation of this study is that en- vironmental assessment of the studied elements and its correlation with blood levels was not done. This aspect needs to be covered in future studies. Broad longitudinal studies begin- ning before or during early pregnancy are urgently needed to accurately meas- ure and assess the relative importance of parental and childhood exposure in order to evaluate adverse effects such as neurophysiologic and other functional defects. There is also an urgent need to accelerate development and use of biomarkers of exposures and genetic susceptibility in epidemiological stud- ies. It is recommended that a larger sample size study be done involving the complete family residing in the industrial areas; knowledge of exact dis- tance from the industrial site; analysis Table 8 Percent distribution of the studied industrial areas in Karachi: those exceeding the reference levels of toxic metals and trace elements in maternal blood, cord blood and meconium Maternal blood (%) Cord blood (%) Meconium (%) Trace elements Zinc (Zn) 90 75 55 Copper (Cu) 80 70 100* Iron (Fe) 90 Not detected 20 Toxic metals Lead (Pb) 55 55 55 Cadmium (Cd) 20 25 20 Aluminium (Al) Comparative published data not available Frequency (%) of industrial towns having trace elements and toxic metals in the maternal blood, cord blood and meconium of the new-born are shown. In meconium, levels >100μg/g are toxic. *100% of the meconium samples did not contain Cu levels in toxic amounts. Al levels have not been documented previously in a research studies. For the remaining, reference values are used (8,15). Book 23-10.indb 686 12/13/2017 9:41:00 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 687 References 1. Iarushkin VIu. Tiazhelye metally v biologicheskoĭ sis- teme mat’-novorozhdennyĭ v usloviiakh tekhnogennoĭ biogeokhimicheskoĭ provintsii (in Russian).Gig Sanit. 1992 May-Jun;5-6(5-6):13–5. PMID:1398163 2. Odland JO, Romanova N, Sand G, Thomassen Y, Brox J, Kho- tova E, et al. Preliminary report of trace elements in mothers and newborns living in the Kola Peninsula and Arkhangelsk region of Russia compared to Norwegian populations. Arctic Med Res. 1996;55 Suppl 1:38–46. PMID:8871686 3. Agha F, Sadaruddin A, Khatoon N. Effect of environmental lead pollution on blood lead levels in traffic police constables in Islamabad, Pakistan. J Pak Med Assoc. 2005 Oct;55(10):410–3. PMID:16304845 4. Corpas I, Benito MJ, Marquina D, Castillo M, Lopez N, Antonio MT. Gestational and lactational lead intoxication produces alterations in the hepatic system of rat pups. Ecotoxicol En- viron Saf. 2002 Jan;51(1):35–43. http://dx.doi.org/10.1006/ eesa.2001.2102 PMID:11800548 5. Privalova LI, Malykh OL, Matiukhina GV, Gnezdilova SV. [The umbilical blood levels of lead and some other toxic metals as a biomarker of environment-induced exposure]. Gig Sanit. 2007 May-Jun;3(3):68–70. PMID:17658049 6. Braun JM, Lanphear B, Schoeters G, Hanke W, Rennezova Z, et al. Comments on ‘Lead neurotoxicity in children: is prenatal exposure more important than postnatal exposure?’. Acta Pae- diatr. 2007 Mar;96(3):473, author reply 474–5. http://dx.doi. org/10.1111/j.1651-2227.2007.00131.x PMID:17407486 7. Berkowitz Z, Price-Green P, Bove FJ, Kaye WE. Lead exposure and birth outcomes in five communities in Shoshone County, Idaho. Int J Hyg Environ Health. 2006 Mar;209(2):123–32. http://dx.doi.org/10.1016/j.ijheh.2005.11.001 PMID:16376613 8. Türker G, Ergen K, Karakoç Y, Arisoy AE, Barutcu UB. Con- centrations of toxic metals and trace elements in the meco- nium of newborns from an industrial city. Biol Neonate. 2006;89(4):244–50. http://dx.doi.org/10.1159/000089953 PMID:16319451 9. Aziz S, Leroy P, Servaes R, Eggermont E, Fevery J. Bilirubin-IXbe- ta is a marker of meconium, like zinc coproporphyrin. J Pediatr Gastroenterol Nutr. 2001 Mar;32(3):287–92. http://dx.doi. org/10.1097/00005176-200103000-00010 PMID:11345177 10. Aziz S, Kotal P, Leroy P, Servaes R, Eggermont E, Fevery J. Bilirubin-IXalpha and -IXbeta pigments, coproporphyrins and bile acids in meconium and stools from full-term and preterm neonates during the first month of life. Acta Paediatr. 2001 Jan;90(1):81–7. http://dx.doi.org/10.1111/j.1651-2227.2001. tb00260.x PMID:11227340 11. Aziz. S. Nature of bilirubin pigments in the newborn infant Ti JdschrKindergeeneskd 1996; 64: 3 12. Aziz S. On the nature of the bilirubin pigments in the newborn infant. ActaBiomedicaLovaniensia 114. KatholiekeUniversitei- tte Leuven. Faculteit der Geneeskunde. Laboratriumvoor- Hepatologie. AfdelingKindergeenskunde. Leuven: Leuven University press; 1995. 13. Aziz S, Anjum S, Rehman A, Akram DS, Naqvi A, Rizvi AH. Bili- rubin pigments in the first meconium of newborn infants JPMA 2005; 55: 188-92 Erratum in. J Pak Med Assoc. 2005;55:313. 14. Rudge CV, Röllin HB, Nogueira CM, Thomassen Y, Rudge MC, Odland JØ. The placenta as a barrier for toxic and es- sential elements in paired maternal and cord blood sam- ples of South African delivering women. J Environ Monit. 2009 Jul;11(7):1322–30. http://dx.doi.org/10.1039/b903805a PMID:20449220 15. Selvaraju R, Raman RG, Narayanaswami R, Valliappan R. Trace element analysis in hepatitis B affected human blood serum by inductively coupled plasma- atomic emission spectros- copy (ICP-AES) Romanian J. Biophys.,Vol 19, No. 1, P. 35-42, Bucharest, 2009. 16. Wu Alan HB. Tietz Guide to laboratory tests. 4th ed. Philadel- phia: WB Saunders; 2006. 17. Engorn B. Flerlage Blood Chemistries and Body Fluids. The Johns Hopkins Hospital. The Harriet Lane Handbook. 20th ed. Philadelphia: Saunders; 2015. pp. 621–33. 18. Optima 8300 ICP-OES Spectrometer. (http://www.perki- nelmer.com/catalog/product/id/optima8300 accessed 31 December 2015). 19. Benes B, Spĕvácková V, Smíd J, Cejchanová M, Cerná M, Subrt P, et al. The concentration levels of Cd, Pb, Hg, Cu, Zn and Se in blood of the population in the Czech Republic. Cent Eur J Public Health. 2000 May;8(2):117–9. PMID:10857051 20. Nashashibi N, Cardamakis E, Bolbos G, Tzingounis V. Inves- tigation of kinetic of lead during pregnancy and lactation. Gynecol Obstet Invest. 1999;48(3):158–62. http://dx.doi. org/10.1159/000010164 PMID:10545737 21. Page KR, Abramovich DR, Aggett PJ, Todd A, Dacke CG. The transfer of zinc across the term dually perfused human pla- cental lobule. Q J Exp Physiol. 1988 Jul;73(4):585–93. http:// dx.doi.org/10.1113/expphysiol.1988.sp003178 PMID:3174917 22. Ahmed A, Ahmad A, Khalid N, David A, Sandhu MA, Rand- hawa MA, et al. A question mark on iron deficiency in 185 mil- lion people of Pakistan: its outcomes and prevention. Crit Rev Food Sci Nutr. 2014;54(12):1617–35. http://dx.doi.org/10.1080 /10408398.2011.645087 PMID:24580562 23. Whitehall JS, Ostrea EM, Bollistety S, Whitehall JF, Patole S. Fetal exposure to pollutant in Towsville, Australia detected in meconium. Pediatr Res. 2000;47:299A. 24. Ostrea EM Jr, Tan E, Ramirez G, Hernandez E, Manlapaz ML. Exposure to environmental pollution adversely affects fatal outcome. Pediatr Res. 1998;43:224A. of placental samples; and father and/ or mother working in the concerned industry as an inclusion criterion. Also, it needs to be determined whether or not industries are using the recommended safety environmental precautions, which should also be critically assessed, as well as government measures taken for the safety of individuals and their families residing at or near the industrial towns. Funding: Pakistan Science Foundation (PSF No. S-DUHS/MED 290) Competing interests: None declared. Book 23-10.indb 687 12/13/2017 9:41:00 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 688 1Department of Food Science and Nutrition, College of Life Sciences, Kuwait University, Kuwait City, Kuwait (Correspondence to: Abdur Rahman: abdurrahman.ahmad@ku.edu.kw). 2Ministry of Health, Kuwait City, Kuwait. 3Department of Community Medicine and Behavioural Sciences, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait. Received: 08/06/16; accepted: 23/01/17 Pregnancy outcome variables and associated factors in different nationalities living in Kuwait Abdur Rahman 1, Haila Al-Rashidi 2 and Saeed Akhtar 3 Différences en matière d’issues de grossesse et leurs prédicteurs entre les diverses nationalités résidant au Koweït RÉSUMÉ La présente étude visait à analyser les différences en matière d’issue de grossesse entre les différentes nationalités résidant au Koweït. Des données transversales ont été recueillies auprès de 369 dyades mère-nouveau- né au moment de l’accouchement sur la taille de la mère, l’hémoglobine (Hb) maternelle, l’hémoglobine de l’enfant (Hbe), le périmètre brachial (PB), l’âge gestationnel, le poids du placenta (PP), le poids de naissance (PN), la taille vertex-talon (TVT), et le périmètre crânien (PC). Des différences significatives ont été observées entre les diverses nationalités en ce qui concerne l’Hb maternelle, le PC, le LVT, le PP et la taille de la mère. Les femmes koweïtiennes et indiennes présentaient un PP plus faible et leurs bébés avaient un PC et une TVT inférieures. La prévalence de l’anémie (Hb <11,0 g/dL) était comprise entre 7,1 % (Libanaises) et 30,0 % (Koweïtiennes) avec une prévalence globale de 19,5 %. La prévalence du faible poids de naissance était de 3,5 %. L’analyse de régression linéaire multiple a révélé que le PP constituait un facteur prédictif pour le PN, la LVT et le PC. Des différences significatives ont été observées entre les diverses nationalités en termes d’Hb maternelle, de PC, de LVT, de PP et de taille de la mère. L’importance de ces différences et les facteurs qui y contribuent nécessitent des recherches supplémentaires. تيوكلا في ةميقلما ةفلتخلما تايسنلجا ينب هتائبنمو لملحا جئاتن في تافلاتخلاا رخا ديعس ،يديشرلا ةلئاه ،نحمرلا دبع .تـيوكلا في ةـميقلما ةـفلتخلما تايـسنلجا ينـب لـملحا جـئاتن في ةـمئاقلا تاـفاتخلاا في قـيقحتلا في ةـساردلا هذـه نـم فدـلها لـثتم :ةـصلالخا ينـبولجوميهو ،ملأا ينـبولجوميهو ،ملأا لوـطب قـلعتت ةدلاوـلا دـنع دـيلاولماو تاـهملأا نـم ًاـجوز 369 نـم ةـيعطقم تاـنايب تـعُجم دـقو طـيمحو ،مدـقلا بـعك لىإ سأرـلا جاـت نـم ينـنلجا لوـطو ،داـيلما دـنع نزوـلاو ،ةميـشلما نزوو ،يدلاوـلا رـمعلاو ،دـضعلا طـيمحو ،لـفطلا نزوــ لاو ةميــ شلما نزوو ينــ نلجا سأر طــ يمحو ملأا ينــ بولجوميه نــ م لك في ةــ فلتخلما تايــ سنلجا ينــ ب ةيرــ بك تاــ فاتخا تــ ظحولو .سأرــ لا سأرــ لا طــ يمح ضاــ فخناب مــ هديلاوم مــ ستيو ةميــ شلما نزو ضاــ فخناب تاــ يدنلهاو تاــ يتيوكلا ءاــ سنلا مــ ستتو .ملأا لوــ طو داــ يلما دــ نع ينــ ب )رليــ سيد/مارج 0 <11 ينــ بولجوميه( مدــ لا رــ قف راــ شتنا لدــ عم حوارــ تو .مدــ قلا بــ عك لىإ سأرــ لا جاــ ت نــ م لوــ طلا ضاــ فخناو .% 3.5 دـيلاولما نزو ضاـفخنا راـشتنا لدـعم غـلبو .% 19.5 غـلب يك راـشتنا لدـعم عـم )تاـيتيوكلا ينـب( % 30.0و )تاـينانبللا ينـب( % 7.1 بـعك لىإ سأرـلا جاـت نـم ينـنلجا لوـطو داـيلما دـنع نزوـلل ًاـهم ًاـئبنم هراـبتعاب ةميـشلما نزو نـع ددـعتم يـطخ رادـحنا لـيلتح فـشكو .انهأـشب ثـحبلا نـم دـيزم ءارـجإ اـهيف ةهماـسلما لـماوعلاو تاـفاتخلاا هذـه ةـيهمأ باـستحا مزلتـسيو .سأرـلا طـيمحو مدـقلا ABSTRACT This study aimed to investigate differences in pregnancy outcome among various nationalities residing in Kuwait. Cross-sectional data were collected from 369 mother–infant dyads at delivery on mother height (MH), mother haemoglobin (mHb), child haemoglobin (cHb), mid-upper arm circumference (MUAC), gestational age (GA), placental weight (PW), birth weight (BW), crown–heal length (CHL), and head circumference (HC). Significant differences among various nationalities were observed in mHb, HC, CHL, PW and MH. Kuwaiti and Indian women had lower PW and their babies had lower HC and CHL. Prevalence of anaemia (Hb <11.0 g/dL) ranged from 7.1% (Lebanese) to 30.0% (Kuwaiti) with the overall prevalence of 19.5%. Prevalence of low birth weight was 3.5%. Multiple linear regression analysis revealed PW as a significant predictor of BW, CHL and HC. Significant differences among various nationalities were observed in mHb, HC, CHL, PW and MH.The significance of these differences and their contributing factors needs further research. https://doi.org/10.26719/2017.23.10.688 Book 23-10.indb 688 12/13/2017 9:41:00 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 689 Introduction Normal pregnancy outcome is impor- tant for the normal development, health and well-being of the newborn. The current hypothesis on the fetal origin of later-life chronic diseases suggests that exposure of the fetus to an adverse environment, including malnutrition, predisposes a person to later life chronic diseases, such as cardiovascular diseas- es, hypertension, diabetes and obesity (1,2). Birth weight is one of the most important predictors of fetal survival and health. Children born with low birth weight are at increased risk of death in the first year of life compared with children born with normal birth weight. In the United States of America (USA), infants with low birth weight make up 8% of all births, yet they represent more than 60% of all infant deaths (3). Although the incidence of low birth weight in Kuwait is low, ranging from 3.4% to 4.5% of births (4,5), a significant increase in poor pregnancy outcomes including stillbirth, low birth weight and macrosomia has been reported recently(6). In addition, differences in birth weights between the main ethnic groups in Kuwait have been reported (7,8). Kuwait is a multiethnic society and two thirds of the population are expatriates of various nationalities. The current population of Kuwait is 4.16 million, of which 1.35 million (30.4%) are Kuwaitis and 3.09 million (69.6%) are non-Kuwaitis (9). According to the 2011 population census, people from South Asia (34%) and other Arab countries (21%) make up most of the non-Kuwaiti population. The main nationalities in Kuwait are Indian and Egyptian (10). Studying the relationship between placental factors and pregnancy outcomes such as birth weight, fetal malnutrition and anaemia has gained considerable interest in recent years (11). The birth weight of a baby de- pends not only on the mother’s nutri- tion but also on the placenta’s ability to transport nutrients to it from its mother (2). Placental weight and volume can predict pregnancy outcome and thus the future health of the newborn (12–14). For example, placental size and shape has been reported to predict blood pressure at age 9 years (15). Thus, the shape and size of the placenta at birth has become a new marker for preg- nancy outcome and for chronic disease in later life (2). It has been reported that placental characteristics are not only influenced by neonatal, nutritional and environmental factors (16–18), but also by ethnicity (19–21). It is there- fore, important to study the influence of ethnicity on placental parameters as well as other variables associated with pregnancy outcome. The multiethnic society in Kuwait provides an opportunity to study differ- ences between nationalities in pregnan- cy and pregnancy outcome variables. The aim of this study therefore was to investigate differences between various nationalities living in Kuwait in mater- nal and pregnancy variables, including placental weight, and infant-related birth characteristics. We also evaluated the predictive value of placental weight on various pregnancy outcome vari- ables. Methods Study design and setting We conducted a cross-sectional study at the Al-Sabah Maternity Hospital, Kuwait. This is the only specialized maternity hospital in Kuwait, with about 12 000 deliveries a year, which represents one third of all deliveries in the country. Sample size and study participants To detect a minimum difference of 0.3 between proportions of mothers with anaemia of any of 2 nationalities, and assuming a prevalence of anaemia of 30% in one of the ethnic groups, an alpha value of 0.05 and study power of ≥ 0.95, we needed a sample of at least 65 mothers in each nationality. Women who were admitted to the hospital and delivered their baby be- tween 07:00 and 19:00 over a period of 3 months in 2011 were recruited into the study. Night deliveries were not included in the study because of re- stricted access to the hospital at night. Eligible participants were women who had been resident in Kuwait for at least 1 year. Women with multiple pregnan- cies, gestational diabetes, and those diagnosed with hypertension and other cardiovascular diseases were excluded from the study. Data collection Maternal interviews and measurements were conducted either before or after delivery depending on the mother’s condition. Information on national- ity, length of stay in Kuwait (in case of non-Kuwaiti nationals), number of children and parity were obtained from the women during the interview. Data on mother’s height and age, mid-upper arm circumference and gestational age were obtained from the medical records. After delivery, birth weight of each neonate was recorded to the nearest 10 g, and crown to heel length and head circumference were meas- ured to the nearest 0.1 cm, using non- stretchable tape. Placental weight was obtained by weighing the placenta after draining all the blood. The haemoglobin (Hb) levels of the child (cHb) and the mother (mHb) are routinely measured at delivery and admittance respectively at the hospital laboratory, and these data were obtained from the hospital records. Placental weight to birth weight ratio was also calculated. Statistical analyses Data were analysed with SPSS for Win- dows, version 21. Data are expressed as mean and standard deviation (SD) as appropriate. One way analysis of vari- ance with Bonferroni correction, as post Book 23-10.indb 689 12/13/2017 9:41:00 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 690 hoc analysis, was used to estimate mean differences. Simple and multiple regres- sion analyses were performed to test the significance of associations. The preva- lence of anaemia, defined as Hb < 11.0 g/dL (22), in the different nationalities was compared with the chi-squared test. The level of significance was set at P < 0.05. Ethical considerations The study was conducted according to the guidelines laid down in the Declara- tion of Helsinki and the study protocol was approved by the Ministry of Health of the State of Kuwait. Written informed consent was obtained from all the par- ticipants. Results A total of 369 mother-baby pairs were included in the study: 80 (22%) were Kuwaitis, 81 (22%) Egyptians, 45 (12%) Indians, 42 (11%) Syrians, 28 (6%) Lebanese and 93 (25%) other nationalities. The other nationalities in- cluded Iranians, Pakistanis, Jordanians and Filipinos; the individual numbers in these nationalities were not enough to conduct meaningful statistical analysis. The maternal and pregnancy out- come variables (mean and SD) accord- ing to nationality are shown in Table 1. Analysis of variance showed significant difference between the nationalities in mHb (P = 0.001), head circumference (P = 0.011), crown-heel length (P = 0.039), placental weight (P = 0.002), maternal height (P < 0.001) and mater- nal age (P < 0.0001). On the other hand, there were no significant differences between the nationalities in birth weight (P = 0.423), cHb (P = 0.337), placental weight/birth weight ratio (P = 0.352), gestational age (P = 0.283) and mid- upper arm circumference (P = 0.330). The Bonferroni post-hoc analysis showed that Syrian women with a mean age of 26.4 (SD 5.3) years were signifi- cantly younger than Kuwaiti and Indian women. Indian women (mean height = 154.6, SD 14.7 cm) were significantly shorter than the other nationalities. Kuwaiti and Indian women had significantly lower mean placental weight [629.9 (SD 78) g and 629.5 (SD 92) g re- spectively] than Lebanese women [695.5 (SD 100) g]. In addition, babies born to Indian women had significantly lower head circumfer- ence compared to Kuwaiti women but not to the other nationalities. Crown-heel length was not sig- nificantly different between the different nationalities. Mean mHb levels in Kuwaiti women were sig- nificantly lower than Egyptian and Indian women but not compared with other nationalities. The overall prevalence of anae- mia (Hb < 11.0 g/dL) in the 369 mother–baby pairs was 19.5%. Although there were wide varia- tions in the prevalence of anaemia between the various nationalities, ranging from 7.1% in Lebanese women to 30.3% in Kuwaiti wom- en (Table 2), the differences were not statistically significant (P = 0.057). There were no significant differences in birth weight between the nationalities. The overall preva- lence of low birth weight (defined as birth weight < 2 500 g) was 3.5%. Multiple regression analysis (Table 3) showed that placental weight was a significant predic- tor of birth weight (P < 0.001), crown-heel length (P < 0.001) and head circumference (P = 0.004). In addition, maternal height was a significant predictor of birth weight (P = 0.044) and crown-heel length (P = 0.04), after adjusting for vari- ous confounding variables. Gesta- tional age was the only predictor of placental weight (P = 0.013). The placental weight/birth weight ratio was not a significant predictor of any of the pregnancy outcome variables (data not shown). Ta bl e 1 M ea n (s ta nd ar d de vi at io n) v al ue s of m at er na l a nd p re gn an cy o ut co m e va ri ab le s in th e va ri ou s na ti on al it ie s N at io na lit y (n ) M ot he r’s a ge (y ea rs ) m H b (g /d L) cH b (g /d L) H C (c m ) C H L (c m ) PW (g ) M H (c m ) G A (d ay s) BW (g ) M U A C (c m ) PW /W B ra ti o Ku w ai ti (8 0 ) 29 .6 (5 .5 )a 11 .5 5 (1. 44 )a 14 .9 1 ( 1.2 8) 33 .9 (1 .3 )ab 49 .6 (2 .6 ) 62 9. 9 (7 8. 1) a 16 0 .1 (4 .7 )a 27 4. 4 (1 0 .8 ) 3. 17 (0 .3 6) 29 .7 (3 .4 ) 0 .2 0 (0 .0 4) Eg yp tia n (8 1) 27 .3 (5 .0 )ab 12 .2 9 (1. 16 )b 14 .9 3 (1. 52 ) 34 .7 (2 .8 )a 50 .7 (2 .7 ) 66 3. 3 (7 7.9 )ab 16 2. 7 (6 .0 )a 27 7.4 (8 .4 ) 3. 43 (0 .4 2) 29 .8 (3 .5 ) 0 .2 0 (0 .0 3) In di an (4 5) 29 .9 (5 .5 )a 12 .4 2 (1. 24 )b 15 .3 4 (1. 50 ) 33 .2 (4 .3 )b 49 .9 (3 .7 ) 62 9. 5 (9 2. 0 )a 15 4. 6 (1 4. 7) b 27 5. 1 ( 8. 6) 3. 78 (4 .3 4) 28 .5 (3 .1) 0 .19 (0 .0 5) Sy ria n (4 2) 26 .4 (5 .3 )b 12 .16 (1 .2 7) ab 15 .3 5 (1. 66 ) 34 .3 (0 .9 )ab 50 .1 (2 .3 ) 66 6. 1 ( 70 .4 )ab 16 3. 9 (6 .5 )a 27 7.5 (7 .8 ) 3. 38 (0 .3 9) 30 .1 (3 .7 ) 0 .2 0 (0 .0 2) Le ba ne se (2 9) 26 .6 (5 .0 )ab 12 .4 1 ( 2. 0 3) ab 14 .7 8 (1. 70 ) 34 .3 (1 .4 )ab 50 .1 (4 .3 ) 69 5. 5 (1 0 0 .1) b 16 2. 2 (6 .1) a 27 6. 0 (8 .6 ) 3. 43 (0 .5 3) 29 .3 (4 .0 ) 0 .19 (0 .0 4) An al ys is o f v ar ia nc e sh ow ed si gn ifi ca nt d iff er en ce b et w ee n th e na tio na lit ie s i n m H b (P = 0 .0 01 ), he ad c irc um fe re nc e (P = 0 .0 11 ), cr ow n− he el le ng th (P = 0 .0 39 ), pl ac en ta l w ei gh t ( P = 0. 00 2) , m at er na l h ei gh t ( P < 0. 00 1) a nd m at er na l a ge (P < 0. 00 01 ). Va lu es w ith d iff er en t s up er sc rip ts w ith in th e sa m e co lu m n di ffe r s ig ni fic an tly (P < 0 .0 5) a s a ss es se d by B on fe rr on i p os t-h oc a na ly si s. m H b = m ot he r h ae m og lo bi n, c H b = ch ild h ae m og lo bi n, H C = h ea d ci rc um fe re nc e, C H L = cr ow n− he al le ng th , P W = p la ce nt al w ei gh t, M H = m ot he r h ei gh t, G A = ge st at io na l a ge , B W = b irt h w ei gh t, M U AC = m id -u pp er a rm c irc um fe re nc e. Book 23-10.indb 690 12/13/2017 9:41:00 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 691 Discussion The overall prevalence of low birth weight in this sample was 3.5%, which is comparable to the previously reported prevalence of low birth weight in Kuwait (4,5). However, we did not find a signifi- cant difference in birth weight between the nationalities studied, in contrast to previously reported studies on birth weight among various ethnic groups in Kuwait (7,8). Our smaller sample size compared with these studies could have resulted in this lack of statistical significance. Another significant finding in our study was the very high prevalence of anaemia (30%) in Kuwaiti pregnant women. Several studies have shown that anaemia is a significant public health problem in Kuwait (23–25). Previous studies from Kuwait reported that 28.7- 36.8% of pregnant Kuwaiti women were anaemic (25,26) and our results agree with these reports. Differences in the dietary pattern between nationalities could be the reason for the difference in the prevalence of anaemia. Although we do not have information about the dietary pattern of this sample, a previous study reported that a large proportion of Kuwaiti pregnant women had not eaten iron-rich foods like beef (62.4%), goat or lamb (45.2%), fish (54.6%), liver (87.3%) and white bread (which is forti- fied with iron and some B vitamins as required by law) (74%) at all during the week preceding the interview (25). In addition, the consumption of tea and coffee, which are known to interfere with iron absorption, was high in this group. We found significant differences between the nationalities in placental weight and head circumference. Kuwaiti and Indian women had significantly lower placental weight compared with Lebanese women, and babies born to Indian women had significantly lower head circumference compared with Egyptian women, suggesting the predic- tive importance of placental weight to pregnancy outcome in Indian women. In a previous study, the placental weight of Indian women was reported to be significantly lower than that of Malay and Chinese women (11). Similarly, Table 2 Prevalence of anemia in various nationalities Nationality Total number Number with anaemia (HB < 11 g/dL) % Kuwaiti 80 24 30 Egyptian 81 11 14 Indian 45 7 16 Syrian 42 9 21 Lebanese 28 2 7 Chi-squared = 10.7 (df = 5); P = 0.057. Table 3 Predictors of pregnancy outcome variables in multiple linear regression analyses Dependent variable Predictors in the final model Regression coefficient (β) 95% confidence interval P-value R2 BW (kg) Model 1 Constant 0.766 – – 0.402 PW (g) 0.003 0.002 to 0.003 < 0.001 MH (cm) 0.556 0.015 to 1.096 0.044 Sex 0.157 0.054 to 0.259 0.003 HC (cm) Model 2 Constant 36.731 – – 0.132 PW (g) 0.005 0.002 to 0.008 0.004 MUAC (cm) –0.143 –0.231 to –0.055 0.002 Sex 0.972 0.370 to 1.573 0.002 CHL (cm) Model 3 Constant 36.541 – – 0.171 PW (g) 0.011 0.006 to 0.016 < 0.001 Hb (g/dL) –0.315 –0.624 to –0.005 0.046 MH (cm) 0.051 0.002 to 0.009 0.040 Sex 1.550 0.629 to 2.471 0.001 PW (g) Model 4 Constant 64.330 – – 0.223 GA 2.136 1.236 to 3.036 < 0.001 BW = birth weight, HC = head circumference, CHL = crown-heel length, PW = placental weight, MH = mother height, MUAC = mid-upper arm circumference, mHb = mother haemoglobin, cHb = child haemoglobin, GA = gestational age. Book 23-10.indb 691 12/13/2017 9:41:00 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 692 lower placental weight has been re- ported previously in Asian women compared with European and Afro- Caribbean women (27). Several other studies have reported that placental characteristics differ between different ethnic groups (27–29). When adjusted for other confounding variable in the regression analysis, placental weight was a significant predictor of birth weight, crown-heel length and head circumfer- ence. Other studies have also shown that placental weight was a predictor of birth weight (11–15), neonatal length and head circumference (11). Several studies have suggested that the placental weight/birth weight ratio is a useful marker for pregnancy out- come (30,31). It has been suggested that the combination of a large placenta and low birth weight is a strong inde- pendent risk factor for cardiovascular disease in adulthood (32). However, in our study, the placental weight/birth weight ratio was not a significant predic- tor of any of the birth outcomes (birth weight, head circumference, crown- heel length). Similar to our findings, other studies have also found that the placental weight/birth weight ratio is not a consistent predictor of pregnancy outcome (27–29). Our study has several limitations. First, we used a convenience sampling approach for logistic reasons, and col- lected our sample only during the day time (07:00 to 19:00), as our access to the hospital during the night was re- stricted. However, not including deliv- eries that occurred at night is unlikely to affect the representativeness of our sam- ple of the general population. Second, the length of residence in Kuwait for the non-Kuwaiti participants was not included in the analysis, which, although unlikely, could have confounded the results. Third, we did not collect data on the nutritional status of the women or their socioeconomic status, which could be potential confounding fac- tors. One of the main predictors of fetal growth is the weight gain during pregnancy. As this was a cross-sectional study and data were collected only at the time of delivery, information on weight gained during pregnancy could not be obtained. Therefore, a prospec- tive longitudinal study in which women are followed throughout pregnancy un- til delivery would provide more robust data on the various factors which could have a confounding effect on the preg- nancy outcome variables. Conclusion Our study found significant differences in head circumference between differ- ent nationalities living in Kuwait and these differences were predicted by placental weight. Further research is needed to elucidate the significance of these differences in pregnancy outcome and factors that contribute to these dif- ferences. Acknowledgements We thank Dr Jehad Al Harmi and other medical staff at the obstetric unit of the Al-Sabbah Maternity Hospital, and the study participants for their support and cooperation. Funding: This project was supported by a graduate student award to Haila Al-Rashidi from the College of Gradu- ate Studies. Competing interests: None declared. References 1. Barker DJ. Sir Richard Doll Lecture. Developmental origins of chronic disease. Public Health. 2012 Mar;126(3):185–9. PMID:22325676 2. Barker DJ, Lampl M, Roseboom T, Winder N. Resource allo- cation in utero and health in later life. Placenta. 2012 Nov;33 Suppl 2:e30–4. PMID:22809673 3. Martin JA, Hamilton BE, Osterman MJK, Curtin SC, Matthews TJ. Births: final data for 2012. Natl Vital Stat Rep. 2013 Dec 30;62(9):1–68. PMID:25671704 4. Al-Awadi F, Amin EK. 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PMID:2390618 Book 23-10.indb 693 12/13/2017 9:41:00 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 694 1Community Medicine Department, Faculty of Medicine, University of Alexandria, Alexandria, Egypt (Correspondence to: Eman A. Sultan: eman.sultan@ alexmed.edu.eg). 2Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, University of Alexandria, Alexandria, Egypt. Received: 20/07/16; accepted: 12/01/17 Near-miss cases admitted to a maternal intensive care unit, Alexandria, Egypt Eman A. Sultan 1, Safia I. Shehata 1, Salwa S. Shaarawy 2 and Mona H.H. Ashry 1 Étude des cas de décès évités de justesse admis en unité de soins maternels intensifs à Alexandrie (Égypte) RÉSUMÉ Les études portant sur les cas de survie à des complications sévères de la grossesse, encore appelés « décès maternels évités de justesse », sont peu nombreuses dans la Région de la Méditerranée orientale. Pour identifier les facteurs et diagnostics prédisposants dans les cas de décès maternels évités de justesse, des patientes admises à l’unité de soins maternels intensifs de l’hôpital universitaire El-Shatby d’Alexandrie (Égypte) ont été examinées. Dans une enquête prospective portant sur 448 cas répondant aux critères OMS de décès évité de justesse et admis à l’unité de soins maternels intensifs de l’hôpital universitaire El-Shatby au cours de l’année 2014, les dossiers ont été examinés et les patientes ont été interrogées puis suivies afin d’évaluer l’évolution de leur état de santé. Le faible niveau d’éducation des mères et l’inadéquation des soins prénatals étaient associés de manière significative à la mortalité maternelle. La pré- éclampsie sévère et l’hémorragie du postpartum étaient les causes d’hospitalisation les plus fréquentes (40,2 % et 23,8 %, respectivement). L’indice de mortalité s’élevait à 8,5 %. La septicémie et les dysfonctionnements organiques multiples étaient des facteurs prédictifs significatifs de la mortalité maternelle. صرم ،ةيردنكسلإا ،تاهملأل ةزكرلما ةيانعلا ةدحو تلخدُأو ةافولا لىع تفراش يتلا تلااحلل ةسارد يشرع يدحم ىنم ،يوارعش نابعش ىولس ،ةتاحش ميهاربإ ةيفص ،ناطلس رونأ نايإ ةاـفولا ىـع ةـفشرلما تلااـلحاب ةـقلعتلما تاـساردلا نأ لاإ ؛ةاـفولا ىـع ةـفشرلما تلااـلحا مـساب ةداـلحا لـملحا تاـفعاضم نـم ةاـجنلا فرـعُت :ةـصلالخا مـييقت مـت ،ةاـفولا ىـع ةـفشرلما تلااـلحا صيخـشتو ةـض ِّرعلما لـماوعلا دـيدحتلو .طـسوتلما قشر مـيلقإ في ددـعلا ةـليلق ةدلاوـلا لوـحو لـملحا ءاـ نثأ نـمضت يقابتـسا حـسم يرـجأو .رـمب ةيردنكـسلإا في يـعمالجا يبطاـشلا ىفـشتسمب "تاـهملأل ةزـكرلما ةـيانعلا ةدـحو" نـلهاخدإ مـت تياـلا تاـضيرلما ةـيانعلا ةدـحو" اـلهاخدإ مـتو ةدلاوـلا لوـحو لـملحا ءاـنثأ ةاـفولا ىـع ةـفشرلماب ةـقلعتلما ةـيلماعلا ةـحصلا ةـمظنم يرـياعم تفوتـسا ةـلاح 448 عـم تاـباقم تاـهملأا مـيلعت ىوتـسم ضاـفخنا طـبتراو .اـهجئاتن مـييقتل اـهتعباتمو اتهاجـس ضارعتـساو 2014 ماـع لاـخ يبطاـشلا ىفـشتسمب "تاـهملأل ةزـكرلما رـثكأ عـضولل لياـتلا فزـنلاو ديدـشلا لـملحا ممـست لكـشو .تاـهملأا تاـيفو لدـعمب ةـللاد اذ ًاـطابترا ةدلاوـلا لـبق اـم ةرـف في ةـياعرلا ةـيافك مدـعو ىوتــ سم ضاــ فخنا ّدــ ُعو .% 8.5 تاــ يفولا شرؤــ م غــ لبو .)لياوــ تلا ىــ ع % 23.8و % 40.2( ةزــ كرلما ةــ ياعرلا ةدــ حول تاــ هملأا لاــ خدلإ ًاعويــ ش بابــ سلأا ينـمهم ينـئّبنم د ِّدـعتلما ءاـضعلأا لـلخو م ُّمـستلا لّكـشو .تاـهملأا تاـيفول ينـمهم نـيددمح ةدلاوـلا لـبق اـم ةـلحرم في ةـياعرلا ةـيافك مدـعو مـيلعتلا .تاـهملأا تاـيفول ABSTRACT Survival of severe pregnancy complication is known as maternal near-miss; however, studies on maternal near-miss are few in the Eastern Mediterranean Region. To identify the predisposing factors and diagnoses of near-miss cases, patients admitted to the maternal intensive care unit of El-Shatby University Hospital in Alexandria, Egypt, were assessed. A prospective survey was conducted where 448 cases that fulfill the WHO criteria of near-miss and admitted to El Shatby maternal intensive care unit during 2014 were interviewed, their records were reviewed and were followed up to assess their outcome. Low maternal education and inadequate antenatal care were significantly associated with maternal mortality. Severe pre-eclampsia and post-partum hemorrhage were the most common causes of admission (40.2% and 23.8% respectively). Mortality index was 8.5%. Sepsis and multiple organ dysfunction were significant predictors of maternal mortality. https://doi.org/10.26719/2017.23.10.694 Book 23-10.indb 694 12/13/2017 9:41:00 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 695 Introduction Maternal death is defined by the World Health Organization (WHO) as “death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes” (1). Maternal death is used for evaluation of health services’ quality as well as the socioeconomic development of a population (2). Globally, there were 289 000 ma- ternal deaths in 2013 with more than 1 life lost every 2 minutes. In Egypt, about 860 Egyptian women died from complications related to pregnancy and childbirth in 2013 with a maternal mor- tality ratio of 45 maternal deaths per 100 000 live births and a lifetime risk of maternal death of 1 in 710 (3). Despite these high national figures, the number of maternal deaths is low at the hospital level. This therefore does not allow for proper identification of the risk factors and the quality of care at the local level (4). In view of this, WHO proposed the evaluation of maternal near-misses, meaning “a woman who nearly died but survived a complication that occurred during pregnancy, child- birth or within 42 days of termination of pregnancy” (1). WHO developed a definition of and identification criteria for maternal near- miss cases in 2009. This was followed by the “WHO near-miss approach for maternal health” in 2011 (5,6). Ac- cording to WHO, the identification of maternal near-miss cases is based on 2 components: • Identification of specific complica- tions such as severe pre-eclampsia and/or critical interventions such as blood transfusion. • Identification based on organ dys- function criteria including clinical, laboratory and management-based criteria (1). Few studies on maternal near-miss- es have been conducted in the Middle East and North Africa (3,7). The aim of this study was to identify the factors associated with maternal near misses and the diagnoses on admission to the intensive care unit (ICU) of a university hospital in Alexandria, Egypt, in relation to the outcome. Methods Study design and setting A prospective study was carried out in the maternal ICU of El Shatby Univer- sity Hospital in Alexandria, Egypt. The study was conducted over 1 year from 1 January to 31 December 2014. Study participants All women (448 women) admitted to the ICU in the study period were included. Data collection The women were interviewed to identify potential predisposing factors and causes of maternal near-miss. For severely ill women, one of their rela- tives (husband, mother or sister) was interviewed instead. Then, all recruited women were followed up to assess their outcome. Data were collected using an inter- view questionnaire that enquired about: sociodemographic characteristics, med- ical history, past and current obstetric histories and antenatal care received. The admission and medical records of the women were also reviewed. Data analysis Data were analysed using SPSS, version 20. Data are presented as numbers and percentages for categorical variables and means and standard deviations (SD) for continuous variables (age of women, inter-pregnancy interval and length of stay in the ICU). For com- parisons between died and survived women, the Student t-test was used for normally distributed quantitative vari- ables and the Mann–Whitney test for non-normally distributed variables. For qualitative variables, the chi-squared, Fisher exact, and Monte Carlo tests were used. Multiple logistic regression analysis was done to determine the predictors of maternal death. The independent variables tested were: maternal age, education, inter-pregnancy interval, presence of co-morbid condition/s, sepsis, pre-eclampsia, organ dysfunc- tion, attending less than 4 antenatal care visits, delivery by caesarean section and postpartum haemorrhage. To avoid multi-colinearity, all independent vari- ables were tested for inter-correlations before being included in the regression analysis. Significant correlation between maternal age and parity resulted in the exclusion of parity. All results were interpreted at the 5% level of significance. Ethical considerations Official approvals for the study were obtained from Ethical Committee of the Faculty of Medicine, University of Alexandria, the head of the maternal ICU and the Director of El Shatby Uni- versity Hospital in Alexandria. The objectives of the study and types of information to be obtained were explained to the women (or their husband, mother or sister) and their informed consent was taken. Confiden- tiality of data was assured. Results Of the 448 women admitted to the ICU and included in the study, 410 survived and 38 died. Table 1 shows the sociodemo- graphic characteristics of the women. Their ages ranged from 16 to 40 years with a mean age of 27.17 (SD 5.42) years. The mean age of the women who survived was 27.09 (SD 5.34) years Book 23-10.indb 695 12/13/2017 9:41:00 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 696 compared with 27.45 (SD 6.04) years among the women who died (P > 0.05). There was a statistically significant relation between education level and outcome: 9.4% of uneducated women and 11.8% of those with basic education died compared with 1.7% of the women with secondary or higher education (P = 0.006). Occupation of the husband was also significantly associated with death: 23.5% of the women whose hus- bands were not working and 12.4% of those married to manual workers died compared with 5.3% of those married to professionals and 5.4% of those married to skilled workers (P = 0.01). The medical history of the women is shown in Table 2. One quarter of the women (25.2%) had 1 or more chronic disease, with heart disease being the most common; of those with a chronic disease, 47.8% had a heart condition, 18.6% had hypertension and 15.9% had diabetes mellitus. Death among women with chronic diseases was not signifi- cantly different from those without a chronic disease; 8.0% and 8.7% died respectively (P = 0.85). Table 3 shows the obstetric history of the women according to outcome. More than half (54.5%) of the parous women had a history of caesarean section. Of these, 8% died compared with 16.5% of those who had not had a previous caesarean section and this difference was statistically significant (P = 0.036). The interval between current preg- nancy and the preceding delivery ranged from 3 to 192 months with a mean of 33.8 (SD 25.1) months. The mean cur- rent inter-pregnancy interval for surviv- ing women was significantly longer than that of the women who died (34.8 and 26.6 months respectively) (P = 0.026). More than a quarter (27.6%) of the women with an inter-pregnancy interval of less than 1 year died compared with 10.5% of those with an interval of 1–4 years and 7.5% of those with an interval of 5 years or more (P = 0.017). With regard to antenatal care, 16.5% of the studied women did not receive antenatal care during their cur- rent pregnancy while 32.1% had had 1–4 visits and 51.3% had had 4 visits or more. More than a third (35.1%) of the women who did not have any antenatal care died compared with 5.6% and 1.7% respectively of those who had had 1–4 visits and 4 visits or more (Table 3). These differences were statistically sig- nificant (P < 0.001). The admission data of the women are shown in Table 4. On admission to the maternal ICU, 40.8% of the women had severe pre-eclampsia or eclampsia and 23.2% had severe post- partum haemorrhage. On comparing the women’s admission diagnoses and outcome, 77.8% of the women admitted with sepsis died compared with 3.8% of those admitted with either severe postpartum haemorrhage or severe pre- eclampsia/eclampsia (P < 0.001). The mean length of stay in the maternal ICU was 3.07 (SD 3.33) days. The mean Table 1 Distribution of the studied women according to their sociodemographic characteristics and outcome Sociodemographic characteristic Survived (n = 410) Died (n = 38) Total (n = 448) P-value No. % No. % No. % Age (years) Mean (SD) 27.09 (5.34) 27.45 (6.04) 27.17 (5.42) 0.691 Range 16−40 16−39 16−40 Level of education 0.0062 Illiterate/read and write 115 90.6 12 9.4 127 100.0 Primary/preparatory 179 88.2 24 11.8 203 100.0 Secondary/higher 116 98.3 2 1.7 118 100.0 Working status Working 28 96.6 1 3.4 29 100.0 0.493 Not working 382 91.2 37 8.8 419 100.0 Husband’s occupation Manual worker 134 87.6 19 12.4 153 100.0 0.014 Skilled worker 191 94.6 11 5.4 202 100.0 Professional 72 94.7 4 5.3 76 100.0 Not working 13 76.5 4 23.5 17 100.0 Wanted pregnancy Yes 375 91.0 37 9.0 412 100.0 0.353 No 35 97.2 1 2.8 36 100.0 1t = –0.39; 2Chi-squared = 10.07; 3Fisher exact test; 4Monte Carlo test. SD = standard deviation. Book 23-10.indb 696 12/13/2017 9:41:00 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 697 length of stay of the surviving women was significantly shorter than that of the women who died (P < 0.001). More than half (57.4%) of women were admit- ted to the maternal ICU after delivery while the rest were still pregnant on admission. Mortality was significantly higher among the women admitted to the maternal ICU after delivery (P = 0.034). Regarding organ dysfunction, car- diovascular dysfunction was the most common organ dysfunction among the women (48.9%) followed by co- agulation/haematological and hepatic Table 2 Distribution of the studied women according to their medical history and outcome Medical history Survived (n = 410) Died (n = 38) Total (n = 448) P-value No. % No. % No. % Yes 104 92.0 9 8.0 113 100.0 0.852 Diabetes mellitus 17 16.3 1 11.1 18 15.9 Hypertension 19 18.3 2 22.2 21 18.6 Heart disease 53 51.0 1 11.1 54 47.8 Other diseases1 32 30.8 5 55.6 37 32.7 No 306 91.3 29 8.7 335 100.0 1Others include liver diseases, renal diseases, bronchial asthma, thyroid diseases, systemic lupus erythematosus, chronic cholecystitis, epilepsy, deep vein thrombosis, leukaemia and HIV. 2Chi-squared = 0.052. Table 3 Distribution of the studied women according to their obstetric history and outcome Variable Survived (n = 410) Died (n = 38) Total (n = 448) P-value No. % No. % No. % Gravidity 0.062 Primigravida 149 94.9 8 5.1 157 100.0 2−4 199 88.4 26 11.6 225 100.0 ≥ 5 62 93.9 4 6.1 66 100.0 Parity 0.093 Nullipara 184 94.4 11 5.6 195 100.0 1−4 194 87.8 27 12.2 221 100.0 ≥ 5 32 100.0 0 0.0 32 100.0 Current inter-pregnancy interval (months) 0.0174 < 12 21 72.4 8 27.6 29 100.0 12−59 153 89.5 18 10.5 171 100.0 ≥ 60 49 92.5 4 7.5 53 100.0 Mean (SD) 34.8 (25.7) 26.6 (23.0) 33.8 (25.1) 0.0265 Range 6−192 3−108 3−192 Previous caesarean delivery 0.0366Yes 127 92.0 11 8.0 138 100.0 No 96 83.5 19 16.5 115 100.0 Type of current delivery1 0.613Vaginal delivery 51 89.5 6 10.5 57 100.0 Caesarean section 287 91.7 26 8.3 313 100.0 Number of antenatal care visits < 0.0017 None 48 64.9 26 35.1 74 100.0 < 4 136 94.4 8 5.6 144 100.0 ≥ 4 226 98.3 4 1.7 230 100.0 1Cases of abortion (n = 78) were excluded. 2Chi-squared = 5.56; 3Fisher exact test; 4chi-squared = 8.09; 5Mann−Whitney Z = −2.22; 6chi-squared = 4.39; 7chi-squared = 82.78. SD = standard deviation. Book 23-10.indb 697 12/13/2017 9:41:01 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 698 dysfunction, which were found in 23.4% and 22.1% of the women respectively. Table 5 shows that 32.4% of the women had multiple organ dysfunction. Of these, 17.9% died compared with only 5.2% and 3.5% of those without or with single organ dysfunction respectively (P < 0.001). The total number of deliveries in El Shatby Hospital in 2014 was 11 982 (5 678 vaginal and 6 304 caesarean deliveries). These data were used to calculate the maternal near-miss indica- tors as shows in Box 1. Results of the multiple logistic regres- sion analysis showed that the significant predictors of maternal mortality were sepsis (OR = 32.6, 95% CI: 8.73–51.77, P < 0.001) and multiple organ dysfunc- tion (OR = 3.94, 95% CI: 1.39–11.08, P = 0.009) (Table 6). Women admitted with severe pre-eclampsia were signifi- cantly less likely to die than those who did not have pre-eclampsia or had mild pre-eclampsia and were admitted with other diagnoses (OR = 0.14, 95% CI: 0.02–0.83, P = 0.030). Discussion Our study included women admitted to El-Shatby maternal ICU during 2014 and compared the women who survived (410 women) with those who died (38 women). The mean age of the women was about 27 years. This almost coincides with the mean age of child- bearing in Egypt (27.8 years) and in the Middle East region as recorded by the United Nations in 2011 (8). We found a significant association between women’s level of education and husband’s occupation and mater- nal death. This relation between low so- cioeconomic status and mortality may be explained by a lack of proper health awareness and inability to perceive threatening signs and symptoms and consequently longer delays in deciding to seek and reach care (9). A quarter of the women in our study had one or more chronic disease. This is similar to a study in Saudi Arabia in 2011 where 16% of obstetric admissions to the ICU had underlying diseases (10). Heart diseases were the most prevalent chronic disease representing 47.8% of the co-morbid conditions. This result is consistent with a Brazilian study in 2012 in which cardiovascular diseases were the most common non-obstetric cause Table 4 Distribution of the studied women according to admission data and outcome Admission data Survived (n = 410) Died (n = 38) Total (n = 448) P-value No. % No. % No. % Admission diagnosis < 0.0012 Severe pre-eclampsia/eclampsia 176 96.2 7 3.8 183 40.8 Severe postpartum haemorrhage 100 96.2 4 3.8 104 23.2 Severe systemic infection or sepsis 4 22.2 14 77.8 18 4.0 Ruptured uterus 9 81.8 2 18.2 11 2.5 Other diagnoses1 121 91.7 11 8.3 132 29.5 Length of stay in ICU (days) < 0.0013 Mean (SD) 2.56 (1.7) 8.71 (8.21) 3.07 (3.33) Range 1−14 1−34 1−34 Pregnancy state on admission 0.0344 Pregnant 181 94.8 10 5.2 191 42.6 Delivered 229 89.1 28 10.9 257 57.4 1Other diagnoses include heart diseases with pregnancy, acute fatty liver of pregnancy, respiratory complications, antepartum haemorrhage, ectopic pregnancy, complications of abortion, vesicular mole, systemic lupus erythematosus, diabetic ketoacidosis and deep vein thrombosis. 2Chi-squared = 120; 3Mann-Whitney Z = -4.61; 4Monte Carlo test. ICU = intensive care unit, SD = standard deviation. Box 1. ICU admission rate in 2014 = x 100 00 = 3 739/100 000 deliveries or nearly 4% Maternal near-miss mortality ratio = maternal near-miss cases:maternal deaths = 10.8:1 Mortality index = x 100 00 = 8.5% Cases admitted to ICU Total number of deliveries Maternal deaths (Maternal near-miss cases + Maternal deaths) Book 23-10.indb 698 12/13/2017 9:41:01 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 699 of ICU admission of pregnant women (11). In studies on women giving birth in El-Shatby Hospital in 2009 and 2015, cardiovascular diseases were present in 8.2% and 3.1% respectively (12,13). This reflects the importance of heart dis- ease as a risk factor for ICU admission. The mean interval between current pregnancy and the preceding delivery was significantly shorter among the women who died in our study. These results are in agreement with a review in the United States of America (USA) in 2012 (14). This may be explained by maternal depletion hypothesis which suggests that women who become pregnant after a short interval are sus- ceptible to poor nutrition, greater expo- sure to disease and other physical and emotional stress resulting from negative energy balance and/or micronutrient deficiencies from the burden of frequent reproductive cycles (15,16). More than half (54.5%) of the parous women had had a previous caesarean section. Similarly, a study in Baghdad in 2013 reported a history of previous caesarean section among 44.5% of near-miss women (17). We found a statistically significant associa- tion between having a previous caesar- ean section and survival. This finding was consistent with the results of the WHO’s 2005 global survey on maternal and perinatal health (18). This could be explained by more compliance of women with previous caesarean section with attending antenatal visits and close monitoring by the medical practitioners for co-morbid conditions. Furthermore, regarding the current delivery in our study, a lower percentage of the women who underwent a caesarean section died (8.3%) compared with those who delivered vaginally (10.5%). However, this difference was not statistically sig- nificant. Nonetheless, it is important to remember that in situations found in the present study, a caesarean section may be interpreted either as a solution for cases of morbidity or as a determin- ing factor of morbidity (19). The present study found a statisti- cally significant association between attending antenatal care and survival; 35.1% of the women who did not have any antenatal care visits during their pregnancy died compared with only 5.6% of those who had 1–4 visits and 1.7% of those who had 4 visits or more. Other studies confirm that antenatal care is an important and modifiable factor in maternal mortality and showed antenatal care was significantly less frequent among women who died (10,20,21). In our study, the most common diagnoses for admission to the mater- nal ICU were severe pre-eclampsia or eclampsia followed by severe postpar- tum haemorrhage. Together, they were the reasons for admission for 64% of the women. This finding is consistent with earlier studies (22–25). The high incidence of hypertensive disorders of pregnancy in the studied women may be due to poor dietary habits, lack of exercise and more stressful conditions in pregnancy. Moreover, these results expose a weakness in early detection of pre-eclampsia; possibly due to poor antenatal care and follow-up. The disease profile for near-miss morbidity in our study differed from that of maternal mortality. While the most common types of near-miss cases were due to severe hypertensive disorders or severe haemorrhage, their mortality indexes were only 3.8% each. At the same time, while sepsis was an uncommon cause of near-miss (4%), it had a significantly higher mortality index of 77.8% reflecting a significant threat to the survival of affected women. These results are in agreement with previous studies. A study in the Syr- ian Arab Republic in 2010 reported mortality indexes of 0.4% and 2.8% for severe hypertensive disorders and se- vere haemorrhage respectively while sepsis showed a relatively high mortality index of 7.4% (7). Similarly, a study in Sudan in 2011 found that despite the high morbidity from haemorrhage and hypertensive disorders (40.8% and 18% respectively), their mortality indexes were lower than that of sepsis (10% and 8.8% respectively compared with 22.2% for sepsis) (26). The significantly lower mortality from haemorrhage and pre-eclampsia/eclampsia in the present study may be attributed to ef- fective management upon arrival at the hospital by appropriate interventions within an adequate timeframe, such as the availability of blood bank services, timely interruption of the pregnancy or the proper use of magnesium sulfate for the prevention of eclampsia in women with severe pre-eclampsia and for the treatment of women with eclampsia, as recommended by WHO (1). The mean length of stay of women in the ICU was about 3 days which con- curs with findings of previous studies (7,19,23). Moreover, the mean length of stay for the surviving women was significantly shorter than that of the women who died. The need for inter- ventions to manage severely ill patients can explain the longer period of hospi- talization. As regards the pregnancy state on ICU admission, 57.4% of studied women were admitted after delivery. This is consistent with previous stud- ies. A study in India in 2011 reported that 83.3% of the patients were admit- ted in the postpartum period (25). In a study in Brazil in 2012, the majority of women (87.3%) were admitted to the ICU following delivery (19). Our study showed a statistically significant association between the pregnancy state on ICU admission and outcome: 10.9% of the women admitted after de- livery died compared with only 5.2% of those admitted during pregnancy. These results are in agreement with studies in India and Tanzania (2013) (27,28). These results may be due to the higher incidence of sepsis in the postpartum period following surgical caesarean delivery or as a complication of postpartum haemorrhage. Book 23-10.indb 699 12/13/2017 9:41:01 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 700 Half of the women in our study had a single organ dysfunction and about a third had multiple organ dysfunction. Near-misses with organ failure repre- sent the most severe forms of maternal morbidity because they face the high- est risk of death and they only survive because of the quality of maternal care they receive. However, using only or- gan dysfunction as the identification criteria for near-misses may lead to an underestimation of the true burden of near-misses. A systematic review of the prevalence of maternal near-misses in 2012 showed that the prevalence of near-misses was much lower when the identification criteria was based on or- gan dysfunction (4). Furthermore, the progression from organ failure to death may be very fast. Therefore, a disease- based approach might be most suitable for identification of near-miss cases in low-resource settings that have higher burdens of maternal ill-health and mor- tality (29). Based on our results, we calculated maternal near-miss indicators which reflect the overall standard of obstetric care. The maternal near-miss mortality ratio was 10.8:1 and the mortality index was 8.5%. These indicators are similar to those reported in studies in Tanzania and Malawi where the range was 5–12:1 (28,30). On the other hand, very high ratios of 117–223:1 were reported in studies from Western Europe which used similar case definition criteria (22,31). This difference may be attribut- ed to the difference in standards of care or the severity of admitted cases. It is important to note that improvements in standards of care will be associated with an increase in the maternal near-miss mortality ratio. So, yearly estimation of this ratio in the study setting can be used to monitor the effects of changes in standards of care carried out and direct improvement plans. Our study has some limitations. It was difficult to involve a larger num- ber of cases in the study due to limited capacity of the unit (only 5 beds) and decreased turnover of cases as some women occupied their bed for long time. In addition, the time needed to complete the questionnaire was rela- tively long for severe and exhausted cases. The questionnaire was completed on several visits depending on the woman’s condition; if a woman was too ill to be interviewed, her relatives were interviewed instead. Conclusion The results of our study show that low level of education, short inter-pregnancy interval and inadequate antenatal care are important determinants of maternal Table 5 Distribution of the studied women according to organ dysfunction and outcome Organ dysfunction Survived (n = 410) Died (n = 38) Total (n = 448) P-value No. % No. % No. % None 73 94.8 4 5.2 77 17.2 < 0.0011Single 218 96.5 8 3.5 226 50.4 Multiple 119 82.1 26 17.9 145 32.4 1Chi-squared = 24.86. Table 6 Predictors of maternal mortality: results of multivariate logistic regression analysis Variable B P-value OR 95% CI Age 0.025 0.729 1.03 0.89–1.18 Low level of education 0.361 0.397 1.44 0.26–7.99 Short inter-pregnancy interval − 0.303 0.98 0.95–1.02 Presence of co-morbid condition/s -0.603 0.397 0.55 0.14–2.21 Postpartum haemorrhage − 0.746 0.75 0.13–4.24 Severe pre-eclampsia − 0.030* 0.14 0.02–0.83 Sepsis 3.480 < 0.001* 32.61 8.73–121.77 Attending < 4 antenatal visits 0.182 0.843 0.83 0.19–4.03 Delivery by caesarean section − 0.851 0.84 0.14–5.02 Multiple organ dysfunction 1.370 0.009* 3.94 1.39–11.08 Model chi-squared (P) 72.295 (< 0.001*) Constant (P) 91.404 (0.007*) >*Statistically significant at P ≤ 0.05. B = regression coefficient, OR = odds ratio, CI = confidence intervals. Book 23-10.indb 700 12/13/2017 9:41:01 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 701 mortality. The commonest diagnoses for admission to the maternal ICU were severe pre-eclampsia, eclampsia and severe postpartum haemorrhage. However, the risk of maternal death was highest for women with sepsis, although admission with sepsis was infrequent. The majority of women admitted to the maternal ICU improved when they left the ICU. The maternal near-miss mortality ratio was 10.8:1 and mortality index 8.5%. It is recommended that the WHO approach to maternal near-misses using WHO criteria for maternal near-miss be applied in the Egyptian national health system to evaluate and improve the quality of care provided during preg- nancy and delivery. Training of health care providers on the use of maternal near-miss criteria and indicators in the management of cases and the use of referral criteria is needed. Studies on maternal near-misses in other maternal ICUs in other governorates would be useful to provide a further data. The association between low level of education, short inter-pregnancy interval and inadequate antenatal care and the risk of death highlights the need to provide population-wide preconcep- tion and antenatal education about re- productive health and family planning. Funding: None. Competing interests: None declared. References 1. Say L, Souza JP, Pattinson RC. WHO working group on ma- ternal mortality and morbidity classifications. Maternal near miss–towards a standard tool for monitoring quality of ma- ternal health care. Best Pract Res Clin Obstet Gynaecol. 2009;23:287–96. 2. Laurenti R, Mello Jorge MHP. Mortes maternas e mortes por causas maternas [Maternal deaths and mortality due to a maternal underlying cause of death]. Epidemiol Serv Saúde. 2008;17(4):283–92. 3. WHO, UNFPA, UNICEF, World Bank and the United Nations Population Division. Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Geneva: World Health Organization; 2014. 4. Tuncalp O, Hindin MJ, Souza JP, Chou D, Say L. The preva- lence of maternal near miss: a systematic review. BJOG. 2012;119:653–61. 5. Pattinson R, Say L, Souza JP, van den Broek N, Rooney C. WHO maternal death and near-miss classifications. Bull World Health Organ. 2009;87:734. 6. Evaluating the quality of care for severe pregnancy complica- tions. The WHO near-miss approach for maternal health. Geneva: World Health Organization; 2011. 7. Almerie Y, Almerie MQ, Matar HE, Shahrour Y, Al Chamat AA, Abdulsalam A. Obstetric near-miss and maternal mortality in maternity university hospital, Damascus, Syria: a retrospective study. BMC Pregnancy Childbirth. 2010;10(65):2–7. 8. World Population Prospects: The 2010 Revision. New York: United Nations, Department of Economic and Social Affairs, Population Division; 2011 9. Gabrysch S, Campbell OM. Still too far to walk: literature review of the determinants of delivery service use. BMC Preg- nancy Childbirth. 2009;9:34. 10. Aldawood A. Clinical characteristics and outcomes of criti- cally ill obstetric patients: a ten-year review. Ann Saudi Med. 2011;31(5):518–22. 11. Coêlho M, Leila K, Isabela C, Aline H, Larissa M, Melania A. Profile of women admitted at an obstetric ICU due to non- obstetric causes. Rev Assoc Med Bras. 2012;58(2):160–7. 12. Abo El Maaty N. Study of maternal mortality and morbid- ity incidence among pregnant women in El Shatby maternity university and Gamal Abd El Naser health insurance hospitals. Alexandria: Faculty of Medicine, Alexandria University; 2015 [Thesis]. 13. Badie D. Maternal morbidity and mortality in El Shatby and Dar Ismail maternity hospitals in Alexandria: a comparative study. Alexandria: Faculty of Medicine, Alexandria University; 2015 [Thesis]. 14. Shachar BZ, Lyell DJ. Interpregnancy interval and obstetrical complications. Obstet Gynecol Surv. 2012;67(9):584-96. 15. Afeworki R, Smits J, Tolboom J, van der Ven A. Positive effect of large birth intervals on early childhood hemoglobin levels in Africa is limited to girls: cross-sectional DHS Study. PLoS One. 2015;10(6):e0131897. 16. Wendt A, Gibbs CM, Peters S, Hogueb CJ. Impact of increasing inter-pregnancy interval on maternal and infant health. Paedi- atr Perinat Epidemiol. 2012;26(1):239–58. 17. Jabir M, Abdul-Salam I, Suheil DM, Al-Hilli W, Abul-Hassan S, Al-Zuheiri A, et al. Maternal near miss and quality of maternal health care in Baghdad, Iraq. BMC Pregnancy Childbirth. 2013;11:3. 18. Souza JP, Cecatti JG, Faundes A, Morais SS, Villar J. Maternal near miss and maternal death in the World Health Organiza- tion’s 2005 global survey on maternal and perinatal health. Bull World Health Organ. 2010;88:113–9. 19. Lotufo FA, Parpinelli MA, Haddad SM, Surita FG, Cecatti JG. Applying the new concept of maternal near-miss in an inten- sive care unit. Clinics (Sao Paulo). 2012;67(3):225–30. 20. Bauserman M, Lokangaka A, Thorsten V, Tshefu A, Goudar SS, Esamai F, et al. Risk factors for maternal death and trends in maternal mortality in low- and middle-income countries: a prospective longitudinal cohort analysis. Reprod Health. 2015;12(Suppl 2):S5. 21. Godefay H, Byass P, Graham WJ, Kinsman J, Mulugeta A. Risk factors for maternal mortality in rural Tigray, northern Ethiopia: a case-control study. PLoS One. 2015;10(12):e0144975. 22. Waterstone M, Bewley S, Wolfe C. Incidence and predic- tors of severe obstetric morbidity: case control study. BMJ. 2001;322:1084–94. 23. Ramachandra Bhat PB, Navada MH, Rao SV, Nagarathna G. Evaluation of obstetric admissions to intensive care unit of a tertiary referral center in coastal India. Indian J Crit Care Med. 2013;17(1):34–7. 24. Adeoye IA, Onayade AA, Fatusi AO. Incidence, determinants and perinatal outcomes of near miss maternal morbidity in Ile- Ife Nigeria: a prospective case control study. BMC Pregnancy Childbirth. 2013;13:93. 25. Gupta S, Naithani U, Doshi V, Bhargava V, Vijay BS. Obstetric critical care: A prospective analysis of clinical characteristics, predictability, and feto-maternal outcome in a new dedicated obstetric intensive care unit. Indian J Anaesth. 2011;55:146–53. Book 23-10.indb 701 12/13/2017 9:41:01 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 702 26. Ali AA, Khojali A, Okud A, Adam GK, Adam I. Maternal near- miss in a rural hospital in Sudan. BMC Pregnancy Childbirth. 2011;11(48):2–4. 27. Ps R, Verma S, Rai L, Kumar P, Pai MV, Shetty J. “Near miss” obstetric events and maternal deaths in a tertiary care hospital: an audit. J Pregnancy 2013;2013:393758. 28. Nelissen EJ, Mduma E, Ersdal HL, Evjen-Olsen B, van Roos- malen JJ, Stekelenburg J. Maternal near miss and mortality in a rural referral hospital in northern Tanzania: a cross-sectional study. BMC Pregnancy Childbirth. 2013;13:141. 29. Adeoye IA, Ijarotimi OO, Fatusi AO. What are the factors that interplay from normal pregnancy to near miss maternal mor- bidity in a Nigerian tertiary health care facility? Health Care Women Int. 2015;36(1):70-87. 30. van den Akker T, Beltman J, Leyten J, Mwagomba B, Meguid T, Stekelenburg J, et al. The WHO maternal near miss ap- proach: consequences at Malawian district level. PLoS One. 2013;8(1):54805. 31. van Roosmalen J, Zwart J. Severe acute maternal morbidity in high-income countries. Best Pract Res Clin Obstet Gynaecol. 2009;23(3):297–304. Book 23-10.indb 702 12/13/2017 9:41:01 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما شراعلا ددعلا 703 1Department of Medical Laboratory Sciences, College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates. 2Academic Affairs, College of Arts and Sciences; 3Department of Biomedical Science, Health Sciences Department; 4 Biomedical Research Center, Qatar University, Doha, Qatar (Correspondence to: Gheyath K. Nasrallah: gheyath.nasrallah@qu.edu.qa). Received: 23/08/16; accepted: 24/01/17 Short communication First study in Qatar to reveal high Legionella counts in cooling towers Raed O. AbuOdeh,1 Hassan A. Aziz,2 Houda Moussa,3 Samah Hussien,2 Tameem Hadwan 2 and Gheyath K. Nasrallah 2,4 رطق في ديبرتلا جاربأ في ةيقليفلا اييرتكبل ةيربك تادادعت نع فشكلا للهارن ثايغ ،ناوده ميتم ،ينسح حاس ،ىسولما ىده ،زيزعلا دبع ناسح ،ةدوع وبأ دئار ةروـشنم رـيراقت يأ دـجوت لاو .دـيبرتلا جارـبأ اـهنمو ،ذاذرـلا دـيلوت ةزـهجأ قـيرط نـع شرـبلا لىإ ءاـلما نـم ةـيقليفلا اـييرتكب لـقتنت :ةـصلالخا جارختـ سا مـ ت اـ ك .يرهـ ش ساـ سأ ىـ ع رـ طق ةـ عماج في دـ يبرت جارـ بأ 10 راـ يتخا ىرـ جو .رـ طق في مـ ظنلا هذـ ه في ةـ يقليفلا اـ ييرتكب نأـ شب لـيلتح مادختـساب ةـيقليفلا اـييرتكبل يـغبصلا يوـللخا ضـملحا خـسن ددـع مـِّيُقو .زـيكرلاو حيـشرلا ةطـساوب ةـيئام ةـنيع 90 نـم اـييرتكبلا /تارمعتـسلم ةـنوكم ةدـحو 199.56 لىإ 0.006 نـم اـييرتكبلا دادـعت حوارـتو .تاـنيعلا نـم % 100 في ةـيقليفلا اـييرتكبلا تفـشُتكاو .RT-PCR 100 نـم برـكأ ًادادـعت )% 7.8( تاـنيع عبـس ترـهظأ ،كـلذ ىـع ًاـضفو .)% 56.7( ةـنيع 51 في ةـجرح تادادـعت ىـع رـثُع كـلذكو ،رـميللم يرـبك ددـع في نـئاكلا اذـه دوـجو لىإ جـئاتنلا هذـه يرـشتو .وـينويو وـيام في تادادـعتلا ىـعأ تفـشُتكاو .رميللم/تارمعتـسلم ةـنوكم ةدـحو .ينـيلحلما ناكـسلا ىـع ةـلمتمح ةـيحص رـطامخ حرـطي اـمم ،ةبرـتخلما دـيبرتلا جارـبأ نـم ABSTRACT Legionella spp. is transmitted from water to humans by aerosol-generating devices, including cooling towers (CTs). There have not been published reports about Legionella in these systems in Qatar. Ten CTs in Qatar University were sampled on a monthly basis. Bacteria were recovered from 90 water samples by filtration and concentration. Legionella DNA copy number (CN) was assessed by quantitative RT-PCR. Legionella DNA was detected in 100% of the samples. The bacterial counts ranged from 0.006 to 199.56 CFU/mL, and critical counts were found in 51 (56.7 %) samples. Moreover, 7 (7.8%) samples showed a count of more than 100 CFU/mL. The highest counts were found in the months of May and June. These results suggest that this organism is found in high number in tested CTs, presenting a potential health risk to the local population. https://doi.org/10.26719/2017.23.10.703 Première étude au Qatar pour mettre en évidence la forte présence de légionelles dans les tours de refroidissement RÉSUMÉ Les Legionella spp se transmettent de l’eau à l’homme par les dispositifs générateurs d’aérosols, notamment les tours de refroidissement. Aucun rapport n’a été publié sur la présence de légionelles dans ces systèmes au Qatar. Des prélèvements mensuels ont été effectués dans dix tours de refroidissement de l’Université du Qatar. Des bactéries ont été retrouvées dans 90 échantillons d’eau par filtration et concentration. Le nombre de copies de l’ADN des Legionella a été évalué par PCR quantitative en temps réel. L’ADN des Legionella a été détecté dans 100 % des échantillons. La numération bactérienne était comprise entre 0,006 et 199,56 CFU/mL et des numérations critiques ont été constatées dans 51 échantillons (56,7 %). En outre, 7 échantillons (7,8 %) présentaient une numération supérieure à 100 CFU/mL. Les numérations les plus élevées ont été relevées aux mois de mai et de juin. Ces résultats semblent indiquer que cet organisme est présent en grand nombre dans les tours de refroidissement ayant fait l’objet de prélèvements, ce qui constitue un risque sanitaire potentiel pour la population locale. Book 23-10.indb 703 12/13/2017 9:41:01 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 704 Introduction Legionella pneumophila causes legionel- losis (Legionnaires disease) and can be found in soil and in aquatic environ- ments such as cooling towers (1,2). This bacterium is an intracellular organism that naturally replicates inside amoe- bae, yet it can infect human alveolar macrophages (3) causing severe lung disease (4). Cooling systems have been impli- cated in a great number of Legionnaires disease outbreaks (1) because of their capacity to disperse water aerosols over long distances (5,6). Interest- ingly, human-to-human transmission has never been reported. The disease is mainly acquired through inhalation of contaminated water droplets (1,6). Cooling towers provide optimum en- vironmental conditions and protect the bacteria from disinfectants (7,8). The temperature in the cooling tower can range from 20 °C to 55 °C (7), which favours growth of Legionella spp. In Qatar, the summer season starts in May and lasts until September, with intense heat and humidity. Central cooling stations are widely distributed in Qatar, and many use open cooling towers. The only survey was conducted in 1990 to examine for the presence of Legionella in water systems (9) in a few buildings, many of which harboured Le- gionella spp. Nevertheless, there were no reported cases of legionellosis, although it is possible this may have been due to a lack of consistent laboratory testing for Legionella in local hospitals. Water treatments using chemical biocides such as monochloramine or chlorine dioxide are commonly used to reduce the Legionella count in water (1,10). Water testing of cooling tow- ers is mandatory in many countries worldwide (11), and demands for standardized testing are increasing (12). Many international guidelines for water treatment consider a Legionella count of > 10 colony-forming units (CFU)/mL critical (13). In this study, the effectiveness of the water treatment protocol utilized at Qatar University campus was exam- ined. We believe that cooling towers in Qatar University may be considered representative of other cooling towers in Qatar in the absence of studies in other sites. Methods Sample collection We sampled 10 cooling towers in Qatar University (7 older technology and 3 new technology units) on a monthly ba- sis during the period November 2013– June 2014. No samples were collected in December, January or February be- cause the cooling towers were not op- erating at full capacity during this time. Because biocide treatment is manually controlled for the old units, one or more samples (1L each) were collected 1, 2, 3 or 4 days post-treatment. Biocide treat- ment was automatically controlled for the new units, therefore only 1 sample of 1L was collected and the units were only sampled during March, April and June. Sample concentration The water samples were concentrated by filtration through 0.45μm pore mem- branes (Water Microbial Concentra- tion Kit, ielab, Spain). The membranes were then placed in a 50 mL tube con- taining 10 mL sterile water and vortexed vigorously for 2–3 minutes to release bacteria. The 10 mL concentrate was further concentrated to 200 μL by cen- trifugation at 2200 g for 10 min using the concentrator cartridge (ielab kit); this was then transferred to a 1.5 mL tube and stored at –80 °C until DNA extraction. DNA extraction and quantitative real-time polymerase chain reaction (qRT-PCR) We extracted DNA from the water concentrates using the Water DNA Extraction Kit (ielab, Spain) accord- ing to the manufacturer’s instructions. For detection and quantitation of the Legionella DNA copy number from the water concentrate, the mericon Quant Legionella spp qRT-PCR kit (Qiagen, Germany) was used. The kit contains primers that detect more than 19 common Legionella species with high sensitivity. To convert the Legionella DNA copy number into approximate CFU/ mL values, the following formula was used: no. of CFU/mL = no. of detected Legionella DNA copies/20 (14). Results Of the 90 samples collected, 51 (56.7 %) showed a Legionella count greater than the critical level of 10 CFU/mL (range 10.2–199.56 CFU/mL) (Ta- bles 1 and 2); the counts in 7 (7.8%) samples were > 100 CFU/mL. The remaining 39 (43.3 %) samples yielded counts ranging from 0.006 to 9.3 CFU/ mL (average 30.5 CFU/mL). The count in the old technol- ogy cooling tower units in November, March, April, May and June was 17.9 CFU/mL (highest in May and lowest in November) (Table 1). The 2005 Centers for Disease Control and Prevention protocol for monitoring Legionella in cooling tow- ers recommends that water samples should be collected at least 3 days post-treatment (11). Accordingly, most water samples were collected 4 days post-biocide treatment. Although the 7 cooling towers were all located in the same area and received the same treatment, there was a great difference in counts between cooling Book 23-10.indb 704 12/13/2017 9:41:01 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما شراعلا ددعلا 705 Table 1 Legionella spp. count four days post biocide treatment in the old technology cooling tower units, Qatar University campus, 2013–2014 Date Cooling tower no. DNA copy no./mL CFU/ml Average count/month 28 November 1 514.4 25.70a 7.2 2 3.000 0.15 3 186.6 9.33 4 4.506 0.22 5 52.59 2.63 6 126.4 6.32 7 120.0 6.00 26 March 1 0.487 0.02 77.7 2 2080.5 104.00a 3 2232.7 111.60a 4 2290.4 114.50a 5 3123.7 156.10a 6 126.4 6.32 7 1036.4 51.80 a 17 April 1 933.4 46.70a 34.1 2 1083.6 54.20a 3 265.0 13.30a 4 917.8 45.90a 5 985.5 49.30a 6 7.642 0.38 7 592.6 29.60a 21 May 1 649.7 32.50a 62.9 2 1030.9 51.50a 3 372.0 18.60a 4 839.8 41.90a 5 3991.3 199.50a 6 998.01 49.90a 7 931.1 46.60a 28 May 1 1163.0 58.20a 41.3 2 690.0 34.50a 3 340.8 17.00a 4 555.3 27.70a 5 949.0 47.50a 6 1380.8 69.00a 7 702.3 35.10a 11 June 1 8.85 0.44 20.5 2 159.02 7.95 3 0.754 0.04 4 11.02 0.55 5 13.47 0.67 6 7.732 0.38 7 5.944 0.29 12 June 1 1027.2 51.40a 2 940.6 47.00a 3 267.7 13.30a 4 1634.56 81.70a 5 768.4 38.40a 6 922.5 46.10a 7 17.18 0.86 Counts for 12 June were taken 5 days post biocide treatment. CFU = colony-forming units. aLegionella spp. count > 10 CFU/mL. Book 23-10.indb 705 12/13/2017 9:41:01 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 706 towers (Table 2). For instance, cool- ing tower 1 showed an average count (4 days after treatment) 25.3 CFU/ mL, while cooling tower 5 showed an average count of 69.3 CFU/mL. These results suggest that these cooling towers responded differently to treatment. The average count in the new tech- nology cooling tower units for April– June was 30.9 CFU/mL (Table 3); the highest count was for June and the low- est was for April, suggesting favourable growth conditions during the warmer months. The results indicate that al- though these cooling towers were new and biocide injection was automatically controlled, the count was still as high as in the old technology cooling towers. Discussion This study was the first of its kind to be conducted in Qatar. The detec- tion of Legionella in water samples is conventionally performed using a se- lective culture method (15), however, interference of background microor- ganisms may lead to false low counts (16), not to mention the necessary expertise in interpreting growth (14). Additionally, culture methods do not detect viable but nonculturable bacteria, which may also represent a health haz- ard (14). Despite these shortcomings, culture remains the method of choice. Other methods, such as qRT-PCR, can yield faster results and are highly sensitive and specific (16,17). However, qRT-PCR has the disadvantage that it cannot differentiate between live and dead bacteria, therefore it may yield false high counts (15). In accordance with the universal standards for reporting Legionella counts (CFU/mL), qRT- PCR results were converted to CFU/ mL (14). Qatar has not established a stand- ard for Legionella counts in cooling towers; however, according to interna- tional standards, a count greater than 10 CFU/mL is considered a potential haz- ard requiring investigation. Since more than half of our samples demonstrated counts greater than 10 CFU/mL, the overall count was relatively high. The average counts in current results showed great fluctuation, therefore, each cooling tower should be con- sidered a separate entity with its own unique micro-environment. Moreover, the monthly counts in the old and new technology units were noticeably high in May and June, which could be due to seasonal changes in weather. Fisman et al. reported that Legionnaires dis- ease outbreaks occurred mainly in hot months, during humid periods (18). In May, the temperature and humidity increase remarkably in Qatar, marking the beginning of summer. The biocide water treatment system in the new cooling tower units was sup- posedly more effective than in the old units. However, more than half of the new cooling tower samples had a count greater than 10 CFU/mL indicating that the automated method was also in- effective. As with the old cooling tower units, the counts were the greatest in the warm months. To date, no outbreaks of Legion- naires disease have been reported in Qatar. This could be due to lack of investigation, making it an unrecog- nized pathogen. Pneumonia caused by Table 2. Legionella spp. count per/month in the new technology cooling tower units on the Qatar University campus Date Cooling tower no. DNA copy no./mL CFU/mL Average monthly CFU/mL 4 April N1 720.25 36.01* 12.02 N2 0.38 0.02 N3 0.75 0.04 9 May N1 10.06 0.50 13.01 N2 190.51 9.53 N3 579.90 28.99* 3 June N1 1191.71 59.59* 62.74 N2 1628.32 81.42* N3 944.54 47.23* CFU = colony-forming units. *Legionella spp. count > 10 CFU/mL. Table 3 Average Legionella spp. counts 4 days post biocide treatment for the old technology cooling tower units, Qatar University campus, 2013–2014 Cooling tower no. Average monthly CFU/mL 1 25.3 2 62.8 3 33.2 4 32.7 5 69.3 6 16.5 7 24.6 CFU = colony-forming units. Book 23-10.indb 706 12/13/2017 9:41:01 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما شراعلا ددعلا 707 Legionella is universally and clinically underestimated as the symptoms ex- hibited are very similar to pneumonia caused by other pathogens (19). There were some limitations to this study. Samples were not collected in every month of the year and data were missed from 2 important hot months, September and October. Addition- ally, the sample size and the study was restricted to one area in Qatar. Thus, our findings may not be representative of the actual situation for Legionella counts in other regions or facilities in Qatar. Nevertheless, as this was the first such study in the country, we believe it provides valuable information on the current situation, and will stand a basis for comparison for future studies. Conclusion This study demonstrated that the overall Legionella count was very high in the cooling towers located in the Qatar University campus. Our findings raise concerns for public health officials in the control and management of cooling towers to prevent any potential cases or outbreaks. Further investigation is needed to determine the factors con- tributing to the increase in Legionella counts in the warmer months and the variations between cooling towers re- ceiving the same treatment protocol. Acknowledgements Special gratitude goes to Maria Smatti, Enas Al-Absi, Rajaa Dalloul and Mooza Alkhinji for their technical help. Funding: This research was funded by an Undergraduate Research Experience Program grant (# UREP 15 - 014 - 3 – 005) from the Qatar National Research Fund (Qatar Foundation). Competing interests: None declared. References 1. Fields BS, Benson RF, Besser RE. Legionella and Legionnaires’ disease: 25 years of investigation. Clin Microbiol Rev. 2002 Jul;15(3):506–26. PMID:12097254 2. Lin H, Xu B, Chen Y, Wang W. Legionella pollution in cooling tower water of air-conditioning systems in Shanghai, China. J Appl Microbiol. 2009 Feb;106(2):606–12. PMID:19120608 3. Allombert J, Fuche F, Michard C, Doublet P. Molecular mim- icry and original biochemical strategies for the biogenesis of a Legionella pneumophila replicative niche in phagocytic cells. Microbes Infect. 2013 Dec;15(14–15):981–8. PMID:24161959 4. Fraser DW, Tsai TR, Orenstein W, Parkin WE, Beecham HJ, Sharrar RG, et al. Legionnaires’ disease. N Engl J Med. 1977 Dec;297(22):1189–97. PMID:335244 5. Berendt RF, Young HW, Allen RG, Knutsen GL. Dose-response of guinea pigs experimentally infected with aerosols of Le- gionella pneumophila. J Infect Dis. 1980 Feb;141(2):186–92. PMID:7365275 6. Nhu Nguyen TM, Ilef D, Jarraud S, Rouil L, Campese C, Che D, et al. A community‐wide outbreak of Legionnaire’s disease linked to industrial cooling towers—how far can contami- nated aerosols spread? J Infect Dis. 2006 Jan;193(1):102–11. PMID:16323138 7. Carducci A, Verani M, Battistini R. Legionella in industrial cooling towers: monitoring and control strategies. Lett Appl Microbiol. 2010 Jan;50(1):24–9. PMID:19874487 8. Nasrallah GK, Abdelhady H, Tompkins NP, Carson KR, Gar- duño RA. Deletion of potD, encoding a putative spermidine- binding protein, results in a complex phenotype in Legionella pneumophila. Int J Med Microbiol. 2014 Jul;304(5–6):703–16. PMID:24928741 9. Utilities, conservation of resources and environmental control. Legionnaire’s disease. [web page] Catnaps.org. (http://www. catnaps.org/islamic/control.html , accessed 23 May 2017). 10. Bodet C, Sahr T, Dupuy M, Buchrieser C, Héchard Y. Legionella pneumophila transcriptional response to chlorine treatment. Water Res. 2012 Mar;46(3):808–16. PMID:22192759 11. McCoy WF, Downes EL, Leonidas LF, Cain MF, Sherman DL, Chen K, et al. Inaccuracy in Legionella tests of building water systems due to sample holding time. Water Res. 2012 Jul;46(11):3497–506. PMID:22560149 12. Procedures for the recovery of Legionella from the environ- ment. Atlanta: Centers for Disease Control and Prevention; 2005. 13. Important factors for assessing risk. Legionella in My Water. Special Pathogens Laboratory. Pittsburgh No date 14. Yáñez MA, Nocker A, Soria-Soria E, Múrtula R, Martínez L, Cat- alán V. Quantification of viable Legionella pneumophila cells using propidium monoazide combined with quantitative PCR. J Microbiol Methods. 2011 May;85(2):124–30. PMID:21329735 15. Ditommaso S, Giacomuzzi M, Gentile M, Moiraghi AR, Zotti CM. Effective environmental sampling strategies for monitor- ing Legionella spp. contamination in hot water systems. Am J Infect Control. 2010 Jun;38(5):344–9. PMID:20083326 16. Park CG, Kim BJ, Kim HY, Yun YJ, Ko KS, Miyamoto H, et al. Analysis of population structure among Korean and Japanese Legionella pneumophila isolates using hsp60 sequences. Microbiol Immunol. 2012 Aug;56(8):572–8. PMID:22672106 17. Mansi A, Amori I, Marchesi I, Marcelloni AM, Proietto AR, Ferranti G, et al. Legionella spp. survival after different disinfec- tion procedures: Comparison between conventional culture, qPCR and EMA–qPCR. Microchem J. 2014 Jan;112:65–9. 18. Fisman DN, Lim S, Wellenius GA, Johnson C, Britz P, Gaskins M, et al. It’s not the heat, it’s the humidity: wet weather increas- es legionellosis risk in the greater Philadelphia metropolitan area. J Infect Dis. 2005 Dec;192(12):2066–73. PMID:16288369 19. Walser SM, Gerstner DG, Brenner B, Höller C, Liebl B, Herr CEW. Assessing the environmental health relevance of cooling towers – A systematic review of legionellosis out- breaks. Int J Hyg Environ Health. 2014 Mar;217(2–3):145–54. PMID:24100053 Book 23-10.indb 707 12/13/2017 9:41:01 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 708 1University of Hassan II Casablanca, Ben M'Sik Faculty of Science, Casablanca, Morocco (Correspondence to: AbdelettahDerouiche: afderouiche@ gmail.com). Received: 01/09/15; accepted: 30/01/17 Short communication Sodium chloride composition of commercial white bread in Morocco Ali Jafri 1, Younes El-Kardi 1 and Abdelfettah Derouiche 1 Teneur en chlorure de sodium du pain blanc commercial au Maroc RÉSUMÉ La présente étude visait à évaluer la quantité de sel qu’apporte la consommation de pain dans l’alimentation quotidienne et à la comparer aux doses recommandées. La concentration d’ions chlorure a été mesurée à l’aide de la méthode de Mohr pour quantifier de façon indirecte le sel ajouté dans les échantillons de pain provenant de 80 boulangeries professionnelles à Casablanca (Maroc). Les résultats ont montré que la quantité moyenne de sel ajouté dans la confection du pain blanc est de 17,42 ± 1,28 g/kg. Ceci représente un apport journalier de 8 à 9 grammes de sel provenant uniquement de la consommation du pain et dépasse toutes les recommandations. La haute teneur en sel du pain blanc pourrait être un facteur qui contribue à la forte consommation de sodium au Maroc, surtout quand nous savons que le pain est un aliment de base dans le pays. Toutes les politiques et initiatives visant à réduire la consommation de sodium devraient cibler le pain comme outil stratégique pour réduire l’apport en sel. برغلما في يراجتلا ضيبلأا زبخلل يحللما بيكترلا شيورد حاتفلا دبع ،يدركلا سنوي ،يرفج يع هـتنراقمو يـمويلا يـئاذغلا كاهتـسلاا في ،ًايـسيئر ًءاذـغ هـنوك ،زـبلخا كاهتـسا نـع ةـتجانلا حـللما ةـيمك مـييقت لىإ انتـسارد تـفده :ةـصلالخا زـبخ تاـنيع في فاـضلما حـللما ةـيمكل شراـبلما يرـغ دـيدحتلل رـهوم ةـقيرط مادختـساب دـيرولكلا نوـيأ تازـيكرت ساـيقب اـنمقف .تاـيصوتلاب 1.28 ± 17.42 غـلبي ضـيبلأا زـبلخا دادـعإ ةـيلمع لاـخ فاـضلما حـللما ةـيمك طـسوتم نأ جـئاتنلا ترـهظأو .ءاـضيبلا رادـلا في ًازـبمخ 80 نـم عـ يجم زواـجتي اـم وـهو ،هدـحو زـ بلخا قـيرط نـع حـللما نـم مارـج 9 لىإ 8 هرادـقم ًاـ يموي ًاكاهتـسا لداـعي اـم وـهو ،مارـج وـليك/مارج زـبلخا نأ راـبتعاب اَّيـس لا ،برـغلما في موـيدوصلا كاهتـسا عاـفترا في مهـسي نأ ضـيبلأا زـبلخا في حـللما ىوـتمح عاـفترا نأـش نـمو .تاـيصوتلا ًاغاوـس اـهرابتعاب زـبلخا فدهتـست نأ موـيدوصلا كاهتـسا ضـفخ لىإ يـمرت تارداـبم وأ تاـسايس يلأ يـغبنيو .دـلبلا في ًايـسيئر ًءاذـغ لـثمي .حـللما كاهتـسا ضـفلخ ًايجيتارـسا ABSTRACT This study aimed to evaluate the amount of salt provided by the consumption of bread in daily food intake and compare it to recommended salt intake. Chloride ion concentrations were measured using Mohr’s Method to indirectly quantify added salt in bread samples from 80 professional bakeries in Casablanca, Morocco. Results showed that the average amount of added salt during the preparation of white bread is 17.42 ± 1.28 g / kg, which is the equivalent of a daily intake of 8 to 9 g of salt through bread alone, and exceeds all recommendations. The high salt content of white bread might be a contributing factor to the high sodium intake in Morocco, especially considering that bread is a staple food in the country. Any policies or initiatives to reduce sodium consumption should target bread as a strategic vehicle to reduce salt intake. https://doi.org/10.26719/2017.23.10.708 Book 23-10.indb 708 12/13/2017 9:41:01 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا و ثلاثلا دلجلما شراعلا ددعلا 709 Introduction High blood pressure is a serious public health problem in Morocco; in 2000, the national survey of cardiovascular risk factors in Morocco found 33.6% of adults aged over 20 years had high blood pressure (1). In 2008, the World Health Organization (WHO) estimated the prevalence of raised blood pressure in Moroccan adults to be 32.4% (2). Evi- dence shows that high intake of sodium leads to hypertension, heart attacks and strokes, and several population-based studies around the world have reported that high salt intake is associated with elevated blood pressure (3). In Morocco, bread is a staple food; its daily consumption can reach 500 g per person per day (4), which makes it a potentially important source of sodium. This study aimed to measure the amount of added salt in commercial white bread, which would provide an estimate of salt intake in Morocco, and compare it with recommended levels of salt intake. Methods We used convenience sampling to col- lect bread samples from 80 of 320 bak- eries in 3 regions of Casablanca. These regions had different water sources at the time of the study (February-April 2011). Two kinds of samples were col- lected from each outlet, samples from regular bread (prepared with salt) and samples from diet bread (prepared without adding salt). The samples of diet bread were used as the reference to control for the added salt and the quality of water (its chloride composition). Added salt was estimated by meas- uring chloride ion concentration using Mohr’s method (5). 1. Bread samples were diluted by adding 5 g of bread to 40 mL of water. 2. The solution was filtered and a 10 mL aliquot was collected in a conical flask. 3. Ten drops of potassium chromate (0.05 mol/L) were added to the ali- quot. 4. Titration was done using a solution of silver nitrate (0.05 mol/L). The endpoint was identified as the first appearance of a red-brown colour of silver chromate. Given that sodium chloride is not the only source of chloride ions, we used diet bread as the control since it is supposed to have the same ingre- dients as regular bread except for the added salt. Thus, the extra amount of chloride found in regular bread should be the equivalent of the chloride from the added salt. A calibration range was prepared using known concentrations of sodium chloride. Statistical analysis was done using SPSS, version 23. We used the Shapiro- Wilk test to verify normality of the data and one-way analysis of variance to compare the 3 surveyed regions. Results The salt content of commercial white bread was not normally distributed in our sample according to the Shapiro- Wilk test (W = 0.984, P = 0.4). The diet bread had a mean of 0.032 (SD 0.012) mol of chloride per kg of bread, whereas regular bread had mean of 0.329 (SD 0.072) mol of chloride per kg (Table 1). Therefore, the mean amount of salt added during the prepa- ration of regular white bread was 17.37 (SD 4.23) g/kg (Table 1). The salt content was not significantly different between the 3 surveyed regions (P > 0.05), although it varied between 8.4 and 30.0 g per kg of bread. Only 1.3% of the regular bread sam- ples had a salt content lower than 10 g per kg, which would meet the WHO recommendations, based on a 500 g daily intake (Table 2). The Moroccan Federation of Bakeries recommends adding the equivalent of 18 g of sodium chloride per kg of bread during the preparation of white bread (6). Results show that 38.8% of the samples exceed- ed both recommendations (Table 2). Assuming individual bread con- sumption was 500 g a day (4), the con- sumption of regular white bread would result in the intake of 8.69 g of salt daily. Table 1 Levels of chloride and their equivalent of added salt in commercial white bread from 3 surveyed regions in Casablanca Region No. of samples Mean (SD) chloride content in 1 kg of bread (mol) Added salt in regular bread (g/kg) Diet bread Regular bread Minimum Maximum Mean (SD) 1 88 0.032 (0.012) 0.329 (0.073) 10.8 30.0 17.39 (4.33) 2 46 0.033 (0.013) 0.326 (0.074) 8.4 26.8 17.16 (4.51) 3 26 0.031 (0.011) 0.334 (0.067) 12.0 23.2 17.70 (4.65) Overall 160 0.032 (0.012) 0.329 (0.072) 8.4 30.0 17.37 (4.23) F – 0.114 0.042 0.067 – – P-value – 0.893 0.959 0.936 – – SD = standard deviation. Book 23-10.indb 709 12/13/2017 9:41:01 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 710 Discussion The amount of added salt in commercial white bread available for consumption in Casablanca exceeds the recommen- dations set by the Institute of Medicine in the United States of America (7) and by WHO. The Institute of Medicine established the sufficient daily intake at 1 500 mg of sodium (3.75 g of salt) for people between 9 and 50 years of age, with lower levels for other ages. In addition, the Institute of Medicine es- tablished the maximum tolerated value of sodium at 2 300 mg (7.75 g of salt) for individuals of over 14 years old, and lower amounts for younger people. In 2003, WHO set the therapeutic target of daily sodium consumption at 2 000 mg (5 g of salt) (8,9). Our results show that, through eat- ing bread alone, the average sodium in- take exceeds all these recommendations by at least 50%. Several countries have implemented strategies to reduce so- dium intake (3), either by encouraging manufacturers to reduce added sodium or by implementing a labelling system. A study about the acceptance of sodium reduction in white bread showed that a reduction by one quarter can be done in a short time without affecting consumer acceptance (10). These measures and policies contributed to a decrease in overall blood pressure and reduction in heart attacks and strokes in the tar- geted populations (3). Indeed, lowering blood pressure in the population, even by small amounts, is likely to have a large benefit in preventing heart attacks and strokes (3). Conclusion Our study highlights the high salt content in commercial white bread in Morocco. Given that bread is a staple food in the country, its consumption alone provides a daily intake of sodium chloride exceeding all recommenda- tions and could be responsible for a high sodium intake in Morocco, which could lead to increased cardiovascular risk. In the absence of data about the exact salt intake in Morocco, we can only recommend using these data to raise awareness about salt over-consumption which may increase the prevalence of hypertension. Acknowledgements The authors acknowledge the efforts and input of the late MrAbdellatifBoulgana, MSc, and the assistance of MrLahouss- ineAzaz, President of the Fédération- Nationale de la BoulangerieetPâtisserie du Maroc. Funding: None. Competing interests: None declared. Table 2 Percentage of samples according to salt content cut-offs of World Health Organization recommendations and the guidelines of the Moroccan Federation of Bakeries % of bread samples with salt content: ≥ 10 g/kga > 10 g/kg to ≥ 18 g/kgb > 18 g/kg 1.3 60.0 38.7 aWHO cut-off; bMoroccan Federation of Bakeries cut-off. References 1. TaziMA, Abir-KhalilS, ChaoukiN, CherqaouiS, LahmouzF, SraïriJE, et al.Prevalence of the main cardiovascular risk factors in Morocco: results of a National Survey, 2000. J Hypertens. 2001;21(5):897–903. 2. Noncommunicable diseases country profiles 2011. Geneva:World Health Organization; 2011. 3. NessRB. Controversies in epidemiology and policy: salt reduction and prevention of heart disease. Ann Epidemiol. 2009;19(2):118–20. 4. Mokhtar N, Belhadj H, Kress D, Zerrari A, Chaouki N. Food-for- tification program in Morocco. Food Nutr Bull. 2001;22(4):427– 30. 5. YoderL. Adaptation of the Mohr volumetric method to general determinations of chlorine. J Ind Eng Chem. 1919;11(8):755. 6. BoulganaA. Teneur du seldans le pain des Boulanger- scasablancaiscas de 80 boulangers-et prévention de l’hypertensionartérielle [Salt content in bakers’ bread in Casa- blanca -case of 80 bakers -and prevention of high blood pres- sure]. Casablanca: Université Hassan II Mohammedia; 2011. 7. Panel on Dietary Reference Intakes for Electrolytes and Water -Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary reference intakes for water, potas- sium, sodium, chloride, and sulfate. Washington, DC: Institute of Medicine; 2005. 8. Diet, nutrition and the prevention of chronic diseases: report of a joint WHO/FAO expert consultation. Geneva: World Health Organization; 2003. 9. Guideline: sodium intake for adults and children. Geneva: World Health Organization;2012. 10. Girgis S, Neal B, Prescott J, Prendergast J, Dumbrell S, Turner C, et al. A one-quarter reduction in the salt content of bread can be made without detection. Eur J ClinNutr. 2003;57(4):616–20. Book 23-10.indb 710 12/13/2017 9:41:01 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 711 1Department of Information, Evidence and Research (IER), WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to: A. Mandil: mandila@who.int). Received: 12/09/17; accepted: 26/10/17 Short communication Assessment of World Health Organization Collaborating Centres in the Eastern Mediterranean Region Ahmed Mandil 1, Samar ElFeky 1 and Arash Rashidian 1 Évaluation des Centres collaborateurs de l’OMS dans la Région de la Méditerranée orientale RÉSUMÉ Une formation en interne a mis en évidence la nécessité d’évaluer la perception de la performance par les Centres collaborateurs de l’OMS de la Région de la Méditerranée orientale, notamment en relation avec le programme de travail de l’OMS. Pour cette raison, un questionnaire a été communiqué aux responsables traitant de domaines tels que le processus de sélection, la fréquence de communication, les mécanismes de suivi, les activités clés proposées, et les lacunes identifiées pendant la mise en œuvre. Il s'agissait notamment de la tendance à mettre en œuvre les mêmes activités, la faiblesse des capacités techniques et une mauvaise communication, un décalage entre les activités planifiées et la mise en œuvre réelle. Les recommandations adressées aux centres étaient les suivantes : établir un plan/ des modalités de communication ; sélectionner des activités à caractère mondial/régional ; et mobiliser des ressources pour la mise en œuvre du plan de travail. Les recommandations faites aux administrateurs responsables consistaient à expliquer clairement les règles et règlements actualisés de l’OMS, à garantir que les attribution spécifiques soient définies conformément aux mandats mondiaux/régionaux de l’OMS ; à mettre au point des mécanismes de communication courants ; à convenir de modalités de suivi et de coordination régulières ; et à assurer que les dispositions en vue des redésignations soient prises au cours de la quatrième année de la période initiale. طسوتلما قشر ميلقإ في ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما زكارلما مييقت نايدشار شارآ ،يقفلا رمس ،ليدنم دحمأ ،طـسوتلما قشر مـيلقإ في ةـيلماعلا ةـحصلا ةـمظنم عـم ةـنواعتلما زـكارملل ر َّوـصتلما ءادلأا مـييقت لىإ ةـجالحا نـع فـَشك ًاـبيردت ةـمظنلما ترـُجأ :ةـصلالخا رتاوتو ،ةـنواعتلما زـكارلما راـيتخا ةـيلمع :يي اـم لوانت ،ينـِّينعلما ينلوؤـسلما ىع نايبتـسا ع ِّزو ، َّمـث نـمو .ةـمظنلما لمع جـمانبرل ةـصاخ ةـيهمأ سيـتكت يـتلا تارـغثلا تفـشتكا دـقلو .ذـيفنتلا ءاـنثأ في اـهنع فـشكلا مـت يـتلا تارـغثلاو ،زـكارلما اـهذ ِّفنُت يـتلا ةيـسيئرلا ةطـشنلأاو ،ةـعباتلما تاـيلآو ،اـبه لاـصتلاا .يعفلا ذـيفنتلاو اله طَّطخُمــلا ةطـشنلأا ينب نـيابتلاو ،لاـصتلاا تاردـقو ةـينقتلا تارُدـُقلا فـعضو ،ةيديلقت ةطـشنأ ذـيفنت لىإ لـيلما :ذـيفنتلا دـنع ةـيتلآا ططخ ذيفنتل ةـمزالا دراوـلما دـشحو ،ةيلماع/ةيميلقإ ةـغبص تاذ ةطـشنأ راـيتخاو ،لاـصتال قرـط/ةطخ عـضو :اـهنم زـكارملل تاـيصوت تـَعِضو دـقو عضو نم دـ ُّكأتلاو ،ًاـيفاو ًاحشر ةـمظنلما في اـبه لومعلما ةث َّدحُمــلا حئاوللاو دـعاوقلا حشر :اـهيف ءاـج ينِّينعلما ينلوؤـسملل تاـيصوت تـَعِضو اـك .لـمعلا قيـسنتلاو ةعباتملل قرط ىـع قافتلااو ،لاـصتال ةـمظتنم تايلآ ءاـسرإو ؛يـميلقلإاو يـلماعلا نيديعصلا ىـع ةـمظنلما فادـهأ قـفو ةد َّدـمح تاـصاصتخا .ةمظنلما عـم ًانواعتم ًازـكرم هـنييعتل ةقباـسلا ةرـفلا نم ةـعبارلا ةنـسلا لاـخ زـكرلما ينـيعت ةداـعلإ طـيطختلا نوـكي نأ ناـضو ،ْينـَمظتنلما ABSTRACT Following in-house training, there was a need for assessing perceived performance of World Health Organization (WHO) collaborating centres in the Eastern Mediterranean Region, with special relevance to WHO’s programme of work. Thus, a questionnaire was shared with responsible officers covering: selection process, frequency of communication, monitoring mechanisms, key delivered activities, and identified gaps during implementation. These included: tendency to implement regular activities, weak technical capacity and communication, and discrepancies between planned activities and actual implementation. Recommendations for centres included: establishing communication plan/modalities, selecting activities of global/regional nature, and mobilizing resources for work plan implementation. Recommendations for responsible officers included: carefully explaining updated WHO rules and regulations; ensuring that specific terms of reference are set as per WHO’s global/regional mandates; setting up regular communication mechanisms; agreeing on regular monitoring and coordination modalities; and ensuring that redesignation planning takes place during the 4th year of prior designation period. https://doi.org/10.26719/2017.23.10.711 Book 23-10.indb 711 12/13/2017 9:41:01 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 712 Introduction World Health Organization (WHO) collaborating centres are institutions such as research institutes, parts of universities or academic institutions, designated by the WHO Director- General to carry out activities in support of WHO programmes (1). The col- laborating centres support the achieve- ment of planned strategic objectives at national and regional levels; enhance the scientific validity of the health work of the WHO collaborating centres; and develop and strengthen institutional capacity in countries and regions. All activities that WHO collaborating cen- tres conduct under their designation should be jointly planned and imple- mented with WHO, clearly linked to WHO strategic plans, and reflected in the work plans of the WHO technical programmes to which they contribute. Currently, there are > 800 WHO collaborating centres in > 80 countries worldwide, of which, 44 are located in the Eastern Mediterranean Region (1). The centres located in the Region cover a wide range of areas of work, and are intended to support WHO work plans in capacity building and research and field activities related to: communicable diseases (rabies, HIV, tuberculosis and mycetoma); noncommunicable dis- eases (mental health, diabetes, cardio- vascular diseases, osteoporosis, tobacco control, metabolic bone disorders, endocrine disorders, cancer education, gastrointestinal cancer, and substance use disorders); health policy and man- agement; mass gatherings; nursing and midwifery; occupational health; nutri- tion and food technology; dental health; blood safety; pharmacovigilence; vision and hearing disabilities; and water and sanitation. The full list of the collaborat- ing centres in the Region is accessible at http://apps.who.int/whocc/List. aspx?cc_region=EMRO&). To regulate the designation of the collaborating centres and planning for joint activities, 2 guidelines have been developed and are regularly updated by WHO: 1 is designed to assist pro- spective centres in their application for designation or redesignation processes (2); and the other is intended for WHO staff supervising the designated centres, whether in the capacity of responsible officers or technical counterparts (3). During 2015, a WHO collaborat- ing centres’ assessment survey was conducted to obtain feedback from responsible officers in the Regional Office for the Eastern Mediterranean and heads of the centres in their per- spective countries. The response rate of the assessment survey was 84% among responsible officers and 30% among centre directors. The assessment revealed key chal- lenges and gaps and came up with rec- ommended actions from both sides that were the basis for the discussion during the “Third Meeting of the WHO Collaborating Centres in the Eastern Mediterranean Region” that took place in Cairo, Egypt from 29 to 30 April, 2015. As a result of an in-house training on WHO collaborating centres’ rules and regulations in February 2016, a need was identified to assess the perceived perfor- mance of WHO collaborating centres in the Region, with special relevance to WHO’s programmes of work during 2012–2015, and to identify monitoring modalities and implementation gaps in the Region for future work. Methodology An assessment exercise was conducted with support of WHO responsible officers in different technical units to provide their feedback, using a cross- sectional approach. A questionnaire was designed and shared with responsible officers at all the 44 active centres. We aimed to collect feedbacks about the collaborative work between WHO and the centres during 2012–2015, with emphasis on setting collaborative areas of work related to WHO work plans and communication and monitoring modalities at the centres. The assessment questionnaire cov- ered the following items: • selection process of the designated centres; • frequency of communication with the WHO collaborating centres to discuss implementation of the agreed-upon work plan; • monitoring mechanisms used for implementation of the agreed-upon activities; • key activities, products and services that the WHO collaborating centres delivered during 2012–2015, in line with the agreed-upon work plan, re- lated to WHO’s programme of work within the corresponding specific area; and • identified gaps during implementa- tion of the action plan with relevant WHO collaborating centre, and ac- tions that have been undertaken to overcome the gaps. Results Out of the 30 responsible officers for the 44 active WHO collaborating centres (some officers are responsible for > 1 centre) who received the assessment tool, 26 completed the questionnaire on behalf of 41 WHO collaborating cen- tres; that is, 41/44 = 93% response rate (taking into consideration the number of centres rather than the number of responding responsible officers). Between 2012 and 2015, 16 (39%) centres took the initiative to contact WHO to be designated as collaborat- ing centres; 12 (29%) centres were ap- proached by WHO; and for 14 (32%) centres, it was not known who made the initial approach. Regarding communication with the WHO collaborating centre, only 29.3% were contacted to discuss the implementation of the agreed-upon Book 23-10.indb 712 12/13/2017 9:41:01 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 713 work plan, whenever there was a specific activity to follow up or a problem to resolve (Figure 1). Almost all responsible officers considered the annual report as the most relevant monitoring mechanism (85.4%), followed by occasional visits of WHO collaborating centre representa- tives to WHO during meetings and workshops (31.7%) (). Only 8 centres (19.5%) were reported to be monitored by their corresponding responsible of- ficers through follow-up visits to the centres. Most activities conducted by WHO Eastern Mediterranean Region collabo- rating centres were reported by respon- sible officers to be broadly linked to WHO functions and work plans during 2012–2015, including: development of regional strategies, technical support and capacity building, advocacy, devel- opment and dissemination of evidence. However, some responsible officers stated that the activities of the WHO collaborating centres were not consid- ered relevant to WHO work plans and focused on national activities rather than regional scope of work. Responsible officers identified some gaps during implementation of the joint work plans with the WHO collaborating centres including: logisti- cal difficulties during implementation of planned activities at the national level; greater tendency to implement regular activities of the institution rather than regionally focused activities; weak technical capacity of the centre over time; lack of communication; effects of emergency situations on implementa- tion of the work plan; need of revisiting the terms of reference; and discrepan- cies between the planned activities and actual implementation. Discussion A WHO collaborating centre is an institution designated by the WHO Director-General to carry out activities in support of WHO’s programmes (1). The collaborating centres support the achievement of planned strategic objec- tives at national and regional levels (1). The findings of the assessment survey of the contribution of the Eastern Medi- terranean Region WHO collaborating centres to the WHO programme of work reflect some gaps that need action at WHO and collaborating centre levels. Addressing such gaps will lead to better collaboration with the centres and a more beneficial impact of their work Table 1 Monitoring mechanisms for WHO Collaborating Centres, Eastern Mediterranean Region, 2012–2015 Categories No. (%) Annual report 35 (85.4) Visit by WHO to the centre 8 (19.5) Visit by WHO collaborating centres director/personnel to WHO 13 (31.7) Others 14 (34.0) Categories were not mutually exclusive, that is, > 1 answer was chosen by some respondents. Figure 1 Communication frequency with WHO Collaborative Centres in the Eastern Mediterranean Region, 2012–2015 0 5 10 15 20 25 30 35 40 45 Not regularly With specific activity or problem Once per month Every other month Twice a year Once a year Others 4.9 29.3 12 4.9 7.3 2.4 39 Book 23-10.indb 713 12/13/2017 9:41:02 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 714 on implementing WHO work plans. Enhancing the role of WHO in identify- ing potential centres to be designated as WHO collaborating centres will widen the scope of collaboration between WHO and active centres. The survey also revealed the need for ensuring that the activities have a regional/global perspective rather than regular work at a national level. Continuous communica- tion between the designated centres and WHO should be ensured during work plan implementation for timely addressing any challenges/constrains and refining as needed. Feedback of the heads/focal points of the WHO collaborating centres within institutions in the Region to the survey results is needed to establish specific modalities to address the identified challenges/ constraints, tangible solutions, and plans of action. Conclusion WHO technical units need to consider centres that have the potential to be WHO collaborating centres and start collaboration with them as a prereq- uisite for designation rather than wait- ing for them to contact WHO. The assessment also concluded that there is lack of regular communication with the centres and limited follow-up of specific activities or problem solving. While most activities of the WHO col- laborating centres during 2012–2015 were reported to be broadly linked to WHO functions and work plans, some activities were not considered relevant to WHO work plans and focused on the national rather than regional scope of the work. Identified gaps and challenges that face responsible officers during their collaboration with the WHO col- laborating centres include a tendency to implement regular activities of the in- stitution rather than regional activities, as well as the influence of emergency situations in some countries on imple- mentation of work plans. Recommendations for WHO collaborating centres 1. Establishing communication plan and modalities between the centre and WHO (especially re- sponsible officers and technical counterparts) during implemen- tation of the work plan, for timely discussion of challenges and con- straints to establish concrete and applicable solutions; 2. selecting the activities to be in- cluded in the work plan with the WHO collaborating centre that are global/regional in nature, rather than regular/subnational/ national activities; 3. mobilizing resources: logistic/ technical/fiscal for implementing the agreed work plan; and 4. providing technical support to develop capacity of the centres whenever needed to improve per- formance and scope of collabora- tion. Recommendations for responsible officers 1. Providing the WHO collaborating centre with updated WHO rules and regulations by disseminating infor- mation and conducting field visits; 2. ensuring that specific terms of refer- ence are established in accordance with WHO’s global/regional man- dates; 3. discussing the gaps with the WHO collaborating centre to establish joint actions through conducting regular meetings and field visits; 4. setting up better/regular commu- nication plans and mechanisms, through which different queries and matters are handled; 5. closely following up implementation of plans with the WHO collaborating centres, and early management of implementation problems, through efficient communication channels; 6. agreeing upon regular monitoring modalities, including visiting the cen- tres on a regular basis; 7. strengthening coordination mecha- nisms; 8. engaging WHO collaborating cen- tres in regional meetings/consulta- tions and WHO global fora; and 9. ensuring that redesignation planning takes place as early as possible during the 4th year of the prior designation period. References 1. WHO Collaborating Centres. Global database. (http://apps. who.int/whocc/List.aspx?cc_region=EMRO&, accessed 8 November 2017). 2. Guide for WHO collaborating centres. Geneva: World Health Organization; 2016 (http://www.who.int/collaboratingcen- tres/Guide_for_WHO_collaborating_centres_2016.pdf?ua=1, accessed 8 November 2017). 3. Guide for WHO staff working with WHO collaborating cen- tres. Geneva: World Health Organization; 2016 (http://www. searo.who.int/entity/research_policy/documents/guide-for- working-with-wcc.pdf?ua=1, accessed 8 November 2017). Book 23-10.indb 714 12/13/2017 9:41:02 AM طسوتلما قشرل ةيحصلا ةلجلمانوشرعلاو ثلاثلا دلجلما شراعلا ددعلا 715 WHO events addressing public health priorities International Health Regulations (IHR; 2005) (1) make up the comprehensive legal framework for the prevention, detection, and containment of public health risks at their source through the collaborative actions of State Parties, WHO and all relevant stakeholders. The purpose and scope of IHR are, “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade” (1). To improve measurement and accountability of the regulations’ implementation, the new IHR monitoring and evaluation framework adopts the recommendations of IHR Review Committee (WHA 68/22 Add.1) (2), Resolu- tion EBSS/3/2015/REC/1 (3) on the Ebola virus disease outbreak, as well as the report of the Ebola Interim Assess- ment Panel (4). These reports urge a move from exclusive self-evaluation in considering novel approaches regarding the short and long-term assessment of national core capacity for the implementation and effective functioning of the IHR. A concept note outlining this revised approach was discussed by the WHO Regional Committees in 2015, and a revised IHR Monitoring and Evaluation Framework – in- cluding four components of annual reporting, joint external evaluation, after action review and simulation exercise – was noted by the Sixty-sixth World Health Assembly. The Director-General proposed that the new IHR monitoring and evaluation framework is used by all State Parties for assessment and reporting on IHR (2005) core capacities. This new IHR monitoring and evaluation framework was presented during the fifth regional stakeholder meeting to review the implementation of IHR (2005) in Cairo, Egypt, 20–22 September 2016 (5). A regional meeting for national IHR focal points was convened in Amman, Jordan, 9–10 April 2017 (6). The meeting was inaugurated by Dr Michel Thieren, Director for Health Emergency Programme, WHO Regional Office for the Eastern Mediterranean. Reminding representatives that the recent Ebola outbreak originated within a country in crisis and characterized by institutional fragility, Dr Thieren emphasized the importance of maintaining collective health security through investing in IHR capacity. Dr Thieren further stressed that supporting these novel monitoring and evaluation approaches to build capacity in crisis countries, in particular through the joint external evaluation, presented a unique opportunity to synergize across disciplines and stakeholders, which was the guiding rationale of the WHO emergency reform. In this context, the meeting sought to address the following objectives: • to introduce tools and modules for the annual reporting, after action review and simulation exercise as part of IHR monitoring and evaluation framework post-2015; • to introduce approaches to conduct joint external evalua- tion in countries under conflict; • to share several scenarios of public health events with poten- tial international concern: and • to discuss and identify elements to empower the national IHR focal points and improve functionality of IHR multi- sectoral committees. Summary of discussions The WHO Eastern Mediterranean Region leads in conduct- ing joint external evaluation (JEE). Key successes focused on multi-sectoral collaboration, helpful preparatory planning missions, identification of priorities, and the effectiveness of the tool and results for domestic policy makers. Challenges in conducting JEE were associated with composing a technically competent and diverse team to cover all areas, nuances with interpreting the tool, availability of background documents, and timeliness of the final report to begin national action. Crisis countries1 in particular need additional support to build their IHR capacities, and WHO will work with these countries to ensure that they are ready to undergo JEE. Undertaking the JEE additionally provides an opportunity to maintain systematic thinking regarding longer-term country capacity planning, and effectively transition out of humanitar- ian dependency. Securing the commitment of partners and donors is crucial in the preparatory phase to guarantee the support, both technical and financial, for implementing the priority actions. Extended preparation to properly ensure 1 Examples of crisis countries include Iraq, Somalia, Syrian Arab Republic and Yemen. National focal points for International Health Regulations1 1 This report is extracted from the Summary report on the Regional meeting for national focal points for the International Health Regulations, Amman, Jordan, 10–9 April 2017 (http://apps.who.int/iris/bitstream/1/255584/10665/IC_Meet_Rep_2017_EN_19725.pdf, accessed 13 November 2017). https://doi.org/10.26719/2017.23.10.715 Book 23-10.indb 715 12/13/2017 9:41:02 AM EMHJ • Vol. 23 No. 10 • 2017 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 716 that the country is ready for the JEE is also needed during this phase, and could be achieved through technical visits and senior advocacy in-country meetings. Undertaking a JEE in crisis countries requires special con- siderations given the country context; however, despite the need to adapt unique approaches, the overall process must be kept consistent and standardized. To maintain the integrity of the tool, the JEE should be performed in its entirety and not divided among technical areas. A draft guidance document outlining the standardized methodology, definitions, and approaches for conducting joint external evaluation in crisis countries is being finalized. Annual reporting on IHR progress is required under Article 54 of the Regulations (1) and remains the sole man- datory component of the IHR monitoring and evaluation framework components. A new tool for States Parties Annual Reporting (SPAR) has been proposed to ensure continuity of the reporting process, as well as consistency with the JEE tool. An after-action review would present an in-depth qualitative review of performance during an acute public health event in order to identify actions to strengthen public health prepared- ness. An after-action review should be held within 3 months of the event and in coordination with multiple sectors. The strengthening of national IHR focal points was one of the key recommendations resulting from the Review Committee on the Role of the IHR in Ebola Outbreak and Response for accelerating country implementation of IHR. Therefore, national IHR focal points should be well-posi- tioned centres composed of sufficient staff with experience, expertise and seniority, and should be supported with the required resources (administrative, logistical and financial) to carry out all of their mandatory coordination and com- munication functions. Recommendations To Member States • sharing national best practices related to IHR implementa- tion with WHO and disseminating them via a reactivated IHR regional bulletin; • operationalizing possible JEE priority actions; • conducting after-action reviews and exercises where feasi- ble, documenting and sharing the outcomes and lessons learned; • developing national action plans using the priority actions identified from JEE; • linking JEE processes with national planning and budget cycles to ensure sustainable follow-up and implementation of the national action plan. To WHO • finalizing the guidance document detailing approaches to conducting joint external evaluation and country planning in crisis countries; • supporting advocacy activities targeting senior officials in countries concerning the scoring system of the JEE indica- tors; • supporting countries to identify both external and internal partners to be involved in JEE and country planning and subsequent implementation; • revising existing guidance document designed for the IHR national focal points, considering current discussions and identified needs; • reactivating the IHR regional bulletin. References 1. World Health Organization. International Health Regulations (2005). Geneva: World Health Organization; 2016 (http:// www.who.int/ihr/publications/9789241580496/en/, ac- cessed 13 November 2017). 2. Sixty-eighth World Health Assembly. Report of the review committee on second extensions for establishing national public health capacities on IHR implementation. Geneva: World Health Organization; 27 March 2015 (http://apps.who. int/gb/ebwha/pdf_files/WHA68/A68_22Add1-en.pdf, ac- cessed 13 November 2017). 3. World Health Organization Executive Board Special Session on the Ebola Emergency. Resolution EBSS/3/2015/REC/1. Geneva: World Health Organization; 25 January 2015 (http:// apps.who.int/gb/ebwha/pdf_files/EBSS3-REC1/EBSS3_REC1- en.pdf#page=15, accessed 13 November 2017). 4. World Health Organization. Report of the Ebola interim as- sessment panel. Geneva: World Health Organization; July 2015 (http://www.who.int/csr/resources/publications/eb- ola/report-by-panel.pdf?ua=1, accessed 13 November 2017). 5. WHO Regional Office for the Eastern Mediterranean (EMRO). Summary report on the fifth regional stakeholders meeting to review the implementation of International Health Regula- tions (2015). Cairo: EMRO; 2016 (http://applications.emro. who.int/docs/IC_Meet_Rep_2016_EN_19347.PDF?ua=1, ac- cessed 14 November 2017). 6. World Health Organization. Summary report on the Re- gional meeting for national focal points for the International Health Regulations. Geneva: World Health Organization; 2017 (http://apps.who.int/iris/bitstream/10665/255584/1/IC_ Meet_Rep_2017_EN_19725.pdf, accessed 14 November 2017). Book 23-10.indb 716 12/13/2017 9:41:02 AM EASTERN MEDITERRANEAN HEALTH JOURNAL IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, con‑ cepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region. It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col‑ laborating Centres and individuals within and outside the Region. LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser‑vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico‑sanitaire, aux ONG, Centres collabora‑ teurs de l’OMS et personnes concernés au sein et hors de la Région. EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website: http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website: http://www.emro.who.int/emh-journal/authors/ EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR). © World Health Organization (WHO) 2017. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence (https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Disclaimer. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. If authors are staff members of the World Health Organization, the authors alone are responsible for the views expressed in this publication and do not necessarily represent the decisions, policy or views of the World Health Organization. ISSN 1020‑3397 تاسايسلا ميدقتل برنم ىهو .ةيلماعلا ةحصلا ةمظنمب طسوتلما قشرل ىميلقلإا بتكلما نع ردصت ىتلا ةيمسرلا ةلجلما ىه يرغو ثاحبلأا جئاتنو ةيئابولا تايطعلماو ميهافلماو ءارلآا لدابتلو ،اله جيوترلاو ةيحصلا تامدلخا فى ةديدلجا تاردابلماو تايلكلاو ،ةيحصلا نهلما ءاضعأ لك لىإ ةهجوم ىهو .طسوتلما قشر ميلقإب اهنم قلعتي ام ةصاخو ،تامولعلما نم كلذ دارفلأاو ةيلماعلا ةحصلا ةمظنم عم ةنواعتلما زكارلماو ،ةينعلما ةيموكلحا يرغ تماظنلما اذكو ،ةيميلعتلا دهاعلما رئاسو ةيبطلا .هجراخو ميلقلإا فى ةحصلاب ينمتهلما طسوتلما قشرل ةيحصلا ةلجلما Correspondence Editor-in-chief Eastern Mediterranean Health Journal WHO Regional Office for the Eastern Mediterranean P.O. Box 7608 Nasr City, Cairo 11371 Egypt Tel: (+202) 2276 5000 Fax: (+202) 2670 2492/(+202) 2670 2494 Email: emrgoemhj@who.int طسوتلما قشرل ةيلماعلا ةحصلا ةمظنلم ةيميلقلإا ةنجللا ءاضعأ نادلبلا ةيملاسلإا ناريإ ةيروهجم . ايبيل . سنوت . نيرحبلا . ناتسكاب . ةدحتلما ةيبرعلا تاراملإا . ناتسناغفأ . ندرلأا صرم . نانبل . تيوكلا . رطق . ينطسلف . نماُع . قارعلا . لاموصلا . نادوسلا . تيوبيج . نميلا . ةيروسلا ةيبرعلا ةيروهملجا ةيدوعسلا ةيبرعلا ةكلملما . برغلما Members of the WHO Regional Committee for the Eastern Mediterranean Afghanistan . Bahrain . Djibouti . Egypt . Islamic Republic of Iran . Iraq . Jordan . Kuwait . Lebanon Libya . Morocco . Oman . Pakistan . Palestine . Qatar . Saudi Arabia . Somalia . Sudan . Syrian Arab Republic . Tunisia . United Arab Emirates . Yemen Membres du Comité régional de l’OMS pour la Méditerranée orientale Afghanistan . Arabie saoudite . Bahreïn . Djibouti . Égypte . Émirats arabes unis . République islamique d’Iran Iraq . Libye . Jordanie . Koweït . Liban . Maroc . Oman . Pakistan . Palestine . Qatar . République arabe syrienne Somalie . Soudan . Tunisie . Yémen Subscriptions and Permissions Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: emrgoksp@who.int). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address; email: emrgoegp@who.int. Cover 23-10.indd 8-10 12/10/2017 8:37:11 AM Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale Volume 23 / No. 10 October/Octobre 10 ددع / نوشرعلاو ثلاثلا دلجلما لولأا نيشرت/ربوتكأ2017 Contents V olum e 23 N um ber 10 O ctober 2017 Editorial Achieving the Sustainable Development Goal 3: challenges in HIV testing in the Eastern Mediterranean Region ................................................................................................................................ 647 Research articles Drug utilization in primary healthcare centres in the Gaza Strip ...........................................................................649 Effect of pre-pregnancy maternal body mass index on pregnancy outcomes in nulliparous women in the Islamic Republic of Iran .................................................................................................................... 657 Factors associated with folic acid knowledge and intake among pregnant women in Sudan .............................662 Developing a socioeconomic index for health research in Iraq ............................................................................670 Toxic metals in maternal blood, Cord blood and Meconium of newborn infants from industrial areas in Pakistan...............................................................................................................................678 Pregnancy outcome variables and associated factors in different nationalities living in Kuwait .........................688 Near-miss cases admitted to the maternal intensive care unit, Alexandria, Egypt ................................................694 Short communication First study in Qatar to reveal high Legionella counts in cooling towers ................................................................ 703 Salt composition of commercial white bread in Morocco ....................................................................................708 Assessment of World Health Organization Collaborating Centres in the Eastern Mediterranean Region ...........711 WHO events addressing public health priorities National focal points for International Health Regulations ..................................................................................... 715 Cover 23-10.indd 5-7 12/10/2017 8:37:11 AM