MSU RETURNING MATERIALS: P1ace in book drop to LJBRAfiJES remove this checkout from .—:——_ your record. flflfié win be charged if book is returned after the date stamped below. in“? 13.4.- w; THE INCIDENCE OF INFANT MORTALITY IN A SAMPLE OF HOUSEHOLDS IN RIYADH: SAUDI ARABIA By Ibrahim M. Ai-Obeidy A DISSERTATION Submitted to Michigan State University in partiai fuifiiiment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Socioiogy 1985 ® Copyright by IBRAHIM AL-OBEIDY 1985 ABSTRACT THE INCIDENCE 0F INFANT MORTALITY IN A SAMPLE OF HOUSEHOLDS IN RIYADH. SAUDI ARABIA By Ibrahim M. Al-Obeidy This study investigates the incidence of infant mortality in a cross-sectional sample of households in theicapital city of Riyadh. Saudi Arabia. Data were derived from interviews with 1.200 heads of households in Riyadh between November 25. 1983. and February 19. 1984. The households were selected as follows: First. 30 of the 320 mosques were randomly selected; second. each area surrounding a selected mosque was divided into subareas; third. one of the subareas was randomly selected; and finally. 40 households in each subarea were selected for interviews. The major findings are: (1) the incidence of infant mortality found in this study is about one-fourth that reported by the World Health Organization in 1963; (2) the percentage of infant deaths found in this study is approximately 26% lower than the 1980-85 United Nations estimate; (3) among the socioeconomic factors (SES. mother's education. and quality of housing). mother's education has the strong- est relationship with infant and neonatal mortality. Children born to illiterate mothers experience the highest incidence of infant and Ibrahim Al-Obeidy neonatal deaths. Children born to low SES parents and those who live in low quality housing experience the highest incidence of infant and neonatal deaths. when compared to those born to high 5155 parents and those living in high quality housing; (4) infant mortality is posi- tively associated with the use of folk healing and inversely associated with the use of health facilities; (5) type of feeding is significantly associated with infant mortality (children who are artificially fed experience higher rates of mortality than those who are breast fed); and (6) the various independent variables (SES. health. and demographic factors) are more highly related to infant mortality than to neonatal mortality. ACKNOWLEDGMENTS I would like to express my thanks and gratitude to my advisor. Professor Allen Beegle. for his encouragement and helpful criticism. Appreciation is extended to my committee members. Professors Harry Schwarzwefller. James McKee. and Christopher Sower. for their advice and help. and to Dr. Osmman Nur and Associate Professor Craig Harris for their eva1uation of my proposal and their useful comments and criticisms. I would also like to thank all of the students who participated in carrying out the interviews. especially Ahmed Alageel. Mohammed Alobaidy. Nasser Ashahrani. Sa'ad Alobaidy. Mansor Alhadab. Fahad Alhowshan. and Abdullah Almasood. I am grateful for the support provided by King Saud University and for the cooperation of the householders who answered the research questions. Sincere appreciation is expressed to my mother; my brothers. Saleh. Rashed. Fahad. and Abdul1ah; my son. Mohammed; my sister; and my wife. for their support. love. and encouragement. TABLE OF CONTENTS LIST OF TABLES O O O O O O O O O O O O O O O O O O O O O 0 LIST OF FIGURES O O O O O O I O I O O O O O O O O O O O 0 Chapter I. THE PROBLEM AND ITS BACKGROUND . . . . . . . . . . Introduction . . . . . . . Population Enumeration . . Vital Statistics . . . . . Health Services . . . . Folk Healing . . . . . . Infant Mortality in Saudi Arabia Purposes of the Study . . . . . . Review of the Literature . . . . . Introduction . . . . . . . . . . . . Socioeconomic Factors and Infant Mortality . . Cultural Factors and Infant Mortality . . . . Type of Feeding and Infant Mortality . . . . . Health Services and Modern Medicine Versus Folk Healing. and Infant Mortality . . . . . Developed Versus Developing Countries and Infant Mortality . . . . . . . . . . . . . . Trends in the Relationship Between Infant Mortality and Socioeconomic Status . . . . . Summary . . .... . . . . . . . . . . . . . . I I O mDEL FRMEWORK O O O O O O O O O O O O O O O 0 0 Introduction . . . . . . . . . . . . . . . . . . Model Framework for This Study . . . . . . . . . SES. Number of Children. and Infant Mortality SES. Attitudes Toward Modern Medicine. Use of Health Facilities. and Infant Mortality . . SES. Quality of Housing. and Infant Mortality SES. Use of Folk Healing. and Infant Mortality Page vi xii NN—a-a-a-a-a Nomkbwd©that the benefits of the development are for the welfare of the entire society. Instead. they claim that the group in power monopolizes all the bene- fits of the development. The conflict perspective thus elucidates the mechanisms under which disorders such as the venereal diseases. low birth weight. and infant mortality cluster in certain social groups. The failure to control preventable diseases is attributed to the unequal distribu- tion of power and resources among various social groups. which makes the overall administration of public health difficult. (May- kovich. 1980. p.106) 40 The most popular and useful model in the study of infant mor- tality is the stratification model. In the use of this model. some scholars have emphasized socioeconomic factors and ignored other impor- tant factors. whereas other researchers have attempted to include cultural. environmental. and medical factors as well. Gortmaker (1977). in his stratification approach. included the following factors as determinants of infant mortality: race. income. education of mother. birth order of child. reproductive health of mother. and health care. Emphasizing the significance of poverty's contribution to infant mortality. Gortmaker wrote. Some specific theories behind the significance of poverty in the infant mortality process may be briefly summarized: The fact of income poverty may be conceptualized as exercising a constraint upon many areas of parental and infant activity. These constraints may manifest themselves in the form of poor housing; poor sanitary facilities at home; lack of adequate food; inadequate prenatal. hospital. or postnatal care; lack of transportation facilities-- meaning difficulty in obtaining needed services; and finally. those in poverty may be more vulnerable to the experience of stressful situations. All of these factors presumably can have damaging effects upon the health of the infant. (p. 9) Individual families in any population are differentiated in many economic. social. psychological. physical. and cultural respects. Some of these characteristics are inherited and some are achieved. Knowledge. education. income. occupation. quality of housing. quality of food. and health and social services. to name just a few factors. are unequally distributed among families. Within this general system of stratification. the human infant is born. with very limited ability to protect himself from any risk or threat. Survival depends on the child's social. cultural. and natural environments. In addition. the 41 infant's survival chances are affected by the family's attitudes. beliefs. socioeconomic status. and-lifestyle. The mother is the most important individual affecting the infant's survival chances. The mother's education. knowledge. atti- tudes. beliefs. lifestyle. personality. and physical characteristics are important factors in the variation of infant mortality rates among different groups. WWW Figure 2.1 depicts a number of factors known to affect infant mortality. It includes the family's socioeconomic status (as measured by father's education and income) and other socioeconomic variables. namely. quality of housing and mother's educational attainment level. and other independent variables including attitudes toward modern medi- cine. use of health facilities. use of folk healing. proportion of artificially fed infants. and number of children born during the past six years. The dependent variable is the infant mortality level. The effects of SES on infant mortality have been investigated in a number of studies. However. few researchers have attempted to describe the mechanism of SES effects on infant mortality in terms of behavioral and nonbehavioral dimensions. SES groups are not only economic groups. they are also distinguished in several other dimen- sions: in their lifestyle. in their way of thinking. and most of all in their behavior and attitudes. Most previous studies have examined SES only in its economic dimension and have left most other dimensions untouched. This study is no exception. The writer focuses only on a 42 _o>on >a__metoz ucmmc_ .>c:um ozu c_ com: hn_e___ena ;b_mn: to em: me__nn: 5.0a to em: _neoz--._.N ntsm_a cote—mcu . mo c0955: comumuaum m.ce;uoz m:_coom we ma>h oc_u_coz ccovoz / ncmzoh moc:u_uu r/I/t // I! \ \\ mc_m:o: to >n__neo mum 43 few factors that might be affected by SES and that are assumed to affect infant mortality. Among these factors are number of children born during the past six years. attitudes toward modern medicine. quality of housing. use of health facilities. and use of folk healing. MW IntanLMortaLitxs As mentioned in the first chapter of this study. high fertility is associated with low SES. Thus families with high SES are more likely to have fewer children than those with low SES. Couples with high SES are more likely to know about and use contraceptive methods. They also are more likely to break with traditions that enhance the large family pattern. The effect of the number of children on infant mortality can be understood through the attention and care the children would receive. An infant born to a family with a large number of children is likely to receive less attention and care than one born to a family with a small number of children. Thus infants born into families with large numbers of children have less chance of surviving than those born into families with small numbers of children. Woe. WW Intant_Moi:tal_i_u SES is a very influential factor on individual attitudes. not only toward modern medicine but toward many other aspects of life. as well. Couples with high SES are more likely to have positive attitudes toward modern medicine. Such positive attitudes would motivate them to 44 use health facilities in the treatment of their infants before birth. during delivery. and during the neonatal and postnatal periods. The role of modern medicine in the reduction of infant mortality is widely recognized. especially in the areas of delivery. care of premature infants. vaccines. .and the reduction in diseases of infancy. WW9; andJntanLMoLtalitx The sensitivity of an infant to environmental factors is well recognized and has led some social scientists to view infant mortality as an index of the sanitation of the environment. The quality of housing in terms of type of house--whether it is a clay house or a villa--is a very important factor affecting the infant's health and in turn his/her chance of survival. Clay houses usually are an approp- riate environment for the growth of flies and other insects that help to spread germs directly to the infant and through contaminating the infant's food and clothing. The quality of housing is most likely to be influenced by the level of SES; people with high SES are more likely to live in better quality housing than those with low SES. SES._U55_o.f_E_o.1k_tloaJ_ino. anantanLMoLtaJth Families with low SES are more likely to be influenced by tradition than those with high SES. Folk healing. as one aspect of tradition. is more likely to be used by those with low SES than those with high SES. The effect of folk healing on infant mortality can be seen through the direct damage that some types of folk healing may 45 cause. or through preventing or decreasing the use of adequate modern medicine. MotboL'LEouoatioand IntanLMoLtaljtx The mother's education has been recognized as an important factor in the infant's chances of survival. Caldwell (1979) suggested three explanations for why this may be true. First. education may encourage the mother to break with tradition. and therefore she may seek modern alternatives for child care. Second. education may make the mother less fatalistic about illness. According to Caldwell. "an educated mother is more capable of manipulating the modern world. She is more likely to be listened to by doctors and nurses. She can demand their attention even when their reluctance to do anything more would completely rebuff an illiterate" (p. 409). Also. she is better able to locate health facilities. "to regard them as part of her world. and to regard their use as right and not a boon" (p. 409). A third factor is that "educati on of women greatly changes the traditional balance of familial relationships with profound effect on child care" (pp. 409- 10). The ability to read is very important in fulfilling the respon- sibilities of motherhood. For example. an illiterate mother must depend on her memory of directions in giving her infant prescribed medications. which may result in over- or underdosage. leading to possible harm. The educated mother. on the other hand. can read the 46 label on the medication and may be more likely to discuss its advan- tages and disadvantages with the physician. The mother's education may affect infant mortality indirectly through the number of children she has. use of health facilities. and use of folk healing. Educated mothers are more likely to have fewer children than uneducated mothers as a result of the age at marriage. Uneducated women are more likely to get married and bear children at an early age. and giving birth 'at an early age increases infant mortality. Also. educated mothers are more likely to know about and to practice birth control. which allows more space between births. and which in turn increases the chances of their infants' survival. Mother's education may also influence infant mortality through its effect on the use of health facilities. An educated mother is likely to seek medical advice whenever she suspects a health problem with her infant. whereas an uneducated mother may ignore the situation until it becomes serious. In addition. an educated mother is more likely to use health facilities effectively by following the physi- cian's advice and by using the medication as prescribed. whereas an uneducated mother may abuse the medication. Also. an educated mother is likely to be suspicious of folk healing and in turn avoid it in the treatment of her infant; an uneducated mother. on the other hand. is likely to believe in folk healing and in turn to treat her infants with it. 47 WW Previous studies have indicated that infant mortality is higher among artificially fed infants than those who are breast fed. The type of feeding may affect infant mortality through the status of nutrition and through sanitary conditions. Breast milk is more likely than artificial milk to contain adequate nutrition for the infant. especi- ally for the first six months. In addition. it may help the infant to resist infection. Artificial milk. on the other hand. is likely to be less nutritious and is subject to contamination during preparation. especially in an inadequate environment. W555 0n the basis of the model framework and the reasoning just outlined. a number of research hypotheses were formulated for investi- gating in this research. The research hypotheses are as follows: Hypothesis 1: SES level is inversely related to the incidence of infant mortality. Hypothesis 2: Mother's educational attainment level is inversely related to the incidence of infant mortality. Hypothesis 3: Use of folk healing is positively related to the incidence of infant mortality. Hypothesis 4: Use of health facilities is inversely related to the incidence of infant mortality. Hypothesis 5: Housing quality is inversely related to the inci- dence of infant mortality. Hypothesis 6: Artificial feeding is positively related to the incidence of infant mortality. Hypothesis 7: Number of children is positively related to the incidence of infant mortality. 48 While our primary focus and analysis were placed on infant mortality. some exploration was made of neonatal mortaltiy. The same independent variables used in infant mortality are again used with neonatal mortality. CHAPTER III METHODOLOGY AND DATA COLLECTION PROCEDURES Studx_Sett1n9 Riyadh is the capital city of Saudi Arabia. It is located in the central region of the Kingdom and had an estimated population of 1.044.000 in 1980. The weather in the city is generally very hot and dry during the summer. The temperature may exceed 45 °C (113 F). and the relative humidity may be as low as 7%. During the winter. the temperature may fall to as low as 5 °C (41 F). The city of Riyadh consists of 31 districts. which can be divided into northern. central. and southern portions. The northern district includes Al Murabba. A1 Mutamarat. Al Malaz. Al Ulya. A1 Wazarat. An Namudhajiyan. Ar Rabwah. Ar Rawdah. Ash Shubah. As Salamah. Azzahara. Sulaimmaniyyan. Ammal Hamanu and A1 Ma'dhn. The central district includes A1 Hazm. A1 Adl. Al Amala. A1 Agig. Al Salam. Al Washm. An Nasiriyyah. An Nur. As Salihiyyah. and As Sinaiyah. The southern district includes Al Badia'h. Al Basatin. A1 Manakhah. Ar Rifa. Manfuhah. and Al Janub. In general. based on the writer's obser- vations. those living in the northern districts have higher socioeco- nomic status than do those living in the central and southern dis- tricts. 119 50 Was In selecting a sample. three factors should be taken into consideration: the cost of data gathering. the efficiency of data gathering. and the information already available about the population. Taking these three factors into account. the most appropriate sampling procedure under the present conditions was determined to be cluster sampling. "Cluster sampling is used to save survey cost and to make the data-gathering procedure more efficient" (Sudman. 1976. p. 69). Raj (1972) pointed out that "when clusters are large it is difficult to enumerate them completely. At the same time. it is unnec- essary to collect information on every element in the sample clusters" (p. 73). He added: It is a very expensive job to make a list of all households in the city before selecting a random sample from it. It is the most convenient to get a map of the city. divide it into identifiable blocks. and select a sample of some blocks. All households in the selected blocks are the subject of further inquiry. The sample is selected by taking a few blocks which are clusters of households. (p. 24) Since the city of Riyadh is not readily divisible into identi- fied blocks. especially in the older parts of the city. it is conveni- ent to use the mosques:as center-points for primary sampling units. The advantages of using mosques to define the primary sampling units are: First. the mosques in the city are to some degree equally dis- tributed amidst households--more so than any other public buildings. such as schools or hospitals. Second. they can easily be located in the city. Third. maps which indicate their locations in the city are readily available. Figure 3.1 indicates the distribution of mosques in 1. Al Adi 2. Al Anal 3. Al 'Aqiq 4 N Bldi'ah 5A1 Bus-tin 6. N Hum 7. Al Janub 8A1 Ma‘dhar 9 A' “In” 10. AI Monomer: 11. Mmiuhlh 12 A) “minor. .03 A: “um 14 A. Mutamam 15. A: UNI 16 A Warm: 17 A: Wmm is An mmjiyynh 15 A:- Nasiriyyan 25:. M Nut 21. A: Rabwah 2. Ar Rowan 23 Ar Rifl' 24. As Salem 25. A: Salamah 26 As Salihiyynh 27. As Sina'iyyah 28. Ash Shubch 29. A: 21hr. so. Suleimaniyyah 31. Urnm al Human: I To Mecca __.' Mosque Main road District boundary 8 kilometers 21 To Al Hoiui l Dhohun 27 / o /-.. x \ \ \\ To A; m». "s As Suleiman won I A: Ymrah Figure 3.l.--Distribution of mosques in greater Riyadh. 52 the city of Riyadh. There are 320 mosques. not including mosques located within public or private buildings. The mosques are not equally distributed in the city. in terms of distance. Whereas the distance between two mosques ranges from 50 to 300 meters in the central and southern districts. the distance ranges from 300 to 1.000 meters in the modern districts (Wazart Ashw'awn Albaladeen Wal Garaween. 1398 A.H. [19791. p. 83). However. the unequal distance between mosques in old and new districts does not cause a sampling problem when the sizes of households and the degree of population density (in persons per room) are taken into account. The houses in the modern districts are two or three times larger than those in the older districts. and the degree of population density is higher in the older districts. 'Therefore. the mosques in all parts of the city serve roughly equal numbers of people. The procedures used for selecting the households to be surveyed were as follows: First. the mosques in the city of Riyadh were identi- fied on the city map and were given identification numbers. Second. 30 mosques were randomly selected from the total of 320 mosques in the city. Third. the households surrounding each mosque were allocated to subareas and given identification numbers. The method of allocating the households to subareas was arbi- trary rather than systematic. It is very difficult to use the city map in this process. especially in the older districts. 'Therefore. the subareas surrounding each mosque were randomly selected. In cases where the required number of households were not found in a selected 53 subarea. another subarea was selected randomly. From each of the 30 areas. 40 households were surveyed. making a total sample of 1.200 households. The sample includes only Saudi Arabian families that have had at least one child during the past six years. The purpose of this criterion is to exclude the older generation. whose experiences of child rearing are in the distant past and who may therefore fail to recall important information. Non-Saudi families are also excluded from the study since most of them have been in Riyadh for only short periods of time. Hence. non- Saudi infant mortality levels would probably have been influenced by cultural. socioeconomic. demographic. and environmental factors differ- ent from those affecting Saudi citizens. WWW Inoeoonoerttiatiables Mommas: IntanLMoLtality 1231.10.11.12!)- W is "the death of any live-born child before it completes its first year of life” (United Nations. 1954. p. 4). Infant mortality does not include fetal death; it includes only live-born children. defined as infants who. after separa- tion from the mother. breathe or show other evidence of life (United Nations. 1954. p. 4). The W is the number of infant deaths per 1.000 live births in a given year. The negnata1_mgntality_nate is the number of infant deaths per 1.000 live births during the first four 54 weeks of life. The pgstnegnatal_mgnta111y_nate is the number of infant deaths per 1.000 live births from 29 days to one year after birth. W. Logan (1953) and Bouvier (1976) pointed out that to measure infant mortality accurately through examination of vital statistics records. one must use records of births and deaths that are complete. This criterion cannot be met in the majority of developing countries (or in some developed countries). A number of countries do not have registration of births and deaths. and in many other nations such records are inaccurate or incomplete. For such countries. the researcher can use other methods to estimate infant mortality rates. For instance. in the past 20 years a number of sample demographic inquiries have been carried out in various African countries. The aim of these studies has been to estimate fertility and mortality rates (including infant mortalityh The primary data used for such estimation are of two kinds: current and retrospective. Current information is obtained from responses to questions about births and deaths in the past year. while retrospective material consists of reports by mothers. divided by age group. of the total number of children born to them and those still alive at the time of the survey. Similar techniques were used in the present study ,to measure the infant mortality rate in the city of Riyadh. Three indicators of the infant mortality level were collected. First. questions were designed to obtain retrospective information about births and infant deaths. Second. questions were used to obtain information about births 55 and infant deaths during the past six years. Third. questions were designed to obtain information about births and infant deaths during the past three years. (See Appendix A.) Since we do not have enough cases for the last 12 months. the information in regard to this period was not included in the present analysis. Information regarding only the retrospective periods. i.e.. the past six years and the past three years. is presented. The infant mortality rate is defined as the number of infant deaths per 1000 live births in a given year. Thus. the term infant mortality rate cannot be used in dealing with infant mortality that occurred in more than a given year since this would violate the accepted definition. Thus. it is appropriate in our study to use the percentage of infant deaths. that is. the number of infant deaths per 100 births; the percentage of neonatal deaths. that is. the number of children dying between the ages of O and 28 days per 100 births; and the percentage of postneonatal deaths. that is. the number of children dying between the ages of 29 days and 12 months per 100 births. MeasnmonLoLtbo Indenendenthniablos WWW. For measuring the socioeconomic status of the family. two indicators are used: income and father's educational attainment level. Income is one of the obvi- ous indicators of socioeconomic status. As Blalock (1983) points out. "income appears to be much more obviously a status variable. pure and simple" (p. 205). It affects all other socioeconomic variables. such 56 as quality of housing and opportunity to receive better education and health services. Occupation is not included in the measurement of the socio- economic status of the family due to the ambiguity of occupational classifications in Saudi Arabia. "There have been no prior studies in Saudi Arabia concerning the classification of jobs in terms of prestige and income" (Al-Thubaiti. 1983. p. 72). The survey questionnaire contained questions to obtain informa- tion about family income and father's educational attainment level. The responses to 'the family income question range from 1 to 10. with 1 corresponding to earnings of SR 2.000 or less and 10 corresponding to SR 18.000 or more. The responses to father's educational attainment level range from 1 (illiterate) to 6 (college or more education). The socioeconomic status scale ranges from 2 to 16 (on a 15- point scale). A high score on this scale indicates high socioeconomic status. For cross-tabulation analysis. the socioeconomic status score was divided into three categories: low (2 to 4 points). medium (5 to 7 points). and high (8 to 16 points). Another socioeconomic variable is the mother's educational- attainment level. The responses to this question range from illiter- ate. low education (experience in reading and writing. or elementary school). and high education (middle school or higher). Measures of quality of housing include type of house. crowded- ness. and facilities available in the house. The type of house score ranges from 1 to 5: 1 point was assigned to clay houses. 2 points to 57 block houses with a wooden roof. 3 points to apartments. 4 points to concrete houses. and 5 points to villas. Crowdedness. which is meas- ured by dividing the number of persons living in a house by the number of rooms. ranges from 1 to 5. with 1 indicating very crowded and 5 indicating low household population density. Information was also obtained about ownership of consumer items. such as refrigerators. washing machines. etc. These items were omitted from the quality of housing score due to the small amount of variation among the respond- ents (see Appendix B). The quality of housing score ranges from 2 to 10. with a lower score indicating a lower quality of housing. Those houses scoring 2 to 4 were assigned low quality. 5 to 7 were assigned average. and those scoring 8 or higher were assigned high quality housing. WWWM _to__h_15___tam_1Jy. The indicators used to measure the father's attitude toward health services deal directly and indirectly with the most relevant dimensions of this variable. These dimensions include the trust the respondent has in physicians' ability to treat his young children. what the father thinks of physicians' actual treatment of his young children. how well the father thinks his children have been helped by physicians. the time physicians spend with his young children during routine visits. and the father's overall satisfaction with health services provided to his young children. Some of these items are direct. while others are indirect. As Blalock (1983) argues. "it 58 may be advisable to combine sets of immediately relevant items along with much more general ones" (p. 78). A series of nine questions were asked to ascertain the father's attitude toward health care services. The dimensions explored. together with their ranges. are: (1) whether or not the father thinks that physicians try to understand his children's health problems. Responses range from "they try very hard" to "they do not try at a1 1." (2) How the father evaluates the effectiveness of physicians in reliev- ing his children's illnesses. Responses range from "very helpful" to "not helpful at all." (3) The amount of time physicians spend with the patient during a typical visit. Responses range from "one minute or less" to "fifteen minutes or more." (4) Whether or not the father usual 1y takes his children to the same doctor. Responses range from "always" to "never." (5) Whether or not the physician usually shares with the father information about the illness of his children. Responses range from "always" to "never." (6) The father's evaluation of the health services provided his family by the hospital. Responses range from "excellent" to "very poor." (7) The father's level of satisfaction with the health services available to his family. Responses range from "very satisfied" to "very dissatisfied." (8) The proportion of physicians trusted by the father. Responses range from "all of them" to "none of them." (9) The father's feeling as to whether or not his child would be treated much better at a different hospital than the one he has been using. Responses range from "yes. certainly" to "no. certainly not." 59 These nine indicators are equally weighted and added together as an index of the father's attitude toward health services. The score on this scale ranges from 9 to 36. with a higher score indicating a more positive attitude toward health services. The householders were assigned to one of three categories according to their scores on this index: negative attitudes for those scoring 17 points or less. neutral for those scoring 18 to 26 points. and positive attitudes for those scoring higher than 26 points. We. Five items are used to meas- ure the respondent's attitudes toward modern medicine. These items explore some basics of modern medicine and include the following: (1) Does vaccinating of infants against some diseases protect them against these diseases"; (2) How important is it to have a physician present during delivery;(3) How important is it to seek medical advice during pregnancy; (4) Can a physician help a woman to deliver a healthy baby; (5) Is there a need for an infant to have a physical examination. The responses to these questions all range from "strongly agree" to "strongly disagreeJ‘ The items probing attitudes toward modern medicine are equally weighted and added to produce a scale of the attitudes of the father toward modern medicine. The score on this index ranges from 5 to 25. with a higher score indicating a more favorable attitude toward modern medicine. The householders were divided into three categories accord- ing to their scores on this index: negative attitudes toward modern medicine for those scoring less than 9 points. neutral for those 60 scoring 9 to 18 points. and positive attitudes for those scoring higher than 18 points. .Att1tudes_towjxd_jglk_healing. ‘Two items wereedesigned to measure respondents' attitudes toward folk healing. The first deter- mines whether or not the respondent believes that a folk healer is able to cure most diseases. and the second asks whether or not the respond- ent agrees that "folk healing is no more than‘juggleryfl' Agreement with the first indicates a favorable attitude toward folk healing; agreement with the second indicates an unfavorable attitude toward folk healing. The score on attitudes toward folk healing ranges from 2 to 10. with a higher score indicating ainore favorable attitude toward folk'healing. WW. Three indicators are employed to deter- mine the use of folk healing. These include treatment of an infant by a folk healer. treatment of an infant by cautery. and treatment of an infant with medications prepared by a folk healer. The householders were divided into three categories: those who never use. those who use one type. and those who use more than one type of folk healing in the treatment of infants. WW. Three indicators are used to measure use of health services. These include number of visits to a hospital by the mother for check-ups during pregnancy. whether vaccinations have been received by the infant. and number of visits to the hospital by the infant for check-ups. These three items are equally weighted and added into a score ranging from 3 to 15. with a higher score indicating 61 greater use of health services. Low use of health facilities was assigned for those scoring less than 6 points. average for those scor- ing 6 to 10 points. and high for those scoring higher than 10 points. EiJoLStooJes Pilot studies were conducted on November 5 and November 14. 1983. The objectives of the first pilot study were: first. to deter- mine whether or not the questionnaire was clear and understandable in its wording and structure. and second. to determine whether or not the questions were socially acceptable. At the end of the interview. the respondents were asked to mention any items which they felt should not have been asked or which they thought other people might hesitate to answer; A third purpose of the pilot study was to determine whether or not the questions were written in such a way as to measure the concepts they were intended to measure. The samples consisted of 25 householders for the first pilot study and 18 for the second pilot study. The samples represented families of different socioeconomic statuses. ages. and locations in the city of Riyadh. As a result of the first pilot study. several items were changed or improved. It was found that 87% of the respondents who had finished elementary school or higher levels of education were able to fill out the questionnaire without help. The time needed to complete a questionnaire schedule ranged from 25 to 45 minutes. depending on the respondent's education (for illiterate respondents. it took between 40 and 45 ininutes). 62 Eight days after the first pilot study. the second pilot study was conducted to ensure that the corrections that had been made on some items as a result of the first pilot did not create new difficulties in understanding the questionnaire. Women: The main objectives of interviewer training are to enable the student interviewers to conduct an interview. to clarify the items on the questionnaire. and to ensure that the students understand the objectives of these items. The training included how to determine whether or not a given householder should be included in the present study. how to persuade a subject to agree to be interviewed. and how to start an interview. A student was directed to introduce himself to the householder and explain in a general statement the purpose of the study. At the same time. he was to hand the householder a copy of the official letter of introduction from the Department of Social Studies at King Saud University; Next. the student was directed to ask the first question. which is: "To what hospital do you usually take your young children for treatment?" After the householder had replied. the interviewer was to find out the age of the youngest child of the householder. If the respondent had not had any children during the previous six years. the student was to terminate the interview. thank- ing the respondent for his cooperation and explaining the reasons the interview was being terminated. If. however. the respondent had had 63 any children during the previous six years. the interview schedule was to be completed. The students were given the following list of instructions: 1. Ask all the questions--do not skip any questions. 2. Read the questions as they were written. If the respondent does not understand the question. simplify it but don't change its meaning. 3. Do not argue with the respondent about the questions or his answers. 4. Try to interview the respondent alone. The students were first asked to interview each other to prac- tice going through the survey items and to allow the researcher to determine the quality of the interviewers' work. The following proce- dure was used: 1. Some students were asked to interview the investigator himself. After these interviews. a discussion between the researcher and the student was held to improve the student's performance. pointing out strong points as well as weak points in the student's interviewing style. 2. Students were observed during interviews of other students. 3. Some householders who had been interviewed by a particular student were reinterviewed. The training of interviewers was repeated several times during different periods of this project. as a result of the withdrawal of some students and the engaging of new students. Almost all of the 64 interviewers for the present study were students at King Saud Univer- sity. .Dntn_QQll§§I19n The following steps were taken before data collection: 1. To guarantee the support of King Saud University. the writer sent a copy of his proposal to the University for evaluation and approval. 0n November-7. 1983. the writer received the approval of King Saud University to carry out this study. 2. 'Two official letters were obtained. ‘The first was from the Governor of Riyadh. approving the conduct of this study in the city. The second letter was obtained from the Department of Social Studies at King Saud University. Both letters indicated the purpose of the study and encouraged householders to cooperate with the investigator. 3. The Arabic and English versions of the questionnaire were given to an expert at King Saud University to allow comparison between the two versions and to receive suggestions for improvement of the questionnaire. Two steps were involved in carrying out the survey in the 30 survey areas. First. the mosque for a given area was located. and the study area boundaries surrounding that mosque were drawn. This step was usually carried out by the writer. although in a few cases he consulted friends familiar with a given area. The second step was the actual interviewing. This step involved the investigator and a number of students from King Saud University who had been trained to conduct the survey. 65 The investigation team usually gathered in the Department of Social Studies office at the university at 3 p.m. At 3:15. the team left for a selected area. In each area. the researcher assigned a number of households to each student and remained with the team for consultation. to collect the interview schedules. and to review samples of each student surveyor's work. The team had to spend two days in most areas to interview the required number of householders; in some areas. the team had to spend more than three days. The first interview was conducted at 3:30 p.m. on November 25. 1983. The investigator and five students started on South Alkhazzan Street in the district of Al Washm. The people were very cooperative with the investigation team. This area could be characterized as having high population density. Most of the homes were'clay or concrete houses and apart- ments; there were no villas in this particular area. In general. the incidence of householders not being home was very low. and in those few cases where the householders were initial 1y absent. the interviewer could find them by returning after two or three hours. By 9:30 p.m.. 40 householders had been interviewed. and a sample of each interviewer's work was reviewed by the investigator in order to evaluate the students' performance. Only two householders were reinterviewed by the investigator'to«check the accuracy of the responses. On the next day. the team moved to the Manfuhah district. In terms of population density. type of housing. and socioeconomic status. 66 Manfuhah was similar to the area that had been selected from the dis- trict of A1 Washm for study. After four days. the three selected areas of Manfuhan had been surveyed. and a total of 120 householders had been interviewed. On the fifth day. three students withdrew from the investi- gating team. Between November 29 and December 4. the investigation team covered the two selected areas of the A1 Ulya district. The major problems facing the interviewers in these two areas. as well as in other upper-middle-class areas such as Al Malaz and Ar Rabwah. were the low population density. the high percentage of householders absent at the time when the interviewers stopped by. and difficulty gaining access to the householders who were home. Maids and other servants often delayed the interviewers'ineeting with the householders by asking questions such as "Who are you?" "What do you want from him?" "Does he know that you are coming?" "What can I tell him?" All these questions and discussions wasted many hours and made it difficult for some stu- dents to continue working on the survey. In addition. many homes had door microphones and cameras. which allowed anyone in the house to make contact with the interviewer but created difficulty for the interviewer seeking to meet the householder. In contrast. in the lower-socioeconomic areas such as A5 Salihiyyah and Manfuhah. these kinds of difficulties were rare; the main problem was in convincing potential respondents to participate in the study. 67 Sports events also created problems for the interviewers. Many householders--especially the younger ones--asked to delay the interview until the end of a game. It was often difficult to cover all those who had asked to be interviewed after the game. The survey took 84 days--from November 25. 1983. to February 19. 1984. More than 30 students were engaged in the survey. Some worked during their free time one or two days a week; a few students worked five days a week. The usual starting time for interviewing teams. 3:30 p.m.. was chosen because the majority of householders were likely to be at home then. The interviews continued until 9:30 p.m. in most of the areas. (In some cases. the team had to work until 11:30 pun) On weekend days (Thursday and Friday). there were two shifts: one during the morning (from 8:30 to 11:30) and the second in the evening (from 3:30 to 9:30). General refusal to participate was very rare. Indeed. only 5 out of 1.200 householders refused to be interviewed. The absence of householders was more important. There were 30 cases in which. even after two follow-ups. the householder could not be reached due to travel outside the city or the country. These 30 cases do not include the households that either were empty or had no one in the house during the interviewers' visits. In such cases. neighbors were asked whether the house was empty or occupied. and if it was occupied. two follow-ups were tried. In more than 25 households that were found to be occupied. no one could be contacted even after two follow-ups. 68 As a result of the large number of interviewers who withdrew from the project and the nature of the upper-class areas. the investigator had to pursue all possible options to ensure the supply of interviewers. Through personal contact with a number of professors in the Department of Social Studies at King Saud University. the researcher obtained their cooperation in encouraging their students to participate. The investigator spent two to four hours every weekday meeting students. explaining the research. and training those students who wanted to participate. However. this was not sufficient to solve the problem. Many students withdrew after a few days of working for the survey. and some who were trained never participated. 'Out of 20 students from the Department of Social Studies. only three worked until the end of the survey; the others dropped out at various points during the project. Under these circumstances. the investigator had to involve some stu- dents who were his relatives and their friends. mainly from the Col- leges of Education. Pharmacy. and Engineering. These people required more training and supervision ti me. However. their performance. enthu- siasm. and seriousness made the extra effort worthwhile. Of the 1.200 householders interviewed. 19 cases were omitted because they were incomplete. Data from the remaining 1.181 cases were punched onto computer cards and entered into a computer for analysis. lbLInstLument An interview survey (see Appendix A) was used to collect data for the study. There are two reasons for conducting an interview 69 survey rather than another type of data collection procedure. The first is the lack of accurate. comprehensive data about infant mortal- ity in Saudi Arabia. In the available data. infant mortality is under- recorded. and the data include only those who were buried by municipalities. Births are also underrecorded. and registration is inefficient. The second reason for using an interview survey results from the writer's approach as a student of social demography. which should be concerned not only with rates and numbers but with the study of phenomena in a holistic framework. including as many factors as pos- sible related to a phenomenon. Death certificates include only a few items of information. such as the name of the deceased. sex. place of birth. age. nationality. religion. occupation. parents' nationality and 'religion. place of residency. place of death. date of death. I.D. number. and cause of death. Such information is very important but is not sufficient to understand the phenomenon of infant mortality. Many factors not included in the death certificate are very important in any attempt to shed light on the issue. Thus. the sample survey. notwith- standing its limitations. is the best way to include the appropriate demographic elements. This study used structured interviews. This type of interview was chosen to reduce costs. It also is easy to code and reduces interviewer bias. Seventy-two questions were prepared to be asked of the heads of selected families. The interview questions covered the following areas (see Appendix A): 70 Type of hospital available to the family Father's attitudes toward the health services provided to his children Beliefs and attitudes about folk healing versus modern medicine Attitudes regarding some specific folk-healing practices Retrospective information about births and infant deaths Births and infant deaths during the past six years Births and infant deaths during the past three years Births and infant deaths during the past 12 months Use of health services during the past six years Use of health services during the past 12 months Quality of housing Demographic information about the parents Socioeconomic status of the family DatazbnalxsiLELooeduLes One of the difficult questions in the study of infant mortality on an individual level is what techniques should be used to analyze infant mortality data. The difficulty stems from the nature of the dependent variable. infant mortality. which is recorded as whether the infant lived or died during the first year. Dealing with a dummy dependent variable will handicap the use of some sophisticated statis- tical tools. Someeauthors have cautioned against using regression with dummy dependent variables (see. for example. Gortmaker. 1977. p. 33). Some sociology students. in order to deal with this situation. have created an index for infant mortality. when three categories of the 71 dependent variable were assumed (see. for example. Kandeh. 1979; Adlakha. 1970). For the present study. the data were analyzed using the follow- ing statistical tools: Frequency distribution: This statistical tool was used to present the distribution of householders according to the various socioeconomic. health. and demographic factors; number of infant and neonatal deaths; and the percentage of neonatal and infant deaths. This information will be presented for all children ever born and for those born during the past six years. Cross-tabulation: This method was used to present thepercent— ages of infants who survived and those who died for each category of the independent variables. ‘This procedure will show how the infant deaths differ among different socioeconomic. health. and demographic groupings. The relationship between each independent variable and the dependent variable will be tested using chi-square to determine the significance of the differences between categories of the independent variables. To determine whether a significant difference existed between specific categories. partitioning of chi-square contingency tables will help to make such a decision. Finally. to determine whether the obtained relationship is real or is attributable to other factors. the relationship between a given independent variable and infant mortality will be elaborated by controlling for other variables. CHAPTER IV PRESENTATION OF THE FINDINGS .Inttoduction This chapter consists of two parts. The first part treats relationships among the independent variables. with emphasis on socio- economic variables. This inquiry is sociologically interesting. espe- cially in a country like Saudi Arabia. where social class is an ambiguous concept and systematic studies of social class effects are lacking. The discussion also will help to illuminate how socioeconomic factors influence or reinforce other factors affecting infant mortal- ity. For example. to what extent is education associated with atti- tudes and behaviors that relate to folk healing and/or the use of moderninedicine? The second part here presents data on the incidence of neo- natal. postneonatal. and infant deaths. It also reports on the distri- bution of householders according to number of infant deaths and various other socioeconomic. health. and demographic factors. 72 73 EaLt_Qn.e.:_Be_l.at_ionsb_ins_Amono_tne Independentiatinbjes SosiooconomlojtatuLano Bantam—in In Chapter II. the presumption was expressed that the socio- economic variables would be found to be interrelated. Socioeconomic status (SES) of the family was presumed to influence quality of housing in terms of type of house. location. and number of persons per room. It was also assumed that socioeconomic factors influence attitudes toward and choices between modern medicine and folk healing in the treatment of infants. This part of Chapter IV tests these assumptions in order to improve the model developed in this study. Table 4.1 shows the relationship between SES level and mother's educational-attainment level. Almost half of all mothers in the sample were illiterate. one-third were classed as having a low level of educa- tion. and the remainder (about one-fifth) had a high level of educa- tion. Results of the 1974 census indicated that the female illiteracy rate for the central region of Saudi Arabia (of which Riyadh city is a part) is 73.4% (Kingdom of Saudi Arabia. 1394 A.H. [1974]). as compared to 47.8% as found in this study. It is possible that this difference is a result of ten years of expansion in female education and female adult education. Also. this difference may result from rural-urban differences. It is evident from the data in Table 4.1 that there is a direct relationship between SES level and mother's education. Only among high SES mothers is there a departure from the specified pattern. The chi-square and gamma values shown in Table 4.1 indicate a strong 74 and positive relationship between SES level and mother's educational level. Table 4.l.--SES level and mother's education (in percent). SES Level Mother's Educational Level Low Medium High ' Total (N=357) (N=426) (N=398) Illiterate (N=565) 80.2 44.8 22.1 47.8 Low education (N=395) 17.6 39.2 41.5 33.4 High education (N=221) 2.2 16.0 38.4 18.8 Totals (N=1.l8l) 100.0 100.0 100.0 100.0 Chi-square = 292.35 Degrees of freedom = 4 p > .01 Gamma = 0.64 It was presumed that SES level influences the quality of hous- ing in terms of type of house. geographic area of residence. and number of persons per room. Tablee4.2 shows the distribution of families according to SES level and residential area. More than 90% of the low SES families live in central and southern districts. whereas over half of the high SES families live in northern districts. The other half are distributed between central and southern districts. .As the low SES families are concentrated in the southern and central districts. and as half of the high SES families are living in the southern and central districts. this may reflect the fact that within the Southern and 75 central districts there are some high-quality residential areas. For example. the southern district’s Al Shafa area (in A1 Basatin dis- trict). is occupied almost entirely by businessmen and traditional merchants whose stores are located in the center of the city. Table 4.2.--Percentage distribution of householders. by SES and residential area (in percent). SES Level Residential Area Low Medium High Total (N=357) (N=426) (N=398) Northern (N=342) 8.4 21.6 55.3 29.0 Central ( ==485) 60.8 43.2 21.1 41.0 Southern (N=358) 30.8 35.2 23.6 30.0 Totals (N=l.l8l) 100.0 100.0 100.0 100.0 Table 4.3 illustrates the relationship between SES level and housing density. as measured by number of persons per room. More than half of the householders have average housing density. one person per room. One-tenth of the sample have high housing density. Comparing the SES groups. it seems that low SES families have the highest per- centage of high housing density--approximately five times higher than among the high SES families. It is evident from the data in this table that there is a direct relationship between SES and housing density. 76 The chi-square and gamma values shown in Table 4.3 indicate a strong and positive relationship between SES level and housing density. Table 4.3.--SES level and housing density (in percent). SES Level Housing Density Low Medium High Total (N=353) (N=422) (N=394) > 1 person/room: High (N=ll4) 15.6 9.9 3.5 9.7 1 person/room: Medium (N=630) 63.h 54.7 44.5 53.9 < l person/room: Low (N=425) 20.0 35.4 52.0 36.4 Totals (N=l.l69) 100.0 100.0 100.0 100.0 Chi-square = 100.31 Degrees of freedom = 4 p > .01 Gamma = 0.42 Table 4.4 indicates the relationship between SES level and type of house. The type of house was ordered according to its quality. Clay and block houses were classed as the lowest type. and villas were classed as the highest type. As shown in this table. more than half of the low SES families live in clay or block houses. while only a small proportion live in villas. Indeed. nine out of ten families live in clay or block houses. concrete houses. or apartments. The middle SES families are approximately equally distributed among these types of 77 housing. with high concentrations in clay or block houses and concrete houses or apartments. Three-fourths of the high SES families live in villas and concrete houses or apartments. and only one-fourth live in clay or block houses. The chi-square and gamma values presented in .Table 4.4 indicate a strong and positive relationship between SES level and type of house. Table 4.4.--SES level and type of house (in percent). SES Level Type of House Low Medium High Total (N=357) (N=426) (N=398) Clay or block (N=4SO) 65.0 36.2 16.1 38.1 Concrete or apartment (N=355) 26.3 37.8 25.1 30.1 Villa (N=376) 8.7 26.0 58.8 31.8 Totals (N=l.l8l) 100.0 100.0 100.0 100.0 Chi-square = 287.57 Degrees of freedom = 4 p > .01 Gamma = 0.61 W lowaLd_and_Uso_of_Eolk_tleaJ_ino In Chapter II it was argued that educational attainment level and SES would affect parents' attitudes toward folk healing and in turn their decisions to treat their young children with it. Maclean (1966) 78 provided evidence that the educated person is more likely than the uneducated individual to believe in modern medicine and to be suspi- cious of folk healing. and therefore he selects health-care services accordingly. 'The following tables and discussion examine the relation- ships between mother's education. father's education. SES level. and attitudes toward and use of folk healing. Table 4.5 shows the relationships between father's educational attainment level and attitudes toward folk healing. As indicated in this table. approximately half of the respondents are neutral about folk healing. and in general the table shows very low relationships between these two variables. as indicated by the gamma and chi-square values. Table 4.5.--Father's education and attitude toward folk healing (in percent). Attitudes Toward Father's Education Folk Healing Illit. Medium High Total (N==215) (N=627) (N=314) Negative (N=301) 16.3 30.0 24.8 26.0 Neutral (N=562) 54.9 46.1 49.4 48.6 Positive (N-293) 28.8 23.9 25.8 23.“ Totals (N=1.156) 100.0 100.0 100.0 100.0 Chi-square = 15.94 Degrees of freedom = 4 p > .01 Gamma = -0.06 79 The relationships between SES and attitudes toward folk healing as presented in Table 4.6 show a similar pattern to that found between father's educational attainment level and attitudes toward folk heal- ing. Approximately half of the entire sample was neutral about folk healing. although there are some differences among the SES groups. However. the magnitude of differences is neither strong nor signifi- cant. Table 4.6.--SES level and attitude toward folk healing (in percent). Attitudes Toward SES Level Folk Healing Low Medium High Total (N=348) (N=4l6) (N=392) Negative (N=301) 19.5 30.5 27.0 26.1 Neutral (N=562) 52.3 45.9 48.3 48.6 Positive (N=293) 28.2 23.6 24.7 23.3 Totals (N=l.lS6) 100.0 100.0 100.0 100.0 Chi-square = 12.29 Degrees of freedom = 4 p > .05 Gamma = 0.079 Tables 4.5 and 4.6 show nonsignificant effects of SES level and father's educational-attainment level. respectively. on attitudes toward folk healing. Therefore. the previously assumed relationships are not supported. This may reflect a reality that SES and father's 80 education have little or no influence on the individual's attitudes toward folk healing. On the other hand. the findings may be distorted by the propaganda against folk healing leading some people to hide their true feelings about it when responding to the survey items. Table 4.7 depicts the relationships between father's educa- tional level and use of folk healing. For the entire sample. approxi- mately two-thirds of the respondents never used folk healing. one- fourth used only one type. and one-tenth used almost all types of folk healing in the treatment of their infants. The table also shows a decrease in the percentage of respondents using folk healing as father's education level increases. For example. while 57% of illit- erate fathers never used folk healing. 70% of the high-educated fathers never treated their infants with folk healing. However. the chi-square and gamma values indicate that the apparent relationship between father's education and use of folk healing is very weak. The relationship between mother's education and use of folk healing is presented in Table 4.8. As indicated in this table. approx- imately half of the illiterate mothers never used folk healing. whereas four-fifths of the highly educated mothers never used folk healing in the treatment of their infants. The chi-square and gamma Values indi- cate a systematic inverse relationship between mother's education and use of folk healing in the treatment of infants. 81 Table 4.7.--Father's education and use of folk healing (in percent). Use of Folk Healing Father's Education Illit. Medium High Total (N=223) (N=642) (N=3l6) Never used (N=753) 57.8 62.6 70.2 63.8 Used one type (N=288) 30.0 25.1 19.0 24.3 Used almost all types (N=l40) 12.2 12.3 10.8 11.9 Totals (N=1.181) 100.0 100.0 100.0 100.0 Chi-square = 10.72 Degrees of freedom = 4 p > .05 Gamma = -0.13 Table 4.8.--Mother's education and use of folk healing (in percent). Use of Folk Healing Mother's Education Illit. Medium High Total (N=565) (N=395) (N=221) Never used (N=753) 58.6 61.3 81.4 63.8 Used one type (N=288) 26.9 '27.8 11.8 24.4 Used almost all types (N=140) 14.5 10.9 6.8 11.8 Totals (N=1.181) 100.0 100.0 100.0 100.0 Chi-square = 39.98 Degrees of freedom = 4 p > .01 Gamma = -O.24 82 Table 4.9 depicts the relationship between attitudes toward folk healing and use of folk healing in the treatment of infants. It is reasonable to assume that householders with positive attitudes toward folk healing will be more likely to use it in the treatment of their infants than will those who have negative attitudes toward folk healing. Table 4.9 bears this out. Of those with negative attitudes toward folk healing. 77% had never used it and the remainder had used one type or more. .Among those with positive attitudes toward folk healing. more than half had used one type or more. The chi-square and gamma values indicate a significant and fairly strong direct relation- ship between attitudes toward and use of folk healing. From the pre- ceding tables it can be seen that approximately one-third of the sample used at least one type of folk healing. Table 4.9.--Attitude toward folk healing and use of folk healing (in percent). Attitudes Toward Folk Healing Use of Folk Hea1ing Negative Neutral Positive Total (N=301) (N=562) (N=293) Never used (N=736) 77.4 65.5 46.1 63.7 Used one type (N=284) 14.6 26.5 31.0 24.5 Used almost all types (N=136) 8.0 8.0 22.9 11.8 Totals (N=1.156) 100.0 100.0 100.0 100.0 Chi-square = 82.59 Degrees of freedom = 4 p > .01 Gamma = 0.38 SELEdooatlonmnthtttudos WW fiealtLanilJtJos In Chapter II it was hypothesized that householders' attitudes toward modern medicine are influenced by their educational attainment and SES levels and that use of health facilities is influenced by educational level. SES level. attitudes toward modern medicine. and attitudes toward health facilities. It was assumed that individuals with high educational levels and high SES would have more positive attitudes toward modern medicine and. in turn. would use health facili- ties more often than would individuals with low educational and SES levels. Table 4.10 presents the relationship between SES level and attitude toward modern medicine. As shown in the table. among the low- SES householders only a small proportion (approximately one-tenth) have positive attitudes toward modern medicine. and the remainder split in half between negative and neutral attitudes. Among high SES house- holds. less than one-fifth had negative attitudes and approximately half had positive attitudes toward modern medicine. Chi-square and gamma values indicate a significant and fairly strong positive rela- tionship between SES level and attitudes toward modern medicine. The relationship between father's education and attitudes toward modern medicine. as presented in Table 4.11. shows a similar pattern. but the relationship between SES and attitudes toward modern medicine (as indicated by the gamma value of 0.39) is stronger than the 84 Table 4JKL--SES level and attitude toward modern medicine (in percent). SES Level Attitudes Toward Modern Medicine Low Medium High Total (N=357) (N=426) (N=398) Negative (N=342) 43.1 26.5 18.8 29.0 Neutral (N=513) 44.5 47.9 37.7 43.4 Positive (N=326) 12.4 25.6 43.5 27.6 Totals (N=1.181) 100.0 100.0 100.0 100.0 Chi-square = 111.89 Degrees of freedom = 4 p > .01 Gamma = 0.39 Table 4.11.--Father's education and attitude toward modern medicine (in percent). Attitudes Toward Father's Education Modern Medicine Illit. Medium High Total (N=223) (N=642) (N=316) Negative (N=342) 45.7 28.3 18.4 29.0 Neutral (N=513) 41.3 46.0 39.9 43.4 Positive (N=326) 13.0 25.7 41.7 27.6 Totals (N=1.181) 100.0 100.0 100.0 100.0 Chi-square = 77.18 Degrees of freedom = 4 p > .01 'Gamma = 0.35 85 relationship between father's education and attitudes toward modern medicine (gamma = 0.35). It was reasoned that people with positive attitudes toward modern medicine would use modern health facilities more often than would those with negative attitudes toward such health facilities. Table 4.12 supports this proposition. Of those with negative attitudes toward modern medicine. one-fifth professed little use of modern health facilities. more than half indicated about average usage. and approxi- mately one-fourth claimed high use. Among those with positive atti- tudes toward modern medicine. only a small proportion (2.8%) claimed low use; the majority indicated high usage of modern medicine. For the entire sample. only one out of ten had low use of health facilities. The majority of the remaining respondents were classed as having high use of health facilities. The chi-square and gamma values presented in Table 4.12 indicate a significant and strong positive relationship between attitudes toward modern medicine and use of modern health facilities. Table 4.13 depicts the relationship between attitudes toward and use of health facilities. It was expected that people with nega- tive attitudes toward health facilities would use them less often than would those with positive attitudes. The results presented in Table 4.13 do show the expected pattern. However. the relationship was not strong enough to support this expectation. as the chi-square and gamma values indicate. 86 Table 4.12.—-Attitude toward modern medicine and use of health facilities (in percent). Use of Health Facilities Attitudes Toward Modern Medicine Negative Neutral Positive Total (N=342) (N=513) (N=326) Low (N=121) 19.3 9.0 2.8 10.2 Average (N=500) 54.7 44.0 26.7 42.3 High (N=560) 26.0 47.0 70.5 47.5 Totals (N=1.181) 100.0 100.0 100.0 100.0 Chi-square = 147.35 Degrees of freedom = 4 p > .01 Gamma = 0.50 Table 4.13.--Attitude toward and use of health facilities (in percent). Attitudes Toward Health Facilities Use of Health Facilities Negative Neutral Positive Total (N=390) (N=546) (N=231) , Low (N=119) 12.3 9.9 7.4_ 10.2 Average (N=492) 44.1 45.6 30.7 42.2 High (N=556) 43.6 44.5 61.9 47.6 Totals (N=1.167) 100.0 100.0 100.0 100.0 Chi-square = 24.95 Degrees of freedom = 4 p > .01 Gamma = 0.17 87 It was hypothesized that parents! educational-attainment level .would affect their use of health facilities in the treatment of their infants. The highly educated parents were expected to have a higher level of use of health facilities than the parents with lower educa- tional levels. Tables 4.14 and 4.15 support strongly this proposition. Table 4.14 depicts the relationship between father's education and use of health facilities. As indicated in this table. approximately one- fifth of illiterate fathers had low use of health facilities. half had average use. and only one-fourth had high use of health facilities. Among highly educated fathers. only a small proportion had low use. and over half of them had high use of health facilities. The chi-square and gamma values indicate a significant and strong direct relationship between father's education and use of health facilities. Table 4.14.--Father's education and use of health facilities (in percent). -Father's Education Use of Health Facilities Illit. Medium High Total (N=223) (N=642) (N=316) Low (N=121) 18.8 10.7. 3.2 10.2 Average (N=500) 56.1 43.7 30.0 8 42.3 High (N=560) 25.1 45.6 66.8 47.5 Tetals (N=1.181) 100.0 100.0 100.0 100.0 Chi-square = 101.87 Degrees of freedom = 4 p > .01 Gamma = 0.45 88 Table 4.15 shows the expected relationship between the mother's educational attainment and use of health facilities. As shown in this table. there was a large increase in use of health facilities with the increase in the mother's educational level. The low use of health facilities decreased from 17% among illiterate mothers toionly'L8% among highly educated mothers. The high use of health facilities increased from 29.7% among illiterate mothers to 76.9% among highly educated mothers. The chi-square and gamma values indicate a strong positive and systematic relationship between these two variables. Table 4.15.--Mother's education and use of health facilities (in percent). Mother's Education Use of Health Facilities Illit. Medium High Total (N=565) (N=395) (N=221) Low (N=121) 17.0 5.3 1.8 10.2 Average (N=500) 53.3 - 35.5 21.3 42.3 High (N=560) 29.7 56.2 76.9 47.5 Totals (N=1.181) 100.0 100.0 100.0 100.0 Chi-square = 174.60 Degrees of freedom = 4 p > .01 Gamma = 0.57 89 W In Part One of this chapter. the relationships between some of the independent variables were discussed. Part Two contains a descrip- tive analysis of the distribution of infant and neonatal mortality according to various socioeconomic. health. and demographic factors. Wad lnianLMoLtaJJn The influence of socioeconomic factors on infant mortality has been recognized in many studies. High infant-mortality rates have been associated with low income. low quality of housing. and lack of educa- tion. The following discussion presents the distribution of house- holders. total births. infant and neonatal deaths. and percentage of infant and neonatal death. all according to SES level. mother's educa- tion. type of house. and area of residence. Table 4.16 shows total births and deaths and percentage of infants dying. according to SES level. as well as the distribution of householders according to infant mortality (for all children ever born) and SES level. The percentage of infants dying decreased from 11.9% among low SES householders to 9.1% among middle SES householders. to 7.1% among high SES householders. The percentage of infant mortality among low SES householders is more than 25% higher than among high SES householders. Columns 5 to 8 of Table 4.16 show the percentage distri- bution of householders according to infant mortality and SES level. As indicated in the table. approximately half of the low SES householders had experienced infant mortality. Half of those who had experienced 90 o.oo_ m.m 6.5 m.m_ m._~ m.m mem.m _om mn~.o A_m_._uzv _mooe e.mm N.~ m.s m... s._m _.N Nem._ KN. mm~._ Ammmuzv ;e_: _.wm m.m “.5 m.m_ m.e~ _.m msm._ em. _mo.~ Ao~sazv s=_eoz ~.om m.o_ ~.o_ m._~ m.mm m... _:_.N mmN m~:.~ Rummazv 364 va any Amy Amv . mfiswo Amy ANV A_v mnumoo mnumoo Lumen mcumoo c_ _mooe e ee>_4 ammo _muoe +ooczh 03h 0:0 02 o mucoocom _o>04 mum >u__muco: acmmc_ cam _o>04 mum mcm>o momMucouLom cu mc_ucoUo< meow—Osmmao: mo mommucoocom ccm .mzumoo .mcuc_m _muOh .Accon co>o coco—_cu __mv _o>o_ mum ucm >u__mucoe ucmmc_ >n .mn_o:om:o; mo mco_u=n_cummv ommucoULoa can ._o>o_ mum >n .mcw>v mucmmcm mo mommucouLoa new .mcumoc acmwc_ .mzuc_n _muo»1i.m_.: «_nmh 91 infant mortality had lost one infant; half of the remainder had lost two infants. and the other half had lost three infants or more. One- fifth of the high SES householders had lost infants. and only a small proportion (2.3) had lost three or more infants as compared with 10.9% among low SES householders. Looking at the entire sample. more than one-fourth of the householders had lost at least one infant out of all children they had. Table 4.17 presents births. neonatal deaths for all children ever born. and the distribution of householders according to neonatal mortality and SES level. As shown in the table. the percentage of neonatal mortality among low SES householders is higher than among high SES householders. 5.0 and 4.0%. respectively. and higher than among middle SES householders. 5.0 and 4.2%. respectively. However. the differences in the percentage of infant mortality are greater among these groups than differences in the percentage of neonatal mortality. For the entire sample. the percentage of infant mortality is twice as high as the percentage of neonatal mortality. Columns 5 to 7 in Table 4.17 show the distribution of the socioeconomic groups according to number of neonatal deaths. One—fourth of the low SES householders lost at least one child in the first 28 days of life. whereas only about one-eighth of the high SES householders lost at least one child in the first 28 days of life. Also. the percentage of low SES householders who had more than two neonatal deaths is more than twice as large as that of high SES householders. 92 o.oo_ o.m m... _.mm m.: mmm.m omN m-.m A_m_._uzv _eooe “.mm m.m m.m m.mw o.: -~._ Ne mm~._ Ammmuzv ;e_= _.mm m.« m... o.mw ~.e :mm._ um _mo.~ AGNJuzv Ee_uez ~.om :.m ~.m_ 3.6“ o.m mem.~ _~_ m~s.~ Aemmuzv 26; Amy msmwwo gmwwo mzmwwo mhqwo Amy va A_v _mu0h +ozh «so 02 ommupoocom co>m4 vo_n _mHOP _o>og mum >u__mucoz _mumcooz vcm _o>oa mum ou mc_ucooo< meow—ocomao: mo mommucoocom mc_>o mommucoocom ucm .mcumoo _mumcooz .mgucmm .Acc0n.co>o coco—_cu __mv _o>o_ mum cam >u__mucoe _mumcooc >a .mc_o:om20c wo mco_u:nmcum_c ommucoocoa cam ._o>o_ mum >3 .mcm>u mucmwc_ _mumcooc mo mommucouLoa tam .mnumoc _mumcooc .mnuc_a _mu0h11.m_.: o_nmp 93 Tables 4.18 and 4.19 show infant and neonatal death figures as related to SES level for the past six years. There is a remarkable difference in the percentage of infant mortality among low and high SES householders. The percentage of infants dying among low SES house- holders is more than twice as high as among high SES householders. Also. the percentage of low SES householders who experienced two or more infant deaths is more than four times higher than the percentage of high SES householders. For the entire sample. only about 11% of the respondents had at least one infant death. The neonatal-death figures show a similar pattern. As presented in Table 4.19. the difference between low- and high SES householders is very large. but the differ- ence between middle and high SES householders in percentage of neonatal mortality is very small. Tables 4.20 and 4.21 show births. infant deaths. and the dis- tribution of householders according to SES level. Table 4.20 shows birth and infant death figures during the past three years. For all householders. the percentage of infant mortality is 6.3%. Eight per- cent of the householders had lost at least one infant during the past three years. The percentage of infant mortality among low SES house- holders is twice as high as among high SES householders. Table 4.21 presents the neonatal-death figures for the past three years. It shows a similar pattern as for infant mortality in regard to the difference between SES groups. The percentage of neonatal deaths for low SES householders is approximately twice as high as for high SES house- holders. During the past three years. less than 5% of the entire 9h o.oo_ ~.~ m.m m.mm 5.0 6mm.~ mm. m~m.~ Amm_._nzv _moo» m.mm o._ 0.6 s.~m m.: _me am was Asmmizv ;e_: o.em m.~ m.m m.mm 3.6 New mm _Nm ANNJqu e=_eoz ~.oM m.: w.o_ 5.3m m.m me“ mu m.» ANmmqu 264 an. em. 2mm... as. e e a _mHOF +ozh one 02 ommupoocom co>_4 co_o _mHOh _o>64 mum >o__mutoz peace. 6:6 _o>64 mum cu mc_ccouo< mama—Ogomao: wo mommucoocom mc_>o mommucouLom can .mgumoo acmmc_ .mcuc_m .Amcmo> x_m ummav _o>o_ mum new >u__mucoe acmmcw >3 .mu_o;om:o; mo mco_u:n_cummv ommucoocoa cam ._o>o_ mum >n .mc_>u mucmwcm mo mommucoocoa ucm .mcumoc acumen .mcuc_n _mu0h11.w_.: o_nmh 95 6.66. 4.6 6.mm 4.m 644.~ mm m~m.~ Ame.._uzv .mooe “.mm m.4 ~.mm m.~ moe om mm“ Aammuzv ;e_z _.om e.m n.4m m.~ 4mm KN _Nm ANNeuzv ea_66z _.om _.m m.om 6.4 _wu mm m.» ANmmnzv 264 Amy Amy 444 Amv ANV A_v _MHOF muwmwo mcwuoo omwuwmeom no>_4 coma _mu0h _o>oa mum >u__mucoz _mumcooz new _o>o4 mum ou mc_vcoou< moon—ozomaoz mo mommucoocom mc_>o mommucoocom ucm .mcumoo _mumcooz .mguc_m .Amcmo> x_m unmav _o>o_ mum cam >u__mucoe _mumcooc >n mu_o;om:o; mo mco_u:n_cum_c ommucoucoa new ._o>o_ mum >n .mc_>u mucmmc_ _mumcooc mo mommucoocoa cam .mcumoc _mumcooc .mzuc_n _mu0h11.m_.a o_nmh 6.66. _.6 6._6 6.6 466.. 66 666.. A66muzv .6464 96 6.66 6.4 6.66 _.4 666 e. 6.4 4.66-26 ;6_= 6.66 6.6 6._6 6.6 664 46 6.6 4466.26 e=_6ez ~.m~ m... >.ww N.@ can mm mm: hmwuuzv 363 A66 “66 6A4w 466 A66 A_6 mcumoo 63 won c_ a _mHOP +630 oz ommucoucoa co>m3 co_o _muOF _o>o3 mum >u__mucoz acmwc_ cam _o>o3 mum mc_>o mommucouLoa ou mc_3cooo< mean—030630: mo mommucoocoa vcm .mcumoo “some. .m3ucmm .Amcmo> 00333 ummmv _o>o_ mum ccm >u__mucoe acmmc_ >3 .mu_0366303 mo mcomu:3_cum_3 ommucoocoa 3cm _o>o_ mum >3 .mc_>3 mucmmc_ mo mommucouLoa 33m .m3umov acmmc_ .63u3_3 _m60h11.o~.: o_3mh 97 6.66. ..4 6.66 6.6 6.6.. .4 666.. .66612. .6666 6.66 6.6 6.66 6.. 664 6 6.4 ..N6uz. 66.: 6.66 4.4 6.66 ..6 666 6. 6.6 .466.2. 66.66: 6.66 6.6 6.46 6.4 664 6. 664 .66612. :64 .6. .6. .4. .6. .6. ... .22 fin“. 2...“... gum”... .2: a; .6.. >u__mucoz _mumcooz 33m _o>o4 mum ou mc_3606o< 6.03—030630: wo mommucoogom mc_>o mommucoULom cam .mcumoo _mumcooz .m3uL_m _o>03 mum .Amgmo> mo.3u umma. _o>o. mum 33m >u__mu.oe _mumcooc >3 .mc_0306303 6o m:0.u:3..um_u vauncoogoa 33m ._o>o_ mum >3 .mc.>3 mucmmc_ _mumcooc mo mommucoogoa tam .msumoc _mumcoo: .m3u6_3 _mu0h11._u.a 6.3mh 98 samp1e1(4l householders) had lost at least one child in the first 28 days. Figure 4.1 shows the percentage of neonatal. postneonatal. and infant mortality according to SES for the past six years. Figure 4.2 illustrates the infant mortality trends by SES level for the three periods under study. The figure indicates that. although the percentage of infant mortality has declined in recent years. the proportional differences between SES groups have remained approximately the same. For the purposes of this study. the city of Riyadh was divided into three major parts: the southern districts. the central districts. and the northern districts. In general. the northern districts are lower in population density. and the houses there are larger than they are in the central and southern districts. Also. more than half of the high SES householders are concentrated in the northern districts (Table 4.2). Almost all houses in the northern districts are villas. concrete houses. or apartments; there are no clay or block houses in these districts. 0n the other hand. the majority of houses in the central and southern districts are clay or block. in addition to low-quality apartments and a small number of villas. Tables 4.22. 4.23. 4.24. and 4.25 show birth and infant and neonatal death figures by residential area for the six-year and three- year periods preceding the study. As illustrated in Table 4.22. the percentage of infant mortality for householders in the central and southern districts was approximately twice as high as that for 99 15 d1 14 Hi 13 3. 3 w a 5 12 -1 ‘E 5‘ 11 "L E H >4 5 10 W .—1 39.1.3 '3 E S 9 JL 5 O u u.‘ >5 .-i U 2 ‘9 ‘3 H U H 8 Hr 9 .. P *i m i: =3 O u an 5 O a: F‘ 9 m 7 -L 0 O a {.1604 H g C 'H z 9" ‘4 f; 3 o H o 6 "’ g o a g J; 5 _JL 4.64 07 8 n". g 34.3 1...... z 0.1 . § 4 7r 2 93.5. 2 ‘3 a: 3 4L ' 2.5 1. 2 4. 1 " Low Middle High SES Level Figure 4.1: Percentages of neonatal, postneonatal, and infant deaths for all children born in the past six years, by family socioeconomic status. 100 A11 15'$ children 4 e b r 14 P ver °.n Children 13'? born in w Children 5 12"r 12;? past six born in 5‘ 11 .. years past three years P L 3 1° ‘ 9.1 9-3 3 9 1 8.2 n-i d i.__.. 5 3 i 7.1 7 .1.- —‘ 6.4 606 o 6'" F“ 2 o 5'" _i;? 4.1 3 z. -- *—" o O. 3 "P' 2 -- 1 a. 0 L M H L M H L M II SES Level Figure 4.2: Percentage of infant deaths for all children ever born, all children born in the past six years, and all children born in the past three years, by SES level. 101 householders in the northern districts. Columns 6 and 7 indicate that almost 6% of the householders living in the northern districts had experienced infant mortality. about 14% and 12%. respectively. of the householders living in the central and southern districts had experi- enced infant mortality. The results in Table 4.23 and Figure 4.3 show that the highest percentage of neonatal deaths occurred among householders who live in the central and southern districts (3.7% and 3.9%. respectively) com- pared to 2.2% among householders who live in northern districts. The percentage of householders in southern and central districts who expe- rienced neonatal mortality is twice as high as that of householders living in the northern districts. For the entire sample. neonatal mortality occurred among only 6.4% of the householders. Table 4.24 shows that the highest percentage of infant deaths during the past three years occurred among householders who live in the central districts; the lowest percentage occurred among householders living in the northern districts. More than 10% of the central house- holders had lost at least one infant during the past three years. compared to 3.9% of those living in the northern districts. Table 4.25 shows the neonatal death figures for the past three years. by residential area. As illustrated in the table. the highest percentage of neonatal deaths occurred among householders living in the southern and central districts of Riyadh. This rate is about twice as high as that among householders living in the northern districts of Riyadh. 102 6.66. 6.6 6.6 6.66 6.6 666.6 66. 666.6 .66....2. .6466 6.66 6.6 6.6 6.66 ..6 6.6 46 666 .646uz. 33:66 4..4 6.4 6.6 ..66 6.6 666.. 66 .6... .664.2. .666666 6.66 6.6 6.6 6.66 6.6 6.6 66 666 .66612. 6.636662 ..6. .6.. ..6... .6.. e a s .6606 +036 one 02 ommupooeom vo>_3 30.3 .6606 >u__mu.o: 63663. 336 moe< oucov_mo¢ cu mc_3.ouu< 6.03—036630: no mommucoocom mc_>n mommucoogom 33m .mcumoa ucmmc_ .m3u._m moL< oocoo_mo¢ .Amemo> x_m 6666. 60.6 oucoc_mo. can >u._muLOE acmwc. >3 .mv.03om:O3 mo 630.633..um_v ommucooeoa vcm .6066 06303.60. >3 .mc.>v 66:66:. .0 mommucoULoa vcm .mcumou ucmmc. .mcu._3 _muOhii.N~.: 6.366 103 6.66. 4.6 6.66 4.6 644.6 66 666.6 .66....2. .6666 6.66 6.6 6.66 6.6 666 cm 666 .646uz. 36:06 ...4 6.6 6.66 6.6 666.. .4 .6... .664uz. .666666 6.66 6.6 6.66 6.6 466 4. 666 .666.2. 6.662 mcmwwo mcmmwo mhwwo Am. .6. 6.. .0606 +030 02 0mmuc0030a 30>.3 30.: .muOP >u__06.oz .mumc00z 3:0 00.4 00:03.60m o» mc_3cooo< 6.03—030630: 6o 60mmuc0oc0m mc_>o 60mmuc0oc0¢ 330 .636003 .mumc00z .m:u..m 00L< 00:03.606 .Amcm0> x_m 6606. 00.0 00:03.60. 3cm >u_.0u.oe .mumco0: >3 .m3.030m:03 mo mco.us3_cum.3 0mmuc0oc0a 330 .0060 00:03.60. >3 .mc.>3 66:06:. _much0c mo m0mmuc0060a 330 .636003 _mumcooc .636..3 .muohii.mu.4 0.306 104 6.66. ..6 6..6 6.6 466.. 66 666.. .66612. .6466 6..6 ..6 6..6 4.6 666 66 664 .6omuz. 36:66 6.64 6.6. 4.66 6.6 466 64 666 .636666 6.66 6.6 ..66 6.6 666 o. 666 .466uz. cutoz .6. .6. .4. .6. .6. ... .6666 .uwmw6 mswueo 66MHUMML66 66>.4 66.6 .6666 >u..0u:o: u:06:. 3:0 00L< 00:03.60m 06 m:.3:ouo< 6303.030630: mo 60m0uc0oc0m m:.>o m0m0uc0ou0m 3:0 .636003 u:0m:. .630..m 00:< 00:03.60m .66300> 00.36 6606. 00:0 00:03.60: 3:0 >6..0u:os 6:0mc. >3 .m3.030m:03 mo m:0.u:3.:um.3 0m06:0o.0a 3:0 .0030 00:03.60: >3 .m:.>3 66:06:. mo n0m0uc0og0a 3:0 .636003 6306:. .mcu:.3 .0uOhii.:6.: 0.306 105 6.66. ..4 6.66 6.6 466.. .4 666.. .666nz. .6666 6..6 6.6 6.46 6.6 664 6. 664 .666.2. 4.466 6.64 4.4 6.66 6.6 466 6. 666 .664.2. .664666 6.66 4.6 6.66 6.. 666 6 666 .466.2. 46.62 .6. .6. .4. .6. .6. ... .06o6 mmwmwa m3wu03 06MMWMML06 30>.4 30.6 .06o6 >3..06.oz .060:00z 3:0 00c< 00:03.606 o6 m:.3.ouo< 6.03.03063o: mo 60mmuc0oe0m m:.>a m0m0uc0ocom 3:0 .636003 .060:O0z .m3u:.m 003< 00:03.60m ..6:00> 00:36 6606. 00.0 00:03.60. 3:0 >6..0u.oe .060:o0: >3 .m3.030m:o3 60 m:0.u:3.:um.3 0m0uc0030a 3:0 .0060 00:03.60: >3 .m:.>3 66:06:. .060:o0: mo m0m0uc0oc0a 3:0 .636003 .060:00: .m3uc.3 .060611.m6.: 0.306 106 Figure 4.3 graphically shows the neonatal. postneonatal. and infant deaths during the past six years for each residential area. The percentages of postneonatal deaths were markedly lower in the northern than in the central and southern districts. Tables 4.26 and 4.27 show birth and infant and neonatal death figures according to type of housing during the past six years. The results in Table 4.26 and Figure 4.4 show that the highest percentage of infant mortality occurred among householders who live in clay or block houses; this rate was approximately three times higher than that of householders who live in villas and almost two times higher than that of householders who live in concrete houses or apartments. The table also indicates the high incidence of two or more infant deaths among householders living in clay or block houses (5.4%). compared to (L8% among householders living in villas. Although the percentage of death declined from the neonatal to the postneonatal period among householders in villas and concrete houses or apartments. this percent- age rose from the neonatal to the postneonatal period among families living in clay and block houses. This may reflect poor living condi- tions in the clay and block houses negatively affecting the infant over time. As shown in Table 4.27. the highest incidence of neonatal mortality occurred among householders living in clay or block houses. This rate was approximately twice as high as that among householders living in villas. Also. the table indicates that the differences in the percentage of neonatal mortality between those who live in villas 107 15 ‘1 14 3r 13 " z? oo .5 12 "l g S 5‘ “ 1 .3 s c: 10 “i 3 1H . 2 a: .2 "‘ 9'” o8.3 :4 :3 61 0 ___. .4 0 0 8‘” .. ... 3 5 3 37.1 ES 7 -1 0 u 61 m 0 0 61 .u : c: o : : ‘H 6'1? 3 21:1, 8 o. 8:; ° :8: =46 2: u 5 4L . 3 3 5 3.74 3.9 1, 4 31 2: g 3.5 __.. 3.2 L. 0 3 -- 9‘ a. 2.2 2"? 1 1 _. 0 7 , Northern Central Southern Figure 0.3: Residential area Neonatal, postneonatal, and infant deaths (in percentages of births) among children born during the past six Years, by residential area. 108 6.66. 6.6 6.6 6.66 6.6 666.6 66. 666.6 .66....2. .6466 6..6 6.6 6.6 6.66 6.. 66.6 666 66 666 ..66.2. 6...> ..66 ... 6.6 6.66 ..6 666 66 .66 ..66.2. 46624.666 .0 060:0:06 6.66 4.6 6... 4.66 6.6 466 66. 666.. .644uz. 400.3 :0 >0.u ...... ...... ...... ...... 6 a s 6. —mHo.—- +°3P 0:0 02 ommuchme U0>mJ ”Own —mHO.—. ”MW-o: $0 0Q>.—u >6..0u:oz 6:06:_ 3:0 06:0: 60 0a>6 06 m:.3:ooo< 6.03—030630: mo m0m0uc0oc0m m:.>o m0m0uc0oc0m 3:0 .636003 6:06:. .634..m ..6:00> x.m 6606. 06:03 .0 06>» 3:0 >4..04.0E ucmmc. >3 .m3.O30m:03 mo m:0.u:3..um.3 0m0uc0030a 3:0 .0m:O3 mo 0a>u >3 .m:.>3 64:06:. mo m0m0uc0oe0a 3:0 .036003 acmwc. .m3u:.3 .0606ii.66.: 0.306 l09 6.66. 4.6 6.66 4.6 644.6 66 666.6 .66....2. .6466 6.6. 6.6 6.66 6.6 666 6. 666 ..6662. 6...> 6.66 ..4 6.66 6.6 666 66 .66 ..66nz. 4:95.666 3:0 060:0:06 6.64 6.6 6.66 ..4 4.6.. 64 666.. .644.2. 466.6 3:0 >0.u .6. .6. .4. .6. .6. ... 6 6 >u..0u:oz .0u0co0z 3:0 00:0: .0 0a>6 o» m:.3:ouo< 6603.0306301 mo m0m0430oc06 06:0: 6o 0a>6 m:.>o mommuc0oc06 3:0 .63600c .060co0z .634:.m .66600> x.m 6606. 06:03 60 0a>u 3:0 >u..0u.oe .060:00: >3 .m3.030m:03 mo m:0.u:3.cum.3 0m06:0u:0g 3:0 .0630; 6o 0a>6 >3 .m:.>3 66:06:. .060:00: 60 m0m06:0060a 3:0 .636003 .060:o0: .636..3 .060611.66.: 0.306 llO 15 4. 14 3r >. 13 - 2 6 . .3 5 12 1f 0 : a 11 7' E H a 10 ‘1? 8908 0 J : >6 H 9 ~ u u 3 6i 0 6i : H 8'3 0 o 0 as 6 H U D-i H ‘H U 3 0 H in a vi a t) 7-* a 0 a 6i 0 0 .4 85.7 ‘6 8 '6 iii “.3 O 6 “P 2: 1 c :5.1 a: : 64 u 5 4* 8 I: g 8 : 4. z: o <3 :3 8 Q) 4 _.’, . : On 0 «H ' 0 2: 0 “ 41 2:9 ‘2 an: 3 ‘2, 2.1 2 3r 1. 1 " O - - - CLay or Block Concrete Villa and Apartment Figure 4.0: Type of House Neonatal, postneonatal, and infant deaths (in percentages of births) among children born during the past six years, by type of house. 111 and those who live in concrete houses or apartments is very small. unlike the same comparison for infant mortality. Tables 4.28. 4.29. and 4430 present the total births. total neonatal and infant deaths. and percentage of infants dying according to mother's educational level. as well as percentage distributions of householders according to number of neonatal and infant deaths and mother's educational level during the retrospective and past-six-year periods. The results in Table 4.28 show that the highest incidence of infant mortality occurred among illiterate mothers. This figure was approximately four times higher than among highly educated mothers and approximately two times higher than among low-educated mothers. Col- umns 5 to 8 indicate that approximately 42% of illiterate mothers lost at least one infant. whereas only 7% of highly educated mothers had experienced infant mortality. The remarkable differences between these groups might be the result of more than education alone because it is obvious that the younger women were more likely to have some education. Thus it is possible for the educational level to reflect the age of the mother. the number of children. and to some extent the socioeconomic status. This issue will be explained more for the six-year period when the child-woman ratio for each educational group can be. calculated. llZ 6.66. 6.6 6.6 6.6. 6..6 6.6 666.6 .66 666.6 .66....2. .6466 6.6. 6.6 6.6 6.6 6.66 6.6 .66 6. 666 ..6612. 46.: 4.66 4.6 6.6 6.4. 6.66 4.6 ..6.. 46. 646.. .466uz. 364 6.64 4.6 6.6. 6.66 4.66 6.6. 6.6.6 664 666.6 .666.2. 646.64.... .6. .6. .6. .6. .4. .6. .6. ... ...... ..6.. ..6.. ..6... ..6...-. >u..0u.oz 6:06:_ 3:0 :o.u00:3m m..03uoz 00 m:.3.000< 6.03—030620: 60 m0m0~c0060m m:.>o m0m04:00.06 3:0 .634003 .m3u..6 .0406 :o.600:3m m..03002 .A:.03 .0>0 :0.3..30 ..0. :o.. 100330 m..03405 3:0 >u..0u.oe 6:0mc. >3 .m3.030m:03 60 m:0.u:3..um.3 0m0uc0060a 3:0 .:0.400:30 m..03uoe >3 .m:.>3 64:06:. 60 m0m04:00.0a 3:0 .636003 0306:. .m3u..3 .0006ii.w6.4 0.306 113 The results in Table 4.29 and Figure 4.5 show that the highest percentage of infant mortality for the past six years is among illiter- ate mothers. This percentage is four times higher than among highly educated mothers and two times higher than among low-educated mothers. Although the percentage of deaths declined from the neonatal period to the postneonatal period among highly educated and low-educated mothers. it rose from the neonatal to the postneonatal period among illiterate mothers. 'This may reflect the factors associated with illiteracy. such as inadequate infant care. negatively affecting infants over time. As stated before. mother's education may reflect the effects of other factors as well. Thus one must at least calculate the child-woman ratio for each group as follows: Illiterate 1.322 557 = 2.37 Low educated 811 393 = 2.06 High educated 392 218 = 1.80 Thus the expectation that illiterate mothers would have a larger number of children than highly educated mothers was demonstrated. It can be concluded that at least part of the differences between these groups may be attributed to other factors than just mother's education. This will be discussed in detail in the following chapter. The differences in the percentage of neonatal infants dying among the various educational groups during the past six years are shown in Table 4.30. The highest incidence of neonatal mortality is among illiterate mothers--twice the rate among low-educated mothers and four times higher than among highly educated mothers. llh 6.66. 6.6 6.6 6.66 6.6 666.6 66. 666.6 .66....2. .6466 6.6. 6.6 ..4 6.66 6.6 666 6 666 .6.6.2. 66.: 6.66 6.. ..6 6.66 6.4 666 66 ..6 .666uz. 304 6.64 6.4 6.6. ..66 6.6 66... 66. 666.. .666.2. 646.64.... ...... ...... ...... ...... ... 6 e .0006 +036 0:0 02 0m06m00.06 30>.4 30.o .0406 >4..04.oz 0:06:_ 3:0 :o.400:3m m..03uoz 06 m:.3.000< 6.03.0306301 mo 60m04:00.06 m:.>3 m0m06:00.0m 3:0 .634003 4:06:. .634..m :o.u00:3m m..03402 ..m.00> x.m 460a. :o.400:30 m..03uoe 3:0 >4..04.oe 4:06:. >3 .m3.030m=03 60 m:0.u:3..un.3 0m0u:00.0a 3:0 .:o.u00:30 m..0cuoe >3 .m:.>3 64:06:. 60 m0mmuc00.0a 3:0 .634003 0306:. .636..3 .0406ii.m6.3 0.306 llS 15 fi‘ 14 41 h 0 13 _. g 41 w 12 -w t: a F‘ 64 E “ “ s 10 '1? w 906 c c a: 9 4' '3 3 '3 .u : H 8 "'1' 0 U H >6 -H c m 0 :J .: 7 __ o o 1. a 64 L) Q) n. .4 a: 0 0 z: 0 c: in 44 6. a 6 .. “a .5 '3 2 2 O 5 _L 4.74'9 2:: u o m 4.) _._'-— O «U 0 0.) 'H = . a:“° as: C) -0 . a 4 a 7 a 2 w 3 2.1 62.2 a. 2 ‘+ .9 1,5 1 4p .6 0 , _ - - - Illiterate Low Educa High Educa Mother's Education Level Table 4.5: Neonatal, postneonatal, and infant deaths (in percentages of births) among children born during the past six years, by mother's education. 116 6.66. 4.6 6.66 4.6 644.6 66 666.6 .66....2. .6466 6.6. 6.6 6.66 6.. 666 6 666 .6.6.2. 66.6 6.66 6.4 6.66 ..6 466 6. ..6 .66612. 364 4.64 6.6 6.66 6.4 666.. 66 666.. .66612. 646.64.... .6. .6. .4. .6. .6. ... .0006 6mwmmo 63Wu0o 0mMMDMML0m 30>.4 30.3 .0006 :o.000:3u 6.60300: >0..00.oz .000:002 3:0 :o.000:3w 6..030oz 00 m:.3.000< 6.03.0306301 60 60m00:00.0m m:.>o 60m00c0060m 3:0 .63000o .000:00: .630..m ..6.00> x.6 0606. :o.000:30 6..030os 3:0 >0..00.oe .000:00: >3 .63.0306:03 6o 6:0.033..06.3 0m00:00.0a 3:0 .:o.000:30 6..030oe >3 .m:.>3 60:06:. .000:00: 60 60m00c0060a 3:0 .630003 .000:00: .630..3 .0006ii.om.: 0.306 117 W): Type of feeding has been found to have a significant effect on infant mortaiity. Previous studies have indicated that breast-fed infants have a higher chance of survivaT than do artificiaTTy fed infants (Howarth. 1905; Woodbury. 1925; Cantre‘lie & Leridon. 1971; Knode'l. 1977; Wray. 1977). Tab‘le,4.3'l and 4.32 show birth and infant death figures for a‘l'l chiidren ever born and for a1] chderen born in the past six years. according to type of feeding. The results in Tab'le 4.31 show that the highest incidence of infant morta‘lity occurred among artificiai‘ly fed infants. Whereas approximately 22% of aT'l mothers who breast fed an their chderen had experienced infant morta'lity. more than 35% of ai'l mothers who arti- ficiaiiy fed their infants had Tost at Teast one chde during the first year of 'life. Table 4.32 and Figure 4.6 show the percentage of infant morta‘lity for a'l‘l chi'ldren born during the past six years. The highest incidence of infant morta'lity occurred among chiidren who were arti- ficia'l‘ly fed; this rate is three times higher than that among infants who were breast fed. A1 so. the table indicates that the percentage of mothers who lost one infant and who artifici‘a'liy fed their chi‘ldren is two times higher than that of mothers who breast fed their chi'ldren. and five times higher for two or more infant deaths. A'lso. the figure shows that although the percentage of deaths among breast-fed infants dec'lined more than 50% from the neonatai to the postneonata‘l period. it rose among the artifici any fed infants. 118 L_o;u mo 020m >_co no» ammocn 0:3 omo;h .uouu_so coon o>mc sect—.cu .co.v__co c_o:u __m tom >__m_u_$_u.m >__mu0u 0:3 omosu tam coco—_su ._o:u __m tom ammocn >__mu0u 0:3 omo;u >_co moon—0c. o_nmu m.ch "ouoz >u._mu.oz acmmc_ vcw mc_voou wo oa>h Ow mc_u.oou< mcou_o;om:o= mo mommucouLom mc_>o mommucou.om can .mzumoo .mnu._m _mu0h o.oo. ~.m m.m o.m. o... m.m mm..: as: “Nm.s .mmmuz. .muoh m.~s m.@ 4.0. m.o. m.:m w.~. we... omN omm.. .Nmmuz. am. >..m.u...a.< N.~m m.~ «.0 ~.m. w.nn m.n -:.~ em. .Nm.~ .Nmmuz. um. ammuam MN. m ... .m. m “w.o m.:w .m. .N. ... m; on gamma gamma 5 o c. o _mu0h +oocsh 03h one 02 ommucoocom vo>_4 uo_o _mu0h mc_noou wo ma>h .A:LOn Lo>o coco—.50 __mv mc.uoow mo oa>u vcm >u. ..mucos ucmwc. >3 .mv_o;om:o; mo mco.u:n..um.c ommucoocoa new .mc.voom mo oa>u >3 .mc.>n mucmec. mo mommucoocoa vcm .mcumon acmwc. .mcu..a _muOHuu. _m. : o_nmh o.oo_ m.~ m.m m.mm m.m cmn._ m__ mwm._ Ammwuzv _mHOP ll9 m.o: o.m m.~. m.~m m.o. we. em Nah .oomnz. no. >..m.u...u.< «.mm m.o ~.o m.~m ..m ~so.. mm muo.. .mumnz. um. ummmtm .5. A». .m. m.:w .m. .N. .e. mcumoo cumoo msumoo c. a m o . o m o . a F +03» «co 02 ammuchLo. a >.. ua.o . u p ac.umu. .0 ma>e >u__mucoz necks. ocm mcmvoom mo oa>h mcm>o mommucOULom o» mc_ucouo< muon_o:om:o: mo momMucoocom new .mcumoo ucmmc. .mnuc_m .Amcmo> x.m ummav mc_uoom mo oa>u new >u__mu.oe gamma. >n .mu_o;om:o; mo mco_u:n_.um_u ommucouLoa ucm .mc.uoom mo oa>u >o .mc.>o mucmmc_ mo mommucoocoa.ucm .mcumou acmmc_ .msuc_n _muOPIu.~m.: o_nmh 120 15 -> h 14 -i 2 4'3 13 AL .3 2° 12 -’ E. 11 -L "319-6 a 10 "i ‘0: T Q H U H 9 -D Q G "O U H F‘ 8 -r ‘ a a: a c o n h o m U 7 .... H U o H w a z u... w H m o 6 -’ JJ m ‘H 5 2504 o c c . __. J.) 5 cm fl 0 H II-fl‘ : o o 8 4 ... é’ S u ”3.1 33 3 "' 2.2 a? "“ 2 w 1 _’ .9 O - Breast-Fed Artificially Fed Type of Feeding Figure 4.6: Neonatal, postneonatal, and infant deaths (in percentages of births) among children born during the past six years, by type of feeding. 121 This finding may refiect the fact that human miik may increase the infant's immunity to diseases and aiso that artificia'l mi'lk is subject to measurement errors and to contamination during preparation. ”WW1. UsuLEQlLHeaJJmmnanianI andJaonataLDeaths Tabies 4.33 and 4.34 show birth and neonata‘l and infant deaths for the past six years according to the use of hea'lth faci‘lities. The figures in Tabie 4.33 show the percentage of neonatai mortaiity accord- ing to use of hea'lth faci‘lities. The tab'le a‘lso indicates that house- ho'lders making iittie use of hea‘lth faciiities in the treatment of infants had a higher percentage of neonatai death than those reporting high use of hea'lth faciiities. Whereas Tabie 4.33 fai'ls to show iarge differences in the percentage of neonatai morta'lity among househoiders with high and Tow use of heaith faci'lities. Tabie 4.34 and Figure 4.7 show remarkab'le differences in infant deaths between househo'l ders mak- ing iittie and high use of heaith faciiities. The percentage of infants dying among househo‘lders with Tow use of heaith faciiities is more than twice as high as among househoiders with high use of heaith faciiities. The 'Iargest differences occurred in postneonatai morta'lity. As the figure shows. the percentage of postneonata'l morta'lity among house— hoiders making iittie use of hea'lth faciiities is six times higher than among those making high use of hea‘lth faci‘lities. A‘lso. it shouid be mentioned that this iarge difference may refiect the effect of other variab‘les on use of hea'lth faci'lities. Tabies 4.14 and 4.15 indicated 122 o.oo. s.o o.mm s.m o:a.~ mm m~m.~ .mw...uz. .maoe m... :.m m.sm ..m omo.. mm mmo.. .Nmmuz. .m.: m.~: . m.o ~.mm o.m mo... .: ma... .mmauz. ommto>< ~.o. ~.m m.om m.m NwN .. mmN .m..uzv so. .0. .m. .a. ..m. .N. ... .muo» mmwmwo mgwuoa omwuhMMLo. ua>.. no.9 .mooe mo.u...um. 5. 23.5: 33502 cam 0m: 3.: _ .umn. 5 .8: cu mc_v.ooo< mcov_o;om:oz mo mommucoucom mc_>o mommucoULom .vcm .mzumoo _mumcooz .mcue_m 5...»: .0 0.: .Amcmo> x_m ummav mo_u___umm cu_mo; .0 0m: vcm >u__mu.oe _mumcooc >5 .mn_o;om:o; mo mco.u:n_.um_u ommucoocoa vcm .mo_u___umm ;u_moc .0 «ma >5 .mc.>u mucmwc_ _mumcooc mo mommucoocoa can .mcumoo _mumcooc .m:u..g _muopuu.mm.: o_nmh 123 o.oo. ..N 3.3 3.33 ..3 3mm.~ m3. mum.~ .mo...uz. .muo. _m..: m.. m.3 m..m m.: omo.. mm m¢o.. .Nmmuz. gm.: 3.~: o.m m.m ...m m.. mmo.. aw ma... ..mquz. umn...< «.o. o.. m.o. m..m m.o. .eN NM mmN .m..uz. zo. .3 .8 .3 .... .3 .3 ... >u__mucoz ucmwc. 3cm om: mo.u.._omm 33.no: 03 m:_3.ouo< meow—03omao: mo mommucoocoa mm 0 mm mc.>o mommucoocom 3y. I u 3 can .mzumoo acmwc_ .mnu._m ..mcmo> x_m ummav mo_u___umw 33.noc .0 mm: 3cm >u_.mucoe acmwc_ >3 .m3_03om203 mo mco.u:3_.um.3 ommucouLoa 3cm .mo_u__.umw 3u_moz .0 mm: >3 .mc.>u mucmwc_ mo mommucoucoa 3cm .mcumon ucmmc_ .m:u..3 _mu0hnn.:m.: o.3m> l2h 15 —l. h 14 2 13 L 4'3 F4 : g0 12 «l .3 "' . ‘1 11 a» 510.1? g Q q, a) C.‘ 10 '1? S r; a; g 9 4. m Ll hi >. ,0 o m r4 0 .4 8 t '4 5‘ a en a "i 1 37 1 '3 87-3 '3 ‘38 .c O l—V “A q o o 6 i a 3 a: s 54.9 2 54V 3 z z 3 ' 07 a! 8 4 1r- _‘ 306‘; 3.1 E 3 l —. 2 '1r .118. 1 ul- 0 Low Average High Use of Health Facilities Table h.7: Neonatal, postneonatal, and infant deaths (in percentages of births) among children born during the past six years, by use of health facilities. 125 the strong correlation between use of health facilities and mother's and father's education. Tables 4.35 and 4.36 show the birth and death figures for the past six years according to use of folk healing. The results in Table 4.35 indicate that the highest incidence of neonatal mortality occurred among householders who used more than one type of folk healing in the treatment of their infants. The lowest percentage of neonatal mortal- ity was among those who never used folk healing in the treatment of their infants. The differences in the percentage of infants dying among house- holders who never used folk healing. those who used only one type. and those who used more than one type during the past six years are pre- sented in Table 4.36 and Figure 4.8. The highest incidence of infant mortality occurred among householders who used more than one type of folk healing in the treatment of their infants; this figure is approxi- mately two times higher than that for those who never used folk healing in the treatment of their infants. More than half of the householders in the entire sample never used any type of folk healing. one-fourth used only one type. and approximately one-tenth used more than one type of folk healing in the treatment of their infants. The greatest difference among these groups of householders is in the percentage of postneonatal mortality. which was more than three times higher among those who used more than one type of folk healing than among those who never used such healing methods in the treatment of their infants. 126 o.oo. :.3 3.mm :.m oo:.~ mm m~m.~ .mm...uz. .muo. m... m.o. ~.mm m.m MNm w. .:m .mm.uz. 0a.. 0:0 can: 050:. “cum: ..:~ m.m m..m m.m m.m mm 3mm .NmNuz. oa>u oco vow: o.:m m.: ~.mm ..N :om.. N: o:m.. ..JNuz. com: .052 a... me ...... a a s 0 _muOP ”Waco 3M2 3 ommupoMLom 30>.3 3o.o _muOP >u..mu.oz .mumcooz tam om: m:..mo: x_ou cu mchucouo< meow—03omaoz wo nommucouLom mc_>o mommucoULom 3cm .mzumoa _mumcooz .mzu..m mm: m:..moz x.o. .Amemo> x_m ummav m:..mo: x.0w .0 mm: 33m >u..mu.oe .mumcooc >3 .m3.03om303 mo mco.u:3..um.3 ommucoo.oa tam .mc__m03 x.ow .0 mm: >3 .mc.>v mucmmc. _mumcooc mo mommucoocoa 33m .mcumou _mumcooc .ncuc.3 _mu0h11.mm.: 0.3mh 127 3.33. ..N 3.3 3.33 ..3 3mm.~ 33. m~m.~ .33....2. .muo. 3... 3.3 ~.~. ..3. 3.3. .33 a: .33 .33.uz. a... 0:0 coca oLOE,3om: ..:N ..N ..m. 3.33 3.3 .33 .3 333 .N3Nuz. oa>u oco now: 3.33 ... «.3 ..N3 3.: 3.3.. a. 333.. ..:.uz. 33.: 33>02 mnmwwa 3mmwo mcmmwo mm3w Amy .N. ._v . 3 .muoe +02. «:3 0: ammuchLu. 3.>.. no.3 .muoe om: 3:..mu3 3.0. >u__mu.oz weave. 33m 03: mc._mo: x_0m Ou m:_3.ouo< neon—030330: mo mommucoocom mc_>o mommucOULoa 3cm .mcumoo gamma. .mcu._m .Amcmo> x_m ummav mc_.mos x.o. no em: 33m >u__mu.oe acmmcm >3 .m3_03om:oz mo mco_ua3_.um_o ommucQULoa 3cm .mc..mo3 3.0» mo 03: >3 .mc.>3 mucmmc. wo mommucoULoa 3cm .mzumon ucmwc_ .333._3 _muOhuu.3m.: 0.3mh 1EJTEilllsi‘l‘{"‘l\lll‘ llll'i it- l28 9 52:32; Hm amumsoocumom .m— 7 kumcooz au— 57 >o=mw=H 8. 7 : Houscoocumommfl Mr Hmuwcooz F A. >235; cm— 4 i kuocoocumom ...“... Hmuocomz 7” 2 .r.r..l. 0,.5 7.,0 :..4 12 F 11 _ 10r- wcw>a souvafico we ucouuom P _ Used One Used More Never Use 3210 Than One Type Type Use of Folk Healing Neonatal, postneonatal, and infant deaths (in Figure 4.8: percentages of births), by use of folk healing. 129 Table 4.37 shows the infant mortality data for the past six years according to number of children and the percentage distribution of householders according to number of children and infant deaths. The highest incidence of infant mortality occurred among householders who had four children or more during the past six years--approximately two times higher than for those who had three children and more than ten times higher than for those who had only one child. These large dif- ferences may reflect the fact that infants born after a short birth interval have a higher risk of dying than infants born aftem'a long birth interval. Since there is no information on birth interval. one may specu- late about it. assuming that infants born to householders who had four children or more during the past six years would have a short birth interval. In addition. children born to householders with a large number of children will receive less attention and care than those born to householders with few children. This also may reflect the fact that low SES householders are more likely to have moreichildren than are high SES householders. 'This can be demonstrated bylcalculating the child-woman ratio (the general fertility ratio) for this sample for each SES group as follows: There were 352 women in low 553 having 8l9 children‘ 422 women in middle SES having 921 children 394 women in high SES having 785 children Thus. the child-woman ratio is: Low $55 = 2.33 Middle SES = 2.18 High 555 = 1.99 [I'll I30 3.33. ..N 3.3 3.33 ..3 333.3 33. 333.3 .33...nz. .mso. 3.3. 3.3. 3.33 ..33 3... 3.3 33 333 .3N.uz. 0.05 .0 .30. ...3 ..3 3... 3.33 3.3 3.. 33 N3. .333»:. mo... 3.0m ~._ n.m N.om w.m on“. n: m_m Ammauzv 03h 3.33 3.3 3.. ..33 3.. 333 . .33 ..33.2. 3:3 3 .MW .NW 3 .MW 0.3.3. .3 .3 ... C— .0303 ”wzha 3wcoo 3W2 3 0m00p0m.0m 00>.3 00.3 .muOh :.Om >u._0u.oz u:0.:_ 0:0 :.03 :0.0..3u .0 .oz 00 m:.0.ooo< 3.03.030330: .0 m0m00:0u.0: m:.>o m0m00:00.0: 0:0 .030003 0:0m:_ .330..m 33.3..33 .3 .oz ..m.00> x_m 03003 :.03 :0.0..30 .0 .0353: 0:0 >u._0u.oe ucmmc. >3 .30_0303303 00 m:0.u=3..um.u 0m00:00.00 3:0 .:.03 :0.0_.30 .0 .0383: >3 .m:.>u 30:00:. .0 m0m0uc0o.0a 0:0 .330000 0:00:. .m:u..3 .000hnu.~m.: 0.30» II. I 1|| 1|! II. III. l- I .II!‘ III I ‘1'}! .II. 131 This indicates the effects of SES level on the differences in house- holders' infant mortality when householders are categorized according to the number of children they have had. Table 4.38 shows the percentage of infant deaths according to the infants! sex for all children ever born to the householders in the study. The percentage of infant deaths among males was higher than among females. The percentage of male infant deaths was 0.8% higher than the average. and the percentage of female infant deaths was 0.9% lower than the average. Table 4.38.--Percentage of infants dying. by sex (children ever born). L3 Sex Mortality Status Male Female Total Total births 3.284 2.995 6.279 Lived 2.942 2.736 5.678 Died 342 259 601 Percent of dying l0.4 8.7 9.6 Sum In Part One of this chapter. the relationships between socio- economic factors and health factors were investigated. The results indicated a significant association between various socioeconomic variables. Strong relationships were found between SES and mother's 132 education. between SES and residential area. and between SES and type of house: Educated mothers were more likely to be high SES. and high SES families were more likely to live in the northern districts and to live in villas. In regard to the relationships between socioeconomic factors and attitudes toward and use of folk healing. there was no relationship between father's education and attitudes toward folk heal- ing. Almost 50% of the three educational groups had neutral attitudes toward folk healing. A similar pattern was found in the relationship between SES and attitudes toward folk healing. but a weak relationship was found between father's education and use of folk healing: The more-educated fathers made less use of folk healing. Highly educated mothers were found to use folk healing less than illiterate mothers or those with low educational levels. A fairly strong relationship was found between attitudes toward and use of folk healing. Those having positive attitudes toward folk healing were more likely to use it in the treatment of their infants. The relationships between SES and attitudes toward modern medi- cine. and between SES and use of health facilities. were also explored. It was found that high SES householders were more likely to have posi- tive attitudes toward modern medicine. A similar relationship was found between father's education and attitudes toward modern medicine. The better educated and higher SES householders were also found to use health facilities more than low education and low SES householders. Mother's education was found to have a great influence on the use of 133 health facilities; educated mothers used the facilities during preg- nancy. at birth. and after birth more than did uneducated mothers. Part Two of this chapter presented the distribution of house- holders and total births. total deaths. and percentage of infants dying in relation to various socioeconomic. demographic. and health factors. The findings indicate high variation in the death rates during the neonatal. postneonatal. and infant periods among different socioeco- nomic groups as well as according to other demographic and health related groupings. It was obvious from the discussion in the first part of this chapter that most of the factors were intercorrelated. especially with SES and mother's educational attainment level. For example. SES was found to correlate with quality of housing. As stated earlier. high SES householders were more likely to live in villas. to have a lower number of persons per room. to use health facilities more often. and to have educated mothers. In addition. the effect of age of mother and her parity are important factors affecting infant mortality. Thus. to understand the relationship between infant mortality and various factors. age oflnother and her parity should be controlled. Also. SES and mother's educational attainment level will be controlled when testing the relationships between infant mortality and type of feeding. use of health facilities. and use of folk healing. This will be discussed in the following chapter. CHAPTER V ELABORATION OF THE FINDINGS lnILQfluQIIQn In Chapter IV. the percentages of neonatal. postneonatal. and infant deaths were presented for various socioeconomic. health. and demographic groups. The findings indicated remarkable variation in the percentage of deaths during these three periods among the various groups. In addition. a significant association was observed among some of the independent variables. especially the intercorrelation of SES and mother's educational attainment level with the rest of the depend- ent variables. SES was found to correlate with housing quality. use of health facilities. and use of folk healing. Also. mother's education was found to correlate with these factors. Thus. to determine whether the relationship between a given independent variable and infant mor- tality is real or is actually attributable to an extraneous factor. one must control for SES and mother45 .05. G = -.26 The result of partit§oning of chi-square: Low-middle = X = l.Ol. df = l. p = .30 Low-high = x2 = 8.73. df = 1. p = > .01 Middle-high = x2 = 4.52. df = 1. p = >.os Although the relationship between SES and infant mortality seems to exist. it is necessary to ask whether the relationship between these two variables will maintain the same pattern in terms of magni- tude and direction when the other variables are controlled. There are a variety of possible explanations for this relationship. Perhaps low SES householders tend to have more children than high SES householders. Thus. children born to low SES householders may have lower birth inter- vals than children born to high SES householders. which is expected to increase the incidence of infant mortality among them. Perhaps the age of the mother tends to be lower among the low SES householders than among middle and high SES householders. 140 Table 5.2 presents the relationship between SES and infant mortality after controlling for the number of children born during the past three years. 'The table shows that. among children born to mothers who had only one child during the past three years. there was no relationship. Differences in percentages of infant deaths between low and middle SES householders are very small (but differences between low and high SES householders are fairly large). Among householders who had more than one child during the past three years. there are note- worthy differences in the percentages of infant deaths among SES group- ings. The incidence of infant deaths among children born to low SES householders is approximately two times higher than among children born to high SES householders and approximately 25% higher than among child- ren born to middle SES householders. Table 5.3 indicates the relationship between infant mortality after the age of the mother was controlled. Among children born to mothers younger than 29 years. the results follow the expected pattern: The highest percentage of infant death occurs among children born to low SES householders. and the lowest percentage of infant deaths occurs among children born to high SES householders. Among children born to mothers older than 28 years. the results in general follow the expected pattern except between the low and middle SES groups. where there is a slight reversal of the trend. It seems that SES and infant mortality are moderately asso- ciated. When the age of mother and the number of children are con- trolled. the results in general follow the expected pattern except for IA] 33.. u 3 .33. A 3 .. u .3 .33. u x .3.- n 3 .33... 3 .3 n .3 .3..3 a 3x 3 .33.-z. .333..uz. 3.33. 3.33. 3.33. .333. 3.33. 3.33. 3.33. 3.33. .333. ..3.:. . .33»:. 3.3. ..3. 3.3. 33.3 3.3 3.3 3.3 3.3 33.3 .3..uz. .33...nz. 3.33 3.33 3.33 33>.>.33 3.33 . 3.33 3.33 3.33 33>...33 ..3nz. .33nz. 33.333 .333uz. ..33uz. ..33uz. 3333.3 .33 ..3.: 3 0.33.: 20.. 323.0: .33 33:. 0.33.: 20.. ..3.—33.0: 333 03.03 __0Em 33.3..33 .3 .33332 .Auc0u.0a :.v :0.3__30 .0 .0383: >3 .>u__0u.oe u:0m:. 3:0 mwmnn.~.m 0_30h 142 .3.- u 3 33.. u 3 .3 u .3 .33.3 u 33 33.- u 3 .33. u 3 .3 u .3 .3.3 u 33 .333uzv .333»:. 3.33. 3.33. 3.33. 3.33. .333. 3.33. 3.33. 3.33. 3.33. .3.3. .33uz. .33»:. 3.3 3.3 ..3 3.3 33.3 3.3 3.3 3.3 3.3 33.3 .333uz. .333uzv 3.33 3.33 3..3 3..3 33>...33 3.33 3.33 ..33 3..3 33>.>.33 .3.3. .33.»:. .33.uz. ..33.2. 3333.3 .3.3. .333nz. .333uz. .333uz. 3333.3 33.: 3.33.: 33. >3..33.oz 33.: 3.33.: 33. >3..33.oz 333 wN c033 .03_o mN c033 .0mc3o> .0330: 00 0m< ..0330E 30 0mm >3 .>u._0u.oe u:0m:. 0:0 mmmuu.m.m 0_3mh 143 children born to mothers with one child and those born to older mothers. where the differences between low and middle SES groups disap- pear. The largest differences in the percentage of infant deaths occur between the low and high SES householders. which maintains the same pattern before and after controlling for the age of mother and number of children. W Mother's educational attainment level is inversely related to the incidence of infant mortality. Table 5.4 presents the relationship between mother's educa- tional attainment level and infant mortality. The table indicates that the incidence of infant deaths among children born to illiterate mothers is approximately eight times higher than among children born to high educated mothers and three times higher than among children born to low educated mothers. The values of chi-square and gamma indicate a significant strong inverse relationship between these two variables. The result of partitioning of chi-square shows that infant deaths differ significantly_between children born to illiterate mothers and children born to low and high educated mothers. but there is no significant difference between children born to low and high educated mothers. Although it seems that there is a significant relationship between mother's educational attainment level and infant mortality. we should ask whether this relationship is real or is actually attribut- able to an extraneous factor. There are possible explanations for this relationship. Perhaps this result occurred because of the association 144 Table 5.4.--Mother's educational level and infant mortality (in percent). Mother's Education Mortality Status Illiterate Low High Total (N=676) (N=427) (N=257) ‘ Survived 89.9 97.0 98.1 93.7 (N=l.274) Died 10.1 3.0 1.9 6.3 (N=86) Total 100.0 100.0 l00.0 100.0 (N=l.360) x2 = 31.99. df = 2. p > .001. G = -.58 The result of partitioning of chi-square: Illiterate-low = x2 = l8.9l. df = 1. p > .001 Illiterate-high = x2 = 17.04. df = 1. p > .001 Low-high = x2 = .76. df = 1. p = .60 between mother's education and SES. As Table 4.1 indicated. there was a significant positive relationship between SES and mother's education: Approximately 80% of the mothers in the low SES group are illiterate. compared to 44.8% among middle SES and 22.l% among high SES groups. Also. Table 5.1 indicated a significant inverse relationship between SES and infant mortality. Thus. by controlling SES we can determine whether or not SES has a significant contribution to this relationship. Since the older mothers had less education than the young mothers (r = -.35 [see Table BlJ). this may affect the relationship between these two variables. Finally. the number of children may interfere in the ll .lnilulll'l‘lll lllllll lIll.|lI I‘ll" 145 relationship. since the high educated mothers were expected to have fewer children than illiterate mothers (r = -»46 [see Table BlJL Table 5.5 shows the relationships between mother's educational attainment level and infant mortality while controlling for SES. Among children born to low SES householders. the results follow the expected pattern. The highest percentage of infant deaths occurred among chil- dren born to illiterate mothers (because there are only a few cases [2.2%] of the low SES with high educated mothers [Table 4.1]. the high and low categories were combinedL. The incidence of infant deaths among children born to illiterate mothers is approximately four times higher than among children born to low and high educated mothers. Among children born to middle SES householders. the table shows remarkable variation in the percentages of infant deaths. For example. the incidence of infant deaths among children born to illiterate moth- ers is approximately two times higher than among children born to low educated mothers and nine times higher than among children born to high educated mothers. Among children born to high SES householders. the table indicates that children born to illiterate mothers had a higher chance of infant death than children born to low or high educated mothers. However. the difference in the percentages of infant deaths among children born to low educated mothers is lower than among high educated mothers. One may speculate that the high educated mothers tend to hold Jobs outside the home. and among high SES families they tend to have maids who may take care of their infants. On the other hand. the 33.- u 3 ..33. u a .3 u .3 .33.3. . 3x .3.- a 3 .333. n a .3 u .3 .33.3. n x 33. u 3 .33. a a .. n .3 .33.. . 3x 1u46 3 3...-z. .3.3-... $3.15 .muoh 3.33. 3.33. 3.33. 3.33. .3303 3.03. 3.33. 3.33. .330» 3...: Gnu... 33qu 30.3 3.3 3.. 3.: 3.3. 30.3 m.c 3.3 3.3 30.3 A .315 33.15 833-5 30>.>.:m n.mm 3.3m m.mm 3.33 30>.>.:m m._a 3.33 ..33 3o>.>c:m ...... ...... ..33... ..3.. ..33. >3..nucot .3303 33.: 304 13.... >3..~ucoz .030» 3 33“: -3..__ >3..0u.0: co.umu:3m 0.00530: 0.33.: 303 mum .AucoULoa 3.. mum >3 .>u._oucoe 3305:. 3:0 _o>o_ _eco.umu:3o 3.30:30t11.m.m «_aah 1‘1].- iu'llI'lllI}. 'lllll'llllll‘ll.‘ "Illll'll 147 mothers with low education are more likely to be housewives and to take care of their own children. Taking into consideration the fact that most of the maids are not prepared to take care of infants. this may increase the risk of infant deaths. In Chapter IV it was found that the child-woman ratio is 2.37 among illiterate mothers. 2.06 among low educated mothers. and 1.80 among high educated mothers. This may lead one to ask whether the relationship found between mother's education and infant mortality will maintain the same pattern and strength when the number of children is controlled. Table 5.6 shows the relationship between mother's education and infant mortality after the number of children was controlled. The percentages of infant deaths among children born to mothers who had only one child during the past three years and born to illiterate mothers is two times higher than among children born to high and low educated mothers. The percentages of infant deaths among children born to mothers who had more than one child during the past three years was three times higher among children of illiterate mothers than among those born to low and high educated mothers. The correlation between mother's education and the age of the mother is -.35 (see Appendix 8). This may reflect the fact that girls' education is Saudi Arabia is. to some extent. a recent occurrence. In 1963 the total number'of elementary girls schools in the entire country was only 60 schools; the number increased to 552 schools in 1973 (Min- istry of Information. p. 43). Thus the younger the mother. the more 1&8 33. u 3 .33. v 3 .. u 33 .3.. a 3x 3x 33.- a 3 .33. A 3 .3 u 33 .33.33 a 3x .33.uz. .333..uz. 3.33. 3.33. 3.33. .3333 3.33. 3.33. 3.33. 3.33. .3333 ..3»:. .3332. 3.3. 3.3. ..3. 33.3 3.3 3.. 3.3 ..3 33.3 .3..uz. .33...uz. 3.33 3.33 3.33 33>..333 3.33 3.33 3.33 3.33 33>..333 .3333 .33uz. .mmuz. 33333 .3333 .333323 .333323 .333323 333333 33.: 3 233 333333.... 33..333oz 33.: 333 333333.... >3..33332 co.umu:3m 3.30330: om333 __mEm 3333..33 33 333332 .Aucoogoa 3.. 3033..3u 30 3035:: >3 ..0>o. .mco.umo:3o 3.303305 3cm >3..mu.os acmmc_-1.o.m 0.333 149 likely she is to have more education. Dealing with the relationship between mother's education and infant mortality. we should, control for the age of the mother in order to partial out the effect of this factor. Table 5.7 presents the relationship between mother's education and infant mortality. controlling for the age of the mother. Among children born to mothers younger than 29 years old. the incidence of infant deaths among children born to illiterate mothers is approxi- mately two times higher than among children born to low educated moth- ers and four times higher than among children born to high educated mothers. Among children born to mothers older than 29 years. the table indicates remarkable differences in the percentages of infant deaths. The incidence of infant deaths among children born to illiterate moth- ers is approximately nine times higher than among children born to low or high educated mothers. It can be concluded that mother's educational attainment level and infant mortality are significantly and negatively associated. The incidence of infant mortality among children born to illiterate mothers is remarkable higher than among children born to low and high educated mothers. After SES. number of children. and age of mother were con- trolled. the relationship maintained the same pattern found in the original table. However. the values of gamma differed among the cate- gories of controlling variables. When SES is controlled. it seems that the relationship between mother's education and infant mortality is stronger within the low SES group than within the middle and high SES 150 33.- u 3 ..33. m 3 .. u 33 .33.3. - 3x 33.- u 3 ..33. m 3 .3 a 33 .33.3. a 3x Anmmnzv Amwmnzv 3.33. 3.33. 3.33. .3333 3 33. 3.33. 3.33. 3.33. .3333 Ammuzv Amauzv 3.3 3. ..3. 33.3 3.3 3.3 3.3 3.3 33.3 Aomauzv .omnuzv 3.33 3.33 3.33 33>.>333 3.33 3.33 3.33 3.33 33>.>3=3 .3333 .33.uz. .333-23 333333! 3333 .333»:. .333323 .3.3-2. 333333 33.: 3 :33 333333..._ >3..33332 . 33.: :33 333333.... >3..333oz :o.umo:3u 3.30330: 33 3333 333.3 mN :03h 303::o> 30330: 3o om< .Auc00303 :.3 303305 3o 0mm >3 .>3..mucoe 3:03:. 3:0 .0>0. .mco.3mo:30 3.303uoz-.m.m 0.303 151 groups. When number of children is controlled. it seems that the relationship is stronger among those with a large number of children than those with only one child. Finally. when the age of the mother is controlled. a stronger relationship is found among older mothers than among younger mothers. ‘flypgth§§1§_3: Use of folk healing is positively related to the incidence of infant mortality. In Chapters I and II. types of folk healing in Saudi Arabia and how they may affect infant mortality were discussed. Here we examine the relationship between use of folk healing and infant mortality. Table 5.8 presents the relationship between use of folk healing in the treatment of infants and infant mortality. The table indicates that the incidence of infant deaths among children born to families that treat their infants with more than one type of folk healing is more than three times higher than among those who have never been treated with any type of folk healing. The values of chi-square and gamma indicate a strong positive relationship between use of folk healing and infant mortality. The result of partitioning of chi-square shows that the per- centage of infant mortality among householders who never used folk healing differs significantly from those who used one type or more of folk healing in the treatment of their infants. There is no signifi- cant difference between those who used only one type of folk healing and those who used more than one. 152 Table 5.8.--Use of folk healing in the treatment of infants and infant mortality (in percent). Folk Healing Use Mortality Never Used One Used More Status Used Type Than One Type Total (N=872) . (N=317) (N=l7l) Survived 96.l 91.2 86.0 93.7 (N=l.274) Died 3.9 8.8 14.0 6.3 (N=86) Total l00.0 100.0 100.0 100.0 (N=l.360) x2 = 29.19. df = 2. p > .001. G = .46 The result of partitioning of chi-square: Never used-used one type: X2 = ll.46. df = l. p > .Ol Never used-used more than one: X2 = 27.99. df = l. p > .001 Used one-used more than one: X = 3.16. df = l. p = .08 In Chapter II. it was assumed that SES and mother's educational attainment level will affect the parents' decision to treat their children with folk healing. The lower the SES and the less the educa- tion of the mother. the more likely they will be to seek the treatment of a folk healer. Tables 4.7 and 4.8 indicate a significant inverse association between SES and mother's educational level and use of folk healing. Another factor that may affect the relationship between use of folk healing and infant mortality is the age of the mother. The older mother is more likely than the young mother to trust folk healing and to treat her infants with folk remedies. Table Bl (Appendix B) 153 shows a significant positive relationship between age of mother and use of folk healing. To increaseeour understanding of the relationShip found between use of folk healing and infant mortality. these variables should be controlled. Table 5.9 presents the relationship between use of folk healing and infant mortality. The table shows that among children born to low SES householders there are remarkable differences in the percentage of infant deaths between those who never use folk healing and those who do use folk healing in the treatment of their infants. For example. while only 3.2% of those children who were never treated by folk healing died in their first year. 11.2% and 24.2% of those who had been treated by one type or more than one type of folk healing. respectively. died during the first year. Among children born to middle SES householders. it seems there are notable differences in the percentage of infant deaths among children who had never been treated with folk healing and those who had been treated with it. However. the differences among middle SES householders are less great than was found among low SES householders. Among children born to high SES householders. it seems hat the only notable differences in the percentage of infant death are between those who had used and those who had never used folk healing in the treatment of their infants. Table 5310 presents the relationship between use of folk heal- ing and infant mortality when the mother's education is controlled. Among children born to illiterate mothers. the findings indicate remarkable differences among those who never used. those who used one 1554 33. n 3 .3.. u 3 .3 . 33 .33.3 . 3x 33. . 3 .33. n 3 .3 . 33 .33.. . 3x 33. . 3 ..33. M 3 .. . 33 ..3.33 . 3x .3.3-z. .3.3323 .333.23 3.33. 3.33. 3.33. 3.33. .3333 3.33. 3.33. 3.33. 3.33. .3333 3.33. 3.33. 3.33. 3.33. .3333 .3..:. .33.2. .33.:. 3.3 3.3 3.3 3.3 33.3 3.3 3.3 3.3 3.3 33.3 3.3 3.33 3... 3.3 33.3 ..33-23 Acme-z. .333.:. 3.33 3.33 3.33 3.33 33>..333 3.33 3.33 3..3 3.3m 333...:3 3..3 3.33 3.33 3.33 333.3333 .3auzv ..3nz. .333.2. .33.:. .33..zv .333.2. .33.23 .3...z. .333.2. .3333 ”um3 “MM3 3333 333333 .3333 “um3 “MM3 3333 333333 .3333 “u“3 ”MM3 333: 333333 03o: 303: 30>0z >3__333o: 030: 303: 30>0z >u__3330t 030: 303: 30>0z >3._3u3o: 33..3o: ..33 3o 33: 33.: 3.33.: :33 333 .A330030a 3_v mum >3 .>3._3u3os 33333. 333 u:..303 3.0» no 03:--.m.m 0.333 155 33.- n 3 ..3. n 3 .. u 33 .33. n x .3. u 3 .33. u 3 .. u 33 .33. u x 33. u 3 ..33. M 3 .3 u 33 ..3.33 a 3x N N 33.3.3qu €3.15 33".: 0.00. 0.00. 0.0:. .0303 o.oo_ o.oo_ o.oo_ .0303 o.oo_ o.oo_ 0.00. 0.00. .0303 .muz: .m.uz. .33uzv m._ m._ o.~ 30.: o.m ~.m _.m 30.: _.c_ m.:~ ~.m_ o.m 30_: ANmNuzv A:_euzv Accouzv _.wm _.mm o.mm 30>w>3am 0.3m m.om m.wm 30>_>3:m m.mm m.m> n.3m o.mm 30>_>3:m Ammuz. .333uzv .33.uzv .333uzv .mmnzv .33hmzv Amoanzv 030: 30 030: 3c 0 >3 0 3 303: maumum 303: 333033 303: 3:303m 330 0: 330 . _ h 30“? 30>02 >3__03302 _ 3 MUM? 30>0z >u_.mugoz .0303 own“ “MM” WNW: 30>02 >u__33302 33..33: 3.33 33 333 :a_: 30: 033303___. com3mua3u 3.30:30: .A3c03303 c_v _0>0_ _0:o_3mu:30 3.305305 >3 .>3__333oa 3cm3c_ 3cm mam—m0: x_03 3o 03: nu.o_.m 0.333 156 type. and those who used more than one type of folk healing in the treatment of infants. The incidence of infant deaths among those who used more than one type of folk healing is more than twice as high as among those who used one type and approximately five times higher than among those who never used folk healing in the treatment of infants. While the relationship between these two variables seems to be signifi- cantly and highly correlated among illiterate mothers. among low and high educated mothers the relationship between use of folk healing and infant mortality seems to disappear. The difference in infant mortal- ity between those who used and those who did not use folk healing is less than 1%. It is difficult to assume that folk healing would affect the infant only among illiterate mothers because there is no logical reason to support this assumption. However. we can only speculate that these two groups of mothers may visit different types of folk healers. As discussed in Chapter I. there are two types of folk healers: those who treat their patients with cautery and herbal medicine and those who use magic and zar practices. Also. one can only speculate that the low and high educated mothers may seek modern medicine in addition to folk healing. This speculation can be partially supported by what was found in regard to the relationship between mother's education and the use of health facilities. which were significant and highly correlated (see Table 4.l5). Table 5.11 shows the relationship between use of folk healing and infant mortality when the age of the mother was controlled. The 157 mu. u o ..oo. A a .N n on .mm.m: u Nx _m. u a .mo. a a ._ u an .:N.: u Nx Anumuzv AmNmnzv o.oo_ o.oo_ o.oo_ o.oo_ _mu0h o.oo_ o.oo_ o.oc_ _muOP Aumuzv Amsuzv o.m m.m~ m.m 0.. oo_o m.m m.m o.: uo_o Aomsuzv Aomfiuzv o.mm _.om :._m o.mm co>_>czm ~.:m m._m a.mm uo>_>c:m Amwmzv A_mhmzv Ammuuzv A~:Msz A_mmuzv o h o h maumum mm b maumum _muOP one cock one cow: >u._mucoz _muoh boot to com: >u._mucoz co>oz . Lo>oz . coo: com: com: oco vow: mc__mo: x_om mo om: mu cosh Lou—o Locuoz wo om< mN cock Lomcao> .Aucoocoa c_v Locuos mo omm >3 .>u__mucoe ucm»c_ tam mc__moz x_0m mo oman-.__.m o_nmk 158 table shows that the incidence of infant deaths among children born to young mothers (less than 29 years old) who used folk healing in the treatment of infants is approximately two times higher than among children born to householders who never used folk healing in the treat- ment of infants. The values of chi-square and gamma indicate a sig- nificant positive relationship. The table also shows the relationship between these two variables among children born to older mothers (29 years or older). The table indicates remarkable differences in the percentages of infant deaths among those who used and those who never used folk healing in the treatment of infants. The values of chi- square and gamma indicate a significant strong relationship between these two variables among children born to older mothers. Table 5.l2 indicates the relationship between use of folk healing and infant mortality after the number of children is con- trolled. The table shows that among children born to mothers who had less than two children in the past three years. the incidence of infant deaths among children born to householders who used more than one type of folk healing in the treatment of infants is two times higher than among those who used only one type and approximately four times higher than among those who never used folk healing. The values of chi-square and gamma indicate a significant positive relationship between these two variables among mothers with a small number of children. The table also shows the relationship between use of folk healing and infant mortality among children born to mothers who had more than two children during the past three years. The table indicates remarkable 159 um. u o .e_o. u a .N u we .s~.m n «x sq. n a ..oo. m a .N u an .Nm.m_ n Nx Amm_nzv . Am-._uzv o.oo_ o.oc_ o.oc_ o.co_ _moop o.oc. o.oo_ o.oo_ o.oo_ _muoh A_~nzv Amwuzv o.m_ m.mm _.mm m.m eo_o m.m ~.~_ m.m :.m uo_a A:__uzv . Aom_._uzv :.:w n.oo m.m~ :._m eo>m>csm ~.:m m.nm «.mm 0.0m no>_>c:m Amhmzv Ammmzv A_muzv Ammhmzv AmNMMzV A_m~uzv o h o h magnum o b o h maumum _mHOh oco cmch oco cwww: >u__mucoz _mu0h one cock oco cwww: >u__mucoz ego: com: com: 2 who: com: com: 2 mc__ma: x_ou to 0.: omen; __mEm cotn__;u co Lassa: .Aucoocoa c_v coco—_co mo consac >3 .>u__mucoe ucmw:_ ocm mc__mo£ x_0w mo Omsuu.~_.m o_nmh 160 differences in the incidence of infant deaths between children born to householders who used and those who never used folk healing. The values of chi-square and gamma indicate a significant and strong posi- tive relationship between infant mortality and use of folk healing in the treatment of infants. It can be concluded that infant mortality and use of folk healing are significantly and positively associated. The high inci- dence of infant deaths is aSsociated with the use of folk healing. but when other variables are controlled. the strength of the relationship seems to differ among the control-variable categories but maintains the same direction. An exception is with mother‘s education. where the relationship between use of folk healing and infant mortality is very strong among illiterate mothers but is nonexistent among low and high educated mothers. .Hypgthesls_4: Use of health facilities is inversely related to the incidence of infant mortality. In Chapter I. we discussed the effect of modern medicine in reducing infant mortality. especially the role of modern medicine in the areas of delivery. care of premature»infants. vaccines. and the reduction of diseases of infancy. It was assumed that people with high use of health facilities would have fewer infant deaths than those with low use of such facilities. It was also assumed that use of health facilities would be influenced by other variables. mainly socioeconomic status. as presented in Table Bl (Appendix B). which indicates a strong relationship between use of health facilities and SES. 161 Table S.l3 presents the relationship between use of health facilities and infant mortality. It seems that the incidence of infant mortality among those with low use of health facilities is more than two times higher than among those with high use of health facilities. The values of chi-square and gamma indicate a significant. moderately inverse relationship between use of health facilities and infant mor- tality. The result of partitioning of chi-square shows that infant mortality among householders who made high use of health facilities differs significantly from that among householders who made average or low use of health facilities. There was no significant difference in infant mortality between householders who made average use and low use of health facilities. While the relationship between these two variables.seems to exist. we should ask whether this relationship is real or whether it occurs as a result of the intercorrelation with other variables. mainly SES. age of mother. and number of children. Table 5.14 presents the relationship between use of health facilities and infant mortality after controlling for SES. The table shows that among children born to low SES householders. the relationship was not as expected. While the percentage of infant deaths among children born to families with low use of health facilities is 8.6%. it is 9.0% among average users and 734% among high users of health facilities. Thus it seems there is only a small difference among these categories. The values of chi- square and gamma indicate the absence of a relationship between use of health facilities and infant mortality among children born to low SES 162 Table S.l3.--Use of health facilities and infant mortality (in percent). Use of Health Facilities Mortality Status Low Average High Total (N=l40) (N=592) (N=628) Survived 89.3 92.6 95.7 98.7 (N=l.274) Died l0.7 7.4 4.3 6.3 (N=86) Total l00.0 l00.0 l00.0 l00.0 (N=l.360) x2 = 10.13. df = 2. p = .006. G = -.30 The result of partitioning of chi-square: Low-average: x2 = 1.65. df = 1. p = .20 Low-high: x2 = 9.07. df = 1. p > .01 Average-high: x2 = 5.58. df = 1. p > .02 householders. Among children born to middle SES householders. there is a large difference in the percentages of infant deaths among use-of- health-facilities categories. The incidence of infant deaths among children born to householders with low use of health facilities is more than two times higher than among average users and three times higher than among high users of health facilities. The values of chi-square and gamma indicate a significant inverse relationship between the use of health facilities and infant mortality. Among children born to high SES householders. the incidence of infant deaths among children born to householders with average and low use of health facilities is more than 1153 o:.- u u .mo. a a ._ u on .m.: u Nx sm.- u o .moo. n a .N u an .ms.m n Nx oo.- u o .nm. . a .~ . cu .NN. u Nx Asosuzv Am_muzv Am~snzv o.oo_ o.oo_ o.oo_ _muo» o.co_ o.oo_ o.oo_ _moo» o.oo_ o.oo_ o.oo_ o.oo_ _mso» Am_uzv Ammuzv Aomuzv N.” s.~ o.¢ uo_o m.s 3.0 0.5. ep_a m.m s.“ o.m 0.» v0.9 Ammmuzv Asmsazv Ammmuzv m.em c.5m o.sm np>_>.=w «.mm «.mm o.mm up>_>.sm o._m o.~m o._m s._m vp>_>.=m AmmNan Ama_nzv magnum _mUOP 3m_: ommco>< >u__muco: A_m~nzv A_-uzv A>auzv msumum 3m_: ommLo><. 303 >u__mucot ANN—«2v ANNNIzv A_muzv maumum _muoh 3m_z ommco>< 303 >u__mucoz mo_u__mumu 3u_oo: he on: ;o_: p_cu_z mum .AacoUcma c_v mum >3 .>u__Mucoa ucmuc_ asp .p_o_._ucc ;s_pp; co pm:--.:..m «_pph 164 two times higher than among householders with high use of health facil- ities. The values of chi-square and gamma indicate a significant inverse relationship between use of health facilities and infant mor- tality. While the relationship between use of health facilities and infant mortality was found to be significant and fairly strong among middle and high SES householders. the relationship disappeared among children born to low SES householders. More than one assumption can be made in regard to the disappearance of the relationship between use of health facilities and infant mortality. It is possible that this result is due to the relationship between use of folk healing and infant mortality. Thus. to determine whether folk healing has anything to do with this result. we should control for the effect of folk healing. As presented in Table S.lS. among those who never used folk healing in the treatment of infants the percentage of infant deaths among children born to householders with low use of health facilities is approximately four times higher than among children born to house- holders with high use of health facilities. However. among children born to householders who used folk healing in the treatment of infants. the relationship between infant mortality and use of health facilities seems to be very weak and in the opposite direction of what was found among those who never used folk healing. The differences between these two groups cannot be attributed totally to the direct effect of folk healing. Rather. one might speculate that those who use folk healing are generally uncertain about the usefulness of modern medicine. Thus I65 mo. " a 50“.. n D nN III. WU «@No u NX J:ol In C some I Q aN ' Wt .MoN u Nx Aw~_nzv Amawuzv o.oo_ o.oo_ o.oo_ o.oo_ _mHOP o.oo_ o.oo_ o.oo_ o.oo_ _muOP Ammuzv Amuzv >.m_ 0.3. N.>_ z... vo_o ~.m 3.. _.m m.o 30.3 Aom_nzv AmmNuzv m.:m 0.:w w.~w 3.mw vo>_>czm w.mm 3.wm m.mm m.mm to>_>c=m Ammnz Ammuzv Ammuzv maumum A~>uzv Am~_uzv Amanzv msumum _muOh 3m_zv ommco>< 303 >u__mucoz _mHOH 3m_: ommco>< 303 >u__mucoz mo_u___omm 3u_mo: mo pm: wow: tom: co>oz mc__mpx x_oa to om: .Aucoocoa :_v mc__moc x_0m wo om: >3 .mcoc_03om303 mum so. chEm >um_mucos ucmwc_ 3cm mo_um__omm 33_mo3 mo om: 11.m_.m 0.3mh 166 they might abuse the medication prescribed by the physician by not following his directions concerning how and when to give their infants the prescribed medications. Table 5.16 presents the relationships between use of health facilities and infant mortality. controlling for the age of the mother. The table shows that. among children born to young mothers (29 years and youngerh. the incidence of infant mortality is approximately two times higher among householders with low use of health facilities than among householders with high use of health facilities. Among children born to older mothers (29 years and olderd. the percentage of infant deaths among householders with low use of health facilities is four times higher than among householders with high use of health facili- ties. Table 5.17 presents the relationship between use of health facilities and infant mortality. controlling for the number of child- ren. The table shows that among children born to mothers with one child the incidence of infant deaths among householders with low and average use of health facilities is approximately two times higher than among householders with high use of health facilities. The table also shows that among householders who had more than one child during the past three years. the incidence of infant mortality among those with low use of health facilities is approximately two times higher than among those with high use of health facilities. 167 ms.- u u ...o. u a .N u we .om.m u Nx o~.- n o .o_. u a .N u an .mm.m n Nx ANNmuzv Amuwuzv o.oo_ 0.00. 0.00. o.oo_ _mHOP o.oo_ o.oo_ o.oo_ o.oo_ _m30h Aumnzv 333123 o.> 3.N _.m w.o_ vo_a w.m w.: _.m 3.0. no_o Aomsnzv Aomuuzv o.mm :.>m m.om ~.mw 3o>_>cam ~.:m N.mm m.mm :.mw vo>_>cam —mHOP Amw—flzv A30Nflzv Aamuzv maumum —muo Amm:flzv AmNmIZV Amonzv maumum 303: ommco>< 3o3 >u__mucoz h 3m_: ommco>< 303 >u__mucoz mp_u___uma ;u_mp= to pm: mN cage .pu_o Locuox mo om< mm cmch comcso> .AucouLoa :33 cozuos mo 0mm >3 .>u__mucoe ucmwc_ 3cm mo_u___omm 33_m03 mo om211.m_.m o_3mh 168 _~.- 1 a .mo. v a ._ u on .mm. 1 ~x _m.- n a .mc. A a .N u we .m.o_ n Nx Amm_uzv AmN~._uzv o.oo_ o.oo_ o.oo_ _muoh o.oo_ o.oo_ c.oo_ o.oo_ _muoh 3_~123 Amonzv 3.m_ m... ~.>_ no_3 m.m w.m w.m m.o_ uo_o A:__uzv Aoo_._u23 :.:m _.mm w.~m no>_>czm >.:m ~.3m ~.:m ..mm vo>_>cam Amsuzv Ammuzv maumum Ammmuzv AONmuzv Am__uzv maumam _muOP 3mm: ommco>< w 303 >u__mucoz _mHOP 3mm: ommco>< 303 >u__mugoz mp_u___uma ;u_pp= to pm: omcm3 __msm cpcu__;u co Luggaz .Aucoocoa c_v coho—330 $0 3035:: >3 .>u__mucoe acmmcm 3cm m0_u___umm 33.003 mo om=11.>_.m 0.3mh ‘1." [ll lllllilll|li|llll l'lllll .Il'll' {I 169 ’In conclusion. the results in the preceding tables confirm the expected relationship between use of health facilities and infant mortality. except for low SES householders. HUDQIh§§15353 Housing quality is inversely related to the inci- dence of infant mortality. In Chapter II. it was mentioned that the quality of housing may affect infant mortality. It was also assumed that the quality of housing would be affected by the househol der's socioeconomic status. The higher the socioeconomic status. the higher the quality of housing. It was assumed that children born to householders living in low quality housing would be exposed to a higher risk of infant mortality than infants born to householders living in high quality housing. Table 5.18 illustrates the relationship between quality of housing and infant mortality. The table shows dramatic differences in the percentage of infant deaths. The incidence of infant deaths among children born to householders living in low quality housing is approxi- mately three times higher than that among householders living in high quality housing and two times higher than among those born to house- holders living in average quality housing. The values of chi-square and gamma indicate a significant inverse relationship between quality of housing and infant mortality. The result of partitioning of chi- square shows that infant mortality among children born to householders living in low quality housing differs significantly from those living in average and high quality housing. There was no significant 170 difference in infant mortality between children born to householders living in high and average quality housing. Table 5.l8.--Ouality of housing and infant mortality (in percent). Quality of Housing Mortality Status Low Average High Total (N=582) (N=416) (N=362) Survived 90.5 95.4 96.7 93.7 (N=l.274) Died 9.5 4.6 3.3 6.3 (N=86) Total 100.0 100.0 100.0 100.0 (N=l.360) x2 = 17.30. df = 2. p = .0002. G = -.39 The result of partitioning of chi-square:: 8.43. df = l. p > .01 12.74. df l > .01 0799 df : .45 Low-average: X2 Low-high: X Average-high: X2 "'0 = 9 l: P While the relationship between these two variables seems to be significant. we should ask whether or not this relationship will main- tain the same pattern when SES is controlled. It is already known that householders in the high SES group are more likely to live in low housing density than those in the low SES group are (Table 4.3) and are more likely to live in villas. whereas the low SES householders are more likely to live in clay or block houses (Table 4.4). Thus it is 171 important to control for SES in order to clarify the relationship between quality of housing and infant mortality. Table 5.19 illustrates the relationship between quality of housing and infant mortality after controlling socioeconomic status. The table indicates that among low SES householders the incidence of infant mortality among children born to householders living in low quality housing is approximately two times higher than among children born to householders living in high quality housing. Among middle SES householders. the percentage of infant deaths is higher among house- holders living in low quality housing than among householders living in average and high quality housing. And among children born to high SES householders. the differences in infant deaths among housing categories seem to be larger than what was found among low and middle SES groups. The incidence of infant deaths among householders living in low quality housing is more than three times higher than among those living in high quality housing. and two times higher than among householders living in average quality housing. It seems that quality of housing and infant mortality are negatively associated. When SES was controlled for. the relationship maintained a similar pattern to the one found before the elaboration of the relationship. fiypgthg51§_§: Artificial feeding is positively related to the incidence of infant mortality. A large number of studies have indicated that artificially fed infants experience higher mortality risks than breast-fed infants. In Chapter 1. how the type of feeding may affect infant mortality was 1372 ms.- a u .no. a Q .~ u on .m~.m . «x -.- a a .oo. . a .~ u 30 .om.m . ~x N~.. - a .ma. n a .~ n on .33.. . ~x 33.3.23 3m_m.z3 Am~3nzv o.oo_ o.oo_- c.oo_ c.oo_ _poo» o.cc_ o.oo_ o.oo_ o.oo_ _auo» o.oo_ o.oo. o.oo_ o.oc. _auoh Am_uzv Ammuzv awn-=3 w.m ~.~ ~.m 3.5 uu_a ~.o ~.m m.: m.m up.a m.o o.: _.o o.m up.a A_osuz3 3:33.23 Amamuz3 3.3m c.5m n.3m ~.~m up>_>.=m m.mm n.3m “.mm _.om uo>_>csm m._m 3.3a «.mm 3.0m op>_>.=m Aumwnzv Aum~lzv Ansuzv mauoum .30.F 30_: ommco>< 303 >33_mucot Ame-:23 A__lev Amolev maumum .030h 3m_: ommeo>< 303 >uw_mucot “mm-:3 Ana-23 3~cnuzv maueum .030» 3a.: omogo>< 303 >u_.o330t mc_m:o: uo >u__m:d ;m_: 0.00.: mum 303 .Aucooeoa any mum >3 .>u__oucos enema. use mc_m303 mo >u__m:doa.m_.m 0.3mh 173 discussed. Table 5.20 illustrates the relationships between type of feeding and infant mortality. The table indicates that infant mortal- ity among artificially fed infants is approximately three times higher than among breast-fed infants. The values of chi-square and gamma. indicate a significant strong relationship between type of feeding and infant mortality. Table S.20.--Infant mortality and type of feeding (in percent). Type of Feeding Mortality Breast Artificially Total Status Fed Fed (N=595) (N=416) Survived 96.5 89.9 93.8 (N=948) Died 3.5 10.1 6.2 (N=63) Total 100.0 100.0 100.0 (N=l.Oll) x2 = 16.96. df = 1. p > .0001. G = .51 While there is a significant association between type of feed- ing and infant mortality. we should ask whether or not this relation- ship will maintain the same pattern for different socioeconomic and demographic groupings. Knodel (1977) pointed out that "the effect of breast feeding on infant mortality risks depends on the'nutritional quality of substitute foods as well as the sanitary conditions 174 surrounding artificial feeding and the overall health condition of the infant's environment" (p. 395). It is possible that high SES house- holders may choose higher quality substitute foods for their infants than low SES householders do. that educated mothers may follow the right methods in preparing the artificial milk more than illiterate mothers do. and that people living in high quality housing would have a more appropriate environment for preparing artificial milk than people living in low quality housing. To determine whether these factors will affect the relationship between type of feeding and infant mortality. the results presented in Table 5.20 were elaborated by controlling for SES. mother's education. and quality of housing. Table 5.21 presents the relationship between type of feeding and infant mortality. controlling for SES. The table shows that among low SES householders the incidence of infant deaths among children who were artificially fed is four times higher than among children who were breast fed. Among middle and high SES householders. the incidence of infant deaths among children who were artificially fed is more than two times higher than among children who were breast fed. Table 5.21 shows that the differences in the percentage of infant deaths between artifi- cially fed and breast-fed infants are higher among low SES than among middle and high SES householders. Table 5.22 presents the relationship between type of feeding and infant mortality. controlling for mother's education. The table indicates that among children born to illiterate mothers. the incidence of infant deaths among children who were artificially fed is more than 1 1 Ill. .l ‘11!) 111111 ||11. I. 1|..||" jlllll1 J1.‘ 175 as. u u ._o. A a ._ n we .mm.o u ~x 53. n o ..oo. u a ._ a cu .om.o_ u x N AMONWZV AwOMWZV o.oo_ o.oo_ o.oo_ _muoh o.oo_ o.oo_ o.oo_ .6663 Ammnzv Aquuzv m.m m.m m.m 00_n m.> o.m_ o.m 00_o Aaomnzv A3mNuzv m.sm ~.om _.om up>_>35m ~.~m 5.3m, c.5m up>_>tsm _muop Akwwuz3 3_wwwzv magnum _moop Aowwuzv Awwwmzv maumum >__p_u_c_u.< umpptm >6__mu.oz >__p_6_c_uc< omppcm >63_mucox mc_uoom mo on>h ;m_= 6cm p_ue_z 363 mum .Aucoocoo :_v mum >3 .>u__mucoe acmwc_ 0cm mcmuoom mo oa>huu._~.m 0.3mh m_. u u_.om. n a ._ u on .mN. u x mm. n a ..oco. N a ._ n ca .mo.~_ u x 176 N N A>_mnzv Aqmauz3 o.oo_ o.oo_ o.oo_ _muoh o.oo_ o.oo_ o.oo_ _mHOF Am_uzv Aomuzv m.~ o.m ~.~ 30_o _.o_ >.m_ o.m co_o Asomuzv Aasquzv m.mm o.>m w.~m 30>3>cam m.mm m.mm o.mm 30>3>cam ..3.”... .0. ..3.”... ..3.. >__m_o_w_uc< ummocm u__mucot >__m_o_m_uc< ammocm 3.. 3302 mc_voou mo oa>h topmoaumucm31 0:0 -303 oumLou___. co_umonvw m.cocuoz .Aucoocoa :33 _0>o_ _mco_umoauo m.cosuoe >3 .>um_mucoe 330033 0cm mc_uoom mo oa>hnu.-.m 0.3mh 177 three ti mes higher than among children who were breast fed. Among children born to mothers with low and high education. the difference in infant mortality between artificially fed children and breast-fed children is very small. The results may reflect the awareness of educated mothers about adequate methods of preparing substitute foods for their infants. Table 5.23 elaborates the relationship between type of feeding and infant mortality by controlling for the quality of housing. The table indicates that among children living in low quality housing. there is a significant difference in infant mortality between arti- ficially fed and breast—fed infants. The incidence of infant deaths among artificially fed children is four times higher than among breast- fed children. While the difference in infant deaths between artifici- ally fed and breast-fed infants seems to be significant and strong in the case of low quality housing. the difference between these two groups drops sharply among those living in average and high quality housing. Thus. the results of this study in regard to the relationship between type of feeding and infant mortality confirm. to some extent. Knodel's statement. As we saw. the differences between artificially fed and breast fed infants become strong and significant only among children born to low SES householders. low educated mothers. and those living in low quality housing. but these differences become less clear among other groups. 178 mo. u 3 .ms. u a ._ n we .mm. n Nx me. u c ..ooo. m a ._ n we .Nm.o_ u Nx Ammmuzv A~aanzv o.oo_ ,o.oo_ o.oo_ _muOk o.oo_ o.oo_ o.oo_ .030? Aswuz3 Ammuzv ~.: m.m m.m 3033 m.m >.:_ _.m eo_o Amamuzv Amoanzv w.mm >.:m _.mm 00>_>L:m N._m m.mw m.3m 00>3>Lam Amm_nzv A_>muzv maumum Am_~nzv Aamuuzv maumum _muOh com com _muOP com com >__m_o_w_uc< ummOLm >u__mucoz >u__mucoz >__m_u_c_uc< ummptm mcmcoou mo oa>k 3m_: cu ommco>< >u__m:d mc3mao: 30.— .Aucuucog c_3 >33_mao mc_m:oz >3 .>3__mocoe Hemm:_ 3cm m:_3oow mo oa>bun.m~.m o_3mh 179 .flypgjhesis_l: Number of children is positively related to the incidence of infant mortality. In Chapter I. the mechanisms of how number of children may affect infant mortality were discussed. Table 4.18(.showed a dramatic increase in infant mortality among families having four children or more during the past six years. In this section. we will emphasize the relationship between number of children born during the past three years and infant mortality. Although we do not have data about birth interval. the number of children born during the past three years may roughly indicate the birth interval. A child born to a mother with two or more births during the past three years is expected to have a lower birth interval than a child born to a mother with no previous births during this period. Table 5.24 illustrates the relationship between number of children and infant mortality. The table indicates a dramatic increase in infant mortality as the number of children increases. 'The incidence of infant deaths among children born to mothers who had three children during the past three years is more than six times higher than among children born to mothers who had only one child; and approximately two times higher than among children born to mothers who had two children. The values of chi-square and gamma indicate a significant strong rela- tionship between these two variables. The result of partitioning of chi-square indicates that infant mortality differs significantly among those children born to a mother who had one child. two children. and three children during the past three years. While the relationship between number of children born 180 during the past three years and infant mortality is significant and very strong. we should ask whether or not this relationship will main- tain a similar pattern for different socioeconomic and demographic groupings--more precisely. whether SES. mother's education. and age of the mother will influence the patterns of the relationship between number of children and infant mortality. Table 5.24.--Number of children and infant mortality (in percent). Number of Children Mortality Status One Two Three Total (N=621) (N=604) (N=135) Survived 97.7 91.6 84.4 93.7 (N=10274) Died 2.3 8.4 15.6 6.3 (N=86) Total 100.0 100.0 100.0 100.0 (N=l.360) x2 = 40.43. df = 2. p > .001. G = .57 The result of the partitioning of chi-square: One child-two children: X2 One child-three children: X2 Two children-three children: X2 22.84: df 1: P > .001 44.17: df 1: p > .001 6.33. df = 1. p > .05 Table 5.25 elaborates the relationship between number of child- ren and infant mortality among low. middle. and high SES householders. 1181 om. . u .moo. M a .N . cu ..m.~_ . Nx om. . 3 ..oo. M a .~ . cu .Nm.¢_ . Nx ~m. . u .moo. m 3 .~ . cu .m~.~_ . Nx 33.3.23 Aa3muzv Anus-23 o.oo_ o.oc_ o.oo_ o.oo_ .666» o.oo_ o.oo_ o.oo_ o.oo_ .6663 o.oo_ o.oo_ o.oo_ o.oo_ .666» Am_.23 Ammnzv Aemuz3 o.n a.~_ n.: s._ uo_o “.3 o.m_ m.» ~.~ no.3 m.a c.s_ m... m.~ 603a 3_os.z3 Asmsuz3 Amanuz3 3.3m ~.sm “.mm m.»« uo>_>aam m.nm 3..3 ~._m n.5m uo>.>c:m m._m ~.mo “.mo m.>m vo>_>.:m Amnlzv Ann—I23 ammulzv maumum Aualzv Aamwlzv Am~ulzv magnum Aamlzv A~_~Izv “mm—lav magnum pouch 0033» 03» 03° >u__muco: .030h 0033» 03h 030 >uw_0ucox _muoh 0033p 03h 0:0 >u._mucot 30.0—_39 mo L3.3352 3a.: o_va_z :o3 mum .Auc0ocua :33 mum >3 .>u_.mucoe 3300:. 030 3033.330 00 303E:zuu.m~.m 0.30h 182 The table indicates that among children born to low SES householders the incidence of infant deaths among children born to mothers who had more than two children during the past three years is about six times higher than among those born to mothers who had only one birth. In this group. it seems that the infant mortality differences between those born to mothers who had two and those who had three 'births are small. Among children born to middle SES householders. the infant deaths among children born to mothers who had three children are seven times higher than among those bern to mothers who had only one child and approximately three times higher than among those born to mothers with two children. The relationship between number of children and infant mortality among high SES householders follows a similar pattern to that found among low and middle SES householders. Table 5.26 presents the relationship between number of children and infant mortality. controlling for mother's education. Among child- ren born to illiterate mothers. the incidence of infant deaths among mothers who had two children or more is approximately four times higher than among mothers who had only one child. However. the difference between those who had two and those who had three children is very small (2.2%). Among children born to low and high educated mothers. the incidence of infant deaths among mothers who had more»than two children is eight times higher than among mothers who had only one child but nearly the same as mothers who had two children. While the difference between mothers who had one child and those who had two children is very large among illiterate mothers 183 .0. u 0 ..00. M 6 .N u .6 .m~.0~ u Nx 00. u 0 ..00. m a .N n .6 .mm.- a ~x Acmmuzv Amumnzv 0.00. 0.00. 0.00. 0.00. .666. 0.00. 0.00. 0.00. 0.00. .666. .m.uzv .mwuzv 0.~ m... ..~ ... 06.0 ..0. ..0. 0.0. ..m 06.0 Aooenzv Amoouzv 0.>m >.mw m.>m m.mm 06>.>.:m m.mm m.mm ..0m m.mm 06>.>.0m _muOh ANcnzv Aowanv ANwmuzv maumum —mu0P Ammflzv AcNmflzv AmmNuzv mnumum 00.3H 03h 0:0 >u._0ucoz 00L3h 03h 03¢ >u__0uco: 06.6..00 .6 .60002 30.: 606 36. 30.000333 m..03uoz 666.66.... .Aucoucoa 3.3 _0>0_ _030.300300 m..03uos >3 .>u__0ucos 3300:. 0:0 30.0—.30 mo .03E:znu.oN.m 0.30h 184 (10.8%). among low and high educated mothers the difference between those who had one child and those who had two children is very small (only 0.4%). However. the difference between illiterate and educated mothers was least of all comparisons when they had more than two chil- dren. From the above discussion. it seems that infant mortality is significantly and strongly associated with number of children born during the last three years. The relationship between these variables maintained a similar pattern when SES and mother's education were controlled. W W In the preceding section. emphasis was placed on the relation- ships between various socioeconomic. health. and demographic factors and infant mortality in the past three years. Whether neonatal mortal- ity differs significantly among socioeconomic. health. and demographic groupings has not been discussed. Since the number of neonatal deaths during the past three years was very small (41 cases). it is difficult to control for the effects of other variables. Rather. we (will first present the chi-square and gamma values. and then partition the chi-square to determine whether neonatal mortality differs significantly between the categories of a given independent variable. Table 5.27 illustrates the relationship between SES and neo- natal mortality. The table indicates that neonatal mortality among 185 children born to low SES householders is two times higher than among children born to high SES householders. However. the difference between low and middle SES householders is less than 1%. The value of chi-square indicates that there is no significant difference in neo- natal mortality between SES groupings. but when the chi-square was partitioned. the only significant difference found was between the low and high SES groups. Table 5.27.--SES and neonatal mortality in the past three years (in percent). SES Mortality Status Low Middle High Total (N=425) (N=519) (N=4l6) Survived 96.0 96.9 ' 98.1 97.0 (N=l.319) Died 4.0 3.1 1.9 3.0 (N=4l) Total 100.0 100.0 100.0 100.0 (Nbl.360) x2 = 3.2. df = 2. p = .20. 0 = -.22 The result of partitioning of chi-square: Low-middle: X2 Low-high: x2 Middle-high: x2 .589 df = 19 P = .40 3.86: df 19 p .05 1.25: df 19 P .25 Table 5.28 illustrates the relationship between mother's educa- tion and neonatal mortality. It shows the incidence of neonatal deaths 186 among children born to illiterate mothers is three times higher than among children born to high educated mothers and more than two times higher than among children born to mothers with low education. The values.of chi-square and gamma indicate a significant strong rela- tionship between motherhs education and neonatal mortality. The results of partitioning of chi-square indicate that neonatal mortality among children born to illiterate mothers differs significantly from that among children born to low and high educated mothers. Also. there is no significant difference in neonatal mortality among infants born to low educated and to high educated mothers. Table 5.28.--Mother's educational level and neonatal mortality (in percent). Mother's Education Mortality Status Illiterate Low High Total (N=713) (N=436) (N=211) Survived 95.8 98.2 98.6 97.0 (N=l.319) Died 4.2 1.8 1.4 3.0 (N=41) Total 100.0 100.0 100.0 100.0 (N=l.360) x2 = 7.5. df = 2. p > .05. e = -.40 The result of partitioning of chi-square: Illiterate-low: x2 = 4.77. df = 1. p = .05 Illiterate-high: X2 = 3.87. df = l. p = .05 Low-high: x2 = .15. df = 1. p = .70 187 Table 5429 presents the relationship between quality of housing and neonatal mortality. The table shows small differences between housing groups. The value of chi-square does not indicate significant differences. Even after the chi-square was partitioned. there is no significant difference in neonatal mortality between housing groups. Table 5.29.--0uality of housing and neonatal mortality (in percent). Quality of Housing Mortality Status Low Average High Total (N=582) (N=416) (N=362) Survived 96.2 97.4 97.8 97.0 (N=l.319) Died 3.8 2.6 2.2 3.0 (N=4l) Total 100.0 100.0 100.0 100.0 (N=l.360) X2 = 202’ df = 20 P = .40) G = -019 The result of partitioning of chi-square: .989 df = 19 P = .40 1.79: df = 1: P = .20 .15. df = 1. p = .70 Low-average: X2 Low-high: x2 Average-high: X2 Table 5.30 illustrates the relationship between use of health facilities and neonatal mortality. ‘The table shows little variation in the percentage of neonatal deaths among children born to householders making low use. average use. and high use of health facilities. The 188 value of chi-square does not indicate significant differences among these three groups. Even when chi-square is partitioned. the results do not indicate significant differences between those with low use and average use. nor between those with high use and low or average use of health facilities. Table 5.30.--Use of health facilities and neonatal mortality (in percent). Use of Health Facilities Mortality Status Low Average High Total (N=l40) (N=592) (N=628) Survived 95.7 96.6 97.6 97.0 (N=l.319) Died 4.3 3.4 2.4 3.0 (N=4l) Total 100.0 100.0 100.0 100.0 (N=l.360) x2 = 2.17. df = 2. p = .45. G = -.19 The result of partitioning of chi-square: Low-average: X2 = .28. df = l. p = .60 Low-high: x2 = 1.56. df = 1. p = .25 Average-high: X2 = 1.08. df = l. p = .30 Table 5.31 presents the relationship between use of folk heal- ing and neonatal mortality. The table indicates that the incidence of neonatal deaths among children born to householders who used folk healing in the treatment of their infants is three times higher than 189 among children born to parents who never used folk healing in the treatment of their infants. The values of chi-square and gamma indi- cate a strong significant relationship between use of folk healing and neonatal mortality. The results of partitioning of chi-square show that the percentage of neonatal deaths among children born to parents who never used folk healing in the treatment of their infants differs significantly from that among children born to parents who use one type or more than one type of folk healing. Also. the results show no significant difference between those who used only one type and those who use more than one type of folk healing. Table 5.31.--Use of folk healing and neonatal mortality (in percent). Use of Folk Healing Mortality Used Used More Status Never One Than One Total Used Type Type (N=872) (N=3l7) (N=l7l) Survived 98.3 94.6 94.7 97.0 (N=l.319) Died 1.7 5.4 5.3 3.0 (N=4l) Total 100.0 100.0 100.0 100.0 (N=l.360) x2 = 13.8. df = 2. p = .001. 0 = .44 The result of partitioning of chi-square: Never used folk healing-used one type: X2 = 11.80. df = l. p = .001 Never used folk healing-used more than one type: X = 8.04. df = l. p > .01 Used one type-used more than one type: X2 = .001. df = l. p = .97 190 The results in Table 5.32 show that the highest percentage of neonatal deaths occurred to children who were artificially fed (5.3%). compared to among children who were breast fed (2.3%). The values of chi-square and gamma indicate strong significant differences in neo- natal deaths between artificially fed and breast-fed infants. The results in Table 5.32 follow the expected pattern of relationships between type of feeding and neonatal mortality. Table 5.32.--Type of feeding and neonatal mortality (in percent). Type of Feeding Mortality Breast Artificially Status Fed Fed Total (N=533) (N=4l9) Survived 97.7 94.7 96.5 (N=919) Died 2.3 5.3 3.5 (N=33) Total 100.0 100.0 100.0 (N=952) X = 6.40 df = 1' P > .05: G = 644 The results in Table 5.33 show that the highest percentage of neonatal deaths occurred to children born to mothers who had three children during the past three years. The second highest percentage of neonatal deaths occurred to children born to mothers who had two child- ren. and the lowest percentage occurred to children born to mothers who 191 had only one birth during the past three years. The values of chi- square and gamma indicate a strong significant relationship between number of children and neonatal mortality. ‘The results of partitioning of chi-square show that the percentage of neonatal deaths among mothers who had three children during the past three years was significantly different from the percentage of deaths among those who had one or those who had two children. There was no significant difference between those who had one and those who had two children. Table 5.33.--Number of children and neonatal mortality (in percent). Number of Children Mortality - Status One Two Three Total (N=634) (N=599) (N=127) Survived 98.1 96.8 92.1 97.0 (N=l.319) Died 1.9 3.2 7.9 3.0 (N=4l) Total 100.0 100.0 100.0 100.0 (N=l.360) x2 = 14.01. df = 2. p = .001. G = .39 ‘The results of partitioning of chi-square: One child-two children: X2 = 2.30. p = .15 One child-three children: x2 = 13.40. p = .001 Two children-three children: X2 = 6.03. p = .02 192 0.1.5.615st The investigation of socioeconomic. health. and demographic factors indicates that the differences among householders on these factors were significantly associated with the percentage of neonatal and infant deaths. Mother's educational attainment level is the strongest factor associated with neonatal and infant mortality. The results of the examination of mother's education show that mother's education is associated negatively with those factors that are posi- tively associated with infant and neonatal mortality. such as high use of folk healing. low use of health facilities. and large number of children; it is positively associated with those factors that are negatively associated with neonatal and infantlnortality. In other words. educated mothers use health facilities more than illiterate mothers do. and use folk healing in the treatment of their infants less than illiterate mothers do. Although no relationship was found between type of feeding and mother's education (r = -.05. Table Bl). the rel a- tionship between type of feeding and infant mortality is found to be influenced by mother's education. While the rel ationship between type of feeding and infant mortality among illiterate mothers shows a sig- nificant difference in infant deaths between artificially fed infants and breast-fed infants. the differences decrease sharply among children born to low and high educated mothers. This result may reflect the greater understanding and awareness on the part of educated mothers about the optimal methods of preparing artificial milk. A mother who can read is expected to follow the directions for artificial milk 193 preparation and to use the exact mixture of water and artificial milk. This simple procedure is very complicated for illiterate mothers. who cannot read the label on the artificial milk. Mother's education also influences the relationship between number of children and infant mortality. except when the educated and illiterate mothers had more than two children. When they had two children. the percentage of infant deaths among illiterate mothers was much higher than among low and high educated mothers. The householders' socioeconomic status shows significant dif- ferences in the percentage of infant and neonatal mortality. Children born to low SES householders experience higher infant and neonatal deaths than children born to high SES householders. The results also show that SES is associated negatively with those factors that are positively associated with infant mortality and positively associated with those factors that are negatively associated with infant mortal- ity. In other words. high SES householders are found to use health facilities more. to live in higher quality housing. and to have fewer children than low SES householders. SES (as measured by income and father's education) influences the infant's chance of survival through the father's awareness of the infant's basic needs and the ability to provide them. The high SES householders not only will be more likely to use the available health facilities in the treatment of their infants. but also they are expected to make better use of these facili- ties. by following the advice of their physician. The examination of the relationship between the use of health facilities and infant 194 mortality reveals an important issue. The results indicate that among high and middle SES householders there are significant differences in infant deaths between those who make low use and those who make high use of health facilities. While the relationship between use of health facilities and infant mortality among middle and high SES householders follows the expected pattern. among low SES householders the relation- ship between these two variables shifts from the expected pattern. and only slight. unsystematic differences occur among low. average. and high use of health facilities. When the low SES householders are divided into two groups. those who never use and those who use folk healing in the treatment of their infants. the relationship between use of health facilities and infant mortality shows that among those who never use folk healing the relationship between use of health facili- ties and infant mortality follows the expected pattern. The results reveal dramatic differences in infant deaths between children born to householders who make little use and those born to householders who make high use of health facilities. Among those householders who use folk healing in the treatment of infants. the relationship between use of health facilities and infant mortality does not show the expected pattern. Instead. the householders who make little use of health facilities have fewer infant deaths than those with average and high use of health facilities. This result may reflect misuse of modern medicine by this group. which instead of helping to increase the infant's chance of survival becomes a factor in decreasing the child's chance of survival. 195 The examination of housing quality shows that differential housing quality is significantly associated with infant mortality. Children born to householders living in low quality housing experience higher infant deaths than those born to householders living in average and high quality housing. The elaboration of this relationship shows that even in situations that stimulate high infant deaths. the quality of housing plays an important role. For example. among illiterate mothers. the infant deaths for children living in low quality housing are twice the number for those living in average and high quality housing. Also. dramatic variations in infant deaths occur when low SES householders live in low quality housing and those living in average and high quality housing are compared. When the relationship between type of feeding and infant mortality is investigated. the housing quality appears to influence this relationship. Among children living in low quality housing the artificially fed infants differ'signifi- cantly from those who are breast fed. Among those living in average and high quality housing. the difference in infant deaths between artificially fed infants and breast-fed infants decreases sharply. With regard to type of feeding. large differences in infant deaths are found between artificially fed and breast-fed infants in low SES householders. illiterate mothers. and those living in low quality housing. Howewer. the difference in infant deaths becomes less obvious among middle and high SES groups. low and high educated mothers. and those living in average and high quality housing. One may speculate that low quality housing is an inadequate environment for preparing 196 artificial milk for infants. For example. a clay house is a more adequate environment for the growth of flies and other insects that may contaminate the feeding bottle: low SES householders may select cheaper and low quality substitute foods which may result in inadequate nutri- tion: and illiterate mothers. even with the absence of the other stim- uli. may influence the quality of the substitute foods by not following the appropriate method of preparation. To our knowledge no attempt has been made in previous studies to determine the relationship between infant mortality and general mortality and the use of folk healing. For the reasons previously discussed (see Chapter I). it was assumed that infant mortality is positively associated with the use of folk healing. The examination of use of folk healing indicates that differences between householders in the use of folk healing are significantly associated with infant and neonatal mortality. In general. the householders who used folk healing in the treatment of infants experience a higher percentage of infant deaths than those who never use folk healing. The comparison of the relationships between socioeconomic. health. and demographic factors and infant mortality on one hand and neonatal mortality on the other hand reveals that. in general. these factors are more strongly associated with infant mortality than with neonatal mortality. Finally. attitudes toward health facilities and attitudes toward folk healing and infant mortality are found not 197 strongly associated (Tables B8 and B9). Attitudes toward modern medi- cine are found to associate significantly with infant mortality (Table B10). CHAPTER V I CONCLUSIONS. POLICY RECOMMENDATIONS. AND SUGGESTIONS FOR FURTHER STUDY .InILQdusilnn This study has attempted to shed some light on infant mortality trends and differentials in Riyadh. Saudi Arabia. It also brought to the reader's attention some factors that have been ignored in previous investigations of infant mortality in developing countries. namely the use of folk healing. In this chapter. we will first summarize the major findings of this study. including the relationships between infant and neonatal mortality and various socioeconomic. health. and demographic factors; and infant mortality trends in Riyadh. Finally. based on the findings of this study. policy recommendations and suggestions for further study will be discussed. Wound WW Among the socioeconomic factors assumed to affect infant mor- tality. it was hypothesized that SES. mother's education. and housing quality all would be inversely related to the incidence of infant mortality. The findings support the hypothesis that SES is inversely 198 199 related to infant mortality. Children born to low SES householders experienced the highest percentage of infant death. while children born to high SES householders had the lowest percentage'of infant deaths. SES was found also to inversely relate to neonatal mortality. Mother's educational attainment level is the variable most clearly and significantly associated with both neonatal and infant mortality. Children born to illiterate mothers experienced the highest percentage of infant and neonatal deaths. whereas children born to the highly educated mothers experienced the lowest percentage of infant and neonatal deaths. This result supports the hypothesis which holds that mother's educational attainment level is inversely related to infant mortality. Finally. the quality of housing. as expected. was found to be significantly and inversely related to infant mortality. Children living in low quality housing had the highest percentage of infant deaths. while those living in high quality housing had the lowest rates. Although the quality of housing was inversely related to neo- natal mortality. the relationship was not statistically significant. 115W W mm It was hypothesized that use of folk healing is positively related to infant mortality. The analysis reveals a significant posi- tive relationship between use of folk healing and infant and neonatal mortality. Children born to householders who never use folk healing had the lowest percentage of infant and neonatal deaths. whereas those born to householders who use more than one type of folk healing in the 200 treatment of infants had the highest percentage of infant and neonatal deaths. In general. the findings support the hypothesis that use of health facilities is inversely related to infant mortality. Children born to householders who made little use of health facilities experi- enced the highest percentage of infant deaths. while children born to householders who made high use of health facilities experienced the lowest percentage of infant deaths. Although the use of health facili- ties was found to be inversely related to neonatal mortality. the relationship was not statistically significant. MW: 30W The analysis shows significant differences in infant and neo- natal deaths between artificially fed and breast-fed infants. Children who were artificially fed had the highest incidence of infant and neonatal death. while those who were breast fed had the lowest percent- age of infant as well as neonatal deaths. This result supports the hypothesis that artificial feeding is positively related to infant mortality. W W The number of children born during the past three years was found to be significantly related to the incidence of infant and neo- natal mortality. Children born to mothers who had more than two child- ren during the last three years experienced the highest incidence of 201 infant and neonatal deaths. Conversely. the incidence of neonatal and infant mortality was the lowest among children born to mothers who had only one child during the past three years. W011 In 1963. Chu estimated the infant mortality rate in Riyadh at 251 per 1.000 live births or 25.1%. The Manfohah Environmental Sanita- tion Demonstration Center estimated infant mortality in Manfohah (now one of Riyadh's districts) at 267 per 1.000 (26.7%). Comparing these estimations with the figures derived from the present study. it appears that infant mortality declined from 25.1% to 9.6%. or by about one- third. in this lB-year period. During the periods examined in this study. the percentage of infants dying declined from 9.6% for all children ever born. to 6.7% for all children born during the past six years. to 6.3% for all children born during the past three»years. Although the difference between the percentages of infants dying in the past six years and in the past three years is very small. the largest decline is noted in the percentage of mortality for all children ever born and for those born during the past six years. Although there has been a remarkable reduc- tion in infant mortality for Riyadh as a whole. the gap between various SES groups is still large. For example. while the difference in infant mortality between low and high SES householders during the whole retro- spective period was 4.8 percent. the difference between the two groups during the past six years was 5.0 percent. Also. the patterns in 202 reduction of infant mortality show the same differences for other factors. Although this study"s estimation of infant mortality for Riyadh probably may be applied to other Saudi cities such as Macca. Al Madeenah. and Dammanu it cannot.be.applied to rural areas of the country. in which higher infant mortality levels may be expected. EQJJSLBsmmmendaflons Infant mortality is the result of various factors. some of which were examined in this study. However. writing policy recommenda- tions is a very perplexing assignment because of the discrepancy between the realm of reality and the realm of the ideal. between what can be done and what should be done. It is important to realize that any attempt to reduce infant mortality is a societal project. which must be recognized as important by the members of the society and its established organizations. if it is to be successful. Indeed. govern- mental effort alone will not bring about significant changes in infant mortality unless these efforts are accompanied by recognition and effort on the part of the people. Thus the recommendations offered are applicable to everyone who may affect the life of an infant: the mother. the father. the physician. the governmental agents. the school. and other social organizations. especially women's societies. Based on the results of this study. the following recommendations are suggested as important steps that should be taken into consideration in any attempt to reduce infant mortality in Riyadh in particular and in Saudi Arabia in general. 203 l. The lack of reliable information related to infant mortal- ity and mortality in general in Saudi Arabia is well-recognized by the United Nations. as well as by other agencies and individuals interested in population studies. To reduce infant mortality in Saudi Arabia. it is necessary to establish a better understanding of the mortality conditions and to identify determinants. especially the causes of death among infants. as well as in other age groups. Such a knowledge base is.only possible through an effective vital registration system and well-organized national surveys. Questions related to infant mortality should be secured in an appropriately sized sample in the population census. A national survey is often needed to correct the deficiencies in mortality data. Such a survey might be expected to reveal important information about the leading causes of death and determinants of mortality. which should help the health authorities as well as indi- viduals to take the necessary action. Also. such information is very important in evaluating health projects and in making further policy decisions. as well as in influencing habits. customs. life style. and other factors that may affect the individual's health. A complete and accurate registration system is important not only to an understanding of mortality and fertility conditions. but it is also essential for development planning for every element of the society. It is vital for policy makers to have information on popula- tion elements. structure. and growth in order to plan effectively. Although the Royal Decree concerning birth and death registrations 204 (Appendix C) was introduced 22 years ago. a large number of births and deaths are still underregistered. To improve the vital registration system. registration procedures should be simple and within the grasp of the people. This can be achieved by involving more than one govern- mental agent in the system. For example. the local public hospitals and the heads of the zones (Am'dah) can provide people in their areas with birth and death certificates. 2. The results of this study indicate the important influence of the mother's educational attainment level on infant mortality. During the past three years. infant mortality among illiterate mothers was approximately five times higher than it was among mothers with a high level of education. Any attempt to reduce infant mortality in Saudi Arabia should take into account the large number of illiterate mothers in the country. This study indicates that approximately half of the mothers in the sample were illiterate (Appendix B). The mother is the primary individual who can change the level of infant mortality. and any improvement in her health. education. and knowledge should bring about a reduction in the infant mortality level. Thus. the enlightenment of mothers about modern infant care and treatment through the mass media. school curricula. and lectures is an important step toward reducing infant mortality. Women's societies have an important role in this educational process. although there are only a few such groups in Saudi Arabia and their objectives are very limited. Expanding the number of women's societies and their objectives is one promising way of organizing 205 efforts to increase mothers' awareness of optimal methods of child care. Such awareness. in turn. should reduce the infant mortality level. Women's societies also can play an important role in dealing with the effects of illiteracy on infant and child mortality by organ- izing workshops dealing with various topics aimed at improving the household environment. the family"s diet. infant and child care. health problems in infancy. and pregnant women's health in an understandable and practical way. 3. The departure from breast feeding to artificial feeding is an unhealthy phenomenon spreading throughout the Saudi Arabian society in both urban and rural locales. As Sebai's (1981) study indicated. more than 33% of infants in one of the rural areas he studied were fed powdered milk. The findings from the present study show that approxi- mately one-third of the mothers in the sample never breast fed any of their children (Appendix B). In addition to the low quality of pow- dered milk. it is more likely to be subject to contamination during preparation. especially in inadequate environments. As a previous study conducted in Saudi Arabia (Oasim region) indicated. many mothers were ignorant about artificial-feeding practice in terms of food prepa- ration and use (Abdula. 1982). This study indicates large differences in infant mortality between mothers who breast fed all of their chil- dren and those who artificially fed all of their children. Infant mortality was approximately three times higher among mothers who arti- ficially fed all of their children. Thus. in order to reduce the infant mortality level. a movement back to breast feeding should be 206 encouraged. Many individuals and organizations can contribute a great deal to a return to breast feeding. Physicians in general and pedia- tricians in particular can make a valuable contribution to this change. Through direct contact with parents. they are in a position to show the advantages of breast feeding. and in cases in which breast feeding is not possible. the physicians'iassistants should explain to mothers the optimal method of preparing the artificial milk for their infants. Governmental agencies such as the Ministry of Health and the Ministry of Education. as well as social Organizations such as women's socie- ties. can play a role in changing women's attitudes toward breast feeding through efforts to increase mothers' awareness of the impor- tance and advantages of breast feeding. 4. Although modern medicine is. to some extent. widely avail- able in Saudi Arabia. especially in large cities such as Riyadh. and public hospitals provide medical services free of charge. some people still use folk healing. whose usefulness or harmfulness has not yet been investigated in depth. Approximately 36% of the respondents in this study admitted that they use at least one type of folk healing in the treatment of their infants. Our study indicates a high incidence of infant mortality among families who use folk healing in the treat- ment of their infants. Scientific investigation of folk healing is an important step in understanding the different aspects of folk healing on which offi- cial regulations can be made. Some types of folk healing are no more than jugglery. which should be prohibited. In the meantime. families 207 should be aware of the risks involved in using folk healing in the treatment of their infants. 5. Low SES families in our study exhibit a high incidence of infant mortality--approximately 50% higher than among high SES fami- lies. Although economic factors play an important role in the differ- ences in infant mortality levels between low and high SES families. other factors are also involved that are related to socioeconomic status. The sharp difference between low and high socioeconomic status involves differences in life style. attitudes. awareness. and knowl- edge. which contribute to differences in infant mortality. To reduce infant mortality. it is necessary to identify the target population. namely those with low socioeconomic status. as this study indicated. For example. infant mortality among families living in low quality housing was approximately three times higher than among families living in high quality housing. Thus. improving the economic. health. environmental. and social aspects of low SES families is an important step toward reducing the infant mortality level among this group and. in turn. could reduce the infant mortality level for the entire country. 6. The findings of this study showed large differences in the infant mortality level among the various districts of Riyadh. The infant mortality levels in the southern and central districts were approximately 50% higher than in the northern districts. Thus. to reduce the infant mortality level. the following recommendations are suggested. 208 a. Additional maternal and child clinics should be established in the southern and central districts. To make these clinics more effective. it is necessary to divide the city into health areas. assigning a given population to a particular clinic and maintaining a health file on each mother and child. This procedure would make health services more effective because physicians would become more familiar with the physical condition of their patients through reviewing their files and knowing the past health history. including the kinds of medications used. In addition. this procedure would save the physi- cians time and allow them to spend more time with their patients. A large amount of money would also be saved on medications given by public hospitals because this procedure would. to some extent. control the movement from one physician to another who prescribes medications without asking whether or not the patient is already on medication. In many cases.,especially among illiterate and poorly educated parents. a child will be taken to a physician. and if the child does not feel better after one or two days. that child will be taken to another physician. who usually prescribes different medications. If the child still shows no improvement. the parents may move to a third and even a fourth physician. Such practices waste the physicians' time and medi- cation and may cause serious problems arising from complications due to the medications. b. The objectives of maternal and child clinics should be extended to include health education and enlightenment. Some of the problems that affect the quality of health services in Saudi Arabia are 209 associated with lack of awareness and knowledge. especially among less educated people. in regard to medicine and illness. Thus. parents should be provided with general information about their children's health and treatment. including medication and how it should be used. In addition. parents should be provided with information regarding infant care before. during. and after birth. This information should include the pregnant woman's diet and the feeding of the infant. W The need for further investigations of infant mortality in Saudi Arabia is obvious. as the present study demonstrates. The infant mortality figures provided previously by various sources are important in giving a rough estimation of the infant mortality level in Saudi Arabia. However. what is more important is an understanding of the relationships between infant mortality and various factors. In addi- tion to an understanding of the patterns and structure of infant mor- tality. an understanding of which factors contribute most to the level of infant mortality should be identified in future research. Such an understanding will reveal information that will facilitate intervention by policy makers and health authorities. Although an attempt was made in this study to include as many of the fiactors affecting infant mortality as possible. many factors that would benefit an understanding of infant mortality were not included. However. the following suggestions should be taken into consideration in future research on infant mortality in order to 210 achieve an optimal information base on which to attempt to reduce infant mortality. It is important for any future study of infant mortality to involve as many governmental agencies and social organizations as possible. in order to help maximize the quality and quantity of desired data. For example. cooperation with private and public hospitals may allow the researcher to obtain information in regard to birth weight and causes of death if available. or to cooperate with the physicians to collect such information. Female colleges. female nursing schools. and women's societies may help provide female interviewers who can obtain valuable information directly from female respondents that can- not be obtained through male respondents. Future investigations of infant mortality in Saudi Arabia should obtain data on the current incidence of infant mortality. This will demand a large sample size. but it is worthwhile t01nake such annual estimates because relying only on retrospective questions may be affected by respondents' failure to recall some events especially those that occurred long ago. The relationship between infant mortality and use of folk healing was explored in this study. Our findings point to a consistent and significant relationship between infant mortality and use of folk healing. Future studies of infant mortality in Saudi Arabia and in developing countries in general should investigate in depth the effects of the use of folk healing on infant mortality. including the type of 211 folk healing used. the morbidity status of infants. previous treatment by modern medicine. and how folk healing may affect infant mortality. The findings of our study raised an important issue in regard to the relationship between use of health facilities and infant mortal- ity. Future studies of infant mortality in Saudi Arabia should inves- tigate in depth the use of health facilities in relation to infant mortality. Since the abuse of medication may occur. especially among poorly educated people. the kinds and frequency of medications given to infants should be investigated. Such information may lead to plans for correcting this possible problem. Also. understanding existing precon- ceptions about medications and drugs may reveal important information that health authorities could use in their attempts to spread health enlightenment. Future studies of infant mortality in Saudi Arabia should include rural areas. Such a procedure would allow an understanding of infant mortality in these areas. as well as the differences and simi- larities between urban and rural areas in relation to various socio- economic. health. demographic. and environmental factors. In addition. infant mortality estimates obtained by such studies are needed to give a more accurate and current level of infant mortality for the whole country. Such information can be compared to previous estimates and projections made by the United Nations. Also. such studies should reveal important data in regard to the effeCtiveness of health services in rural areas. The inclusion of nomads in such investigations would reveal important information in regard to infant mortality problems 212 among nomadic peoples.~ In addition. it would strengthen the accuracy of infant mortality estimates for the whole country. Future research of infant mortality should investigate the effects of the mother's diet during pregnancy on infant mortality. It would also be worthwhile to investigate. in addition to type of feed- ing. the introduction of solid foods and other types of foods to infants. Finally. it would also be important to investigate the rela- tionship between infant mortality and mother's knowledge and under- standing of infant care. APPENDICES 213 APPENDIX A INTERVIEW QUESTIONS 2111 215 INTERVIEW QUESTIONS AS SUBMITTED IN ARABIC v/ ‘ 'u v . C‘PWIMLQ .. .4 t t I ’0 Area No. Mosque No. F. Id. No. 0313820113,..131331JL3L3131L‘913...-10113.5()... .51-3.11 3.139131; UGAIQU/ ) 9551.11.03! 0005113001331 .5141 :.6_1 DQfiLIoWI_I 06;..11013341_2 0961“}10g3.._3 DbU-laLQLII_4 deiogiis..._5 Ibffiwou 0511:1115,» 6,1,L4, F113;.39101MQJ.4131_2 ?wul.<11_.31 1:11.. (p.61.T 0,1,1. ...-1...: 01.23pm 0,1,1. r"'-2 031.954.901.93 ren—3 D 1.4" 30.4: 0.1.14? 3.1—4 06515914506.14~1‘31-s enmiflflqsigofisumm13.4.301011133J3_3 5.1.31 011.0,..-1 Ub»Jlb,4,b..2 DeflszadIb,$_-ifi_3 030094-4 UéfigIdfidfibb—J—f) oljujlgwcgullngwulww.3wg_4 S'ZpUI UJSIfiZZja—l DJEJRJIW3_2 0536333413.: 03;.fuujupd..i_4 anfi‘Li-JaflI—S 216 Coding Column u: ............. I‘JkiféwU'HQUGJJIW5kJ"b-5 DL_.JI:_I 0009136-: 000,0Iua6_3 DEW—4 DIHI_5 Twadhgémué‘flwfifl'dfilgybb36 - Ugh-I 0009136-: 000,913-; 02315-4 DI._J_5 16: ............. 00013463031Incwkyi.0,u,mz_.3,y_7 £31.31 .0050 10.12. J-JI 70.31 03533.": DEA—3-2. 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I31 331431414150133LWIJIA-50L3w3-” n.» so” use; ..4 Did-12.3“:I-' 05—551-: 01151003-: DJJCI_4, 0310“,;JCI_5 figulfl3,013.95“.13154w,,3ly.31-xs Coding Column ......... 218 93.15.23.344!” 03.13531,I_1 05451-2 011503.333 03J131_4 03.0JJCI_5 ngawaoigsLuutgujwuum OWEN—l GHQ-2 BIKE-33-3 005,131..4 03.1.1.3,01_5 aiuwgylyHIWJwfilyqeuuH37 SBQZMQJKI3IJ?JJ,QI DWJ‘fi—l 03.50-: 010103.333 03,0134 031:..J'JCI_5 ?JL;>I,;3,.:., .3563'1365311 301-16 0:3..1365L1 _DHI,I_2 015103333 03301-4 033.0.yuI_s ?CM¢$335JILS¢UuLI-,é1353y_19 0151603-: 031-2 03...: scwgawyglucsylwwlyéi0si~p_2o 01516-3333 03-2 0‘.._.;_1 4.60.1-1 ngawlra.13_2n UIJ'LugJ33 01-2 0.36-1 cyan-«1. iriv-l' 2.091. Ci." ww‘ae‘ d» .k—22 010003-11 031-2 0.3.: It?!" 00131.1 .1 £51. 4 991 (...-...I J. _. 23 Coding Column 219 01.51603-3 051-2 0.3-1 09.330.033.416,.Quwwiyéldyy-24 015003-3 09-2 0.3-1 6...... 30101105101550 2.1.1.31 (J. 131.1,. 0.3.2191. - 25 90.1» 0161.03.3_3 031-2 0.35-.1 9000:0335, $.01 0111.91 surf-.26 I've ~33); ;v:4~"2;illdu1.§1.»‘.f-27 Try (.5), 4.9L“ QUYI 0‘ny a» ‘3’ .. 28 UV-2 DH'_I rr _r- 112.?! Jr—‘v‘ 1'“! 2.1.?! .351: 131 1.335425 4.1.1.” .5ny a» J _ 30 ('31., .6.. (31.11.01) 912;." 1.1. 0.101),. 01! .f _ 31 {...-1| U111611 “1.1.11 “0.11 9121.11 J‘U‘Jih“ TOTAL 001." JAM Cb“ 0.11:1! 9101.1”: . U D D D D 0»I,(£3~5|_1 0 D 0 0 D D bx\:_\_2 1:1 1:1 0 0 0 0 bfo-\O_3 1:1 1:1 0 c1 0 0 2.310,.1-1-4 0 0 0 1:1 0 1:1 3,;1-5 Ihfl‘pb—n SWVIJJM 0 0 0 0 0 0 ,5. 0 1:1 0 0 0 0 ”51 93.3111 cl.» .3. «J» w .51». .25.. J- _ as Coding Column 220 031-2 0.35-1 u_r::1:..\JIg,.:.Ir..-.¢6L¢\Jlulflfl 523111 01,0231 .1513...3;,;,,3111.1u»i11 wry-34 9:310 01,-... 0.11 0513.305), “11114;.111 01.1.01 3.3-35 01,310.05. 031013.633. 33010119101001.00-36 .1513 “01:34.91 3&0... 1,31! 001.91.33.13 ,5-37 ?$:\>' 1,11, @111 41212411 111-4,1 w 1.24.- $5192.25 11* _ 41 ‘ S'yul . D Y ...2 D 1"_'”.""l u — 11' 21.1.2311 4,4,1 Pg, 211,911.;46131 S'rn» OK "{..42 9,912, .1» (11121511) Jam 1.1. 01.21) ,2 .31! 1'! _ 43 9.2-.11 9121.11 W' J” 9121.11 Jul TOTAL 0.213.! cl," aw 9511.11 Jpn c1 1:1 1:1 1:1 0 1:1 (,3 3.2.1-1 :1 1:1 0 1:1 :1 1:1 1,311-1-2 n 0 1:1 1:1 :1 1:1 12,3111-1o-3 c1 c1 c1 c1 Dayan—4 a 1:1 13 1:1 1: 1:1 uygLs w?fib-“ 119121211122 :1 1: D 0 1:1 1:1 ,55 0 1:1 0 a 1:1 0 us? 12,2111 01,-... .5515! J»: 2,1,. gt. :4}, J‘ _ 45 D 31.- 2 D ...» _ 1 11 ..1-1 21:31 55,91 v4.2.3 24911;..311’ 131 92,2111 91,-... owl .Jvu fig :55, “$111 dubs" 2.1; 15 _ 46 <:2,.2111 01,-... mun .151,- 1*- 1.2.5), $211,;211 .JuL'YI 3.1:. r’ _ 47 92,11 91,1. 295151 .1»- ,9, 2:55, 3:111 .2611 .1121'v1 a.» ,r _ 4s 92,2111 91,1. 2:31:11 J»- 1,11, (£211 31121.1 a g? 9.1; J. _ 49 Coding Column 222 031-2 [Jr—25-1 0'1-.. Lfilgfiifiggfil .356 131 s'rgm all! J12»? a» VI.» $.56, .13 (Juwo J21." 1:1. 01.21)” .31! r! _ 51 2M“ W M M TOTAL .2111” 9!:qu .JN D D D fofi-‘i—l 0 1:1 :1 19:11-1..2 1:1 [3 c1 12,312-1o-3 :1 1:: D 2.3112,:11_4 1:1 1:1 1:1 2,3,;1_s flyb-52 9913131114. E] D D ,53.1 D U D 9211.2 99111122933'1wa 1611453,, .53 03'..2 DV—‘J'd 9/1_o: L§1gfiifigpfi1g1§1si 9ajjl|hbéyb_54 0&1-2 D;3_1 9.12H11hu,¢i_55 Dun-..J|Q_1 0.3.414_2 Qywlliarbvb_so Ely—2 Dr—fi—l 2&1NHW1IQQ32,§-57 Dgfy‘fwl,3f_l nguizwy;,_2 DEUGJJK2,_3 Daffy-..4 Coding Column 223 Dyiko313>cf2f_s 01.1.4-6 S'szlgydlg‘Jy-” D‘J_2 Elf—..6..: ox .JWIQPI ‘ y_,2,1?y1¢.;1{131 9 212,112.;J2u1 122,.‘o1r'rr-59 DrxJ‘Jfi-' Db): \1-\—2 Dbxm_\o_3 Uni-wxfi—4 ?'h¢fl}oé¢fl'o»r{_60 ?,¢1211.;5,11._§ 11:11 1:1. 4 ca $211,123.31)» 1” _61 ?2,11-J121,.2'v1¢11;.. ‘5; J2 _ 62 D v-0 0 rd—\ 386—1 u y_o D rd—\v—g)\aULi_2 1:1 v-0 0 ‘4—11944—3 :1 31.0 D -'—\ Judi—4 D v-0 D 1"5-‘ 13):“‘-5 (3.12.11 1.12 25111 2,2,; 921. _03 DbLe-gSL-_2 Dz}...1 UM‘vbwrflag-JH3 .M‘ybffl 0.54.3-4 S'flflrf—M Uc»\l\_yj‘_l UQYAJ‘ 11-2 DWYAJ‘Y\—3 DthJ'Y\-4 DwflAJ'tK—S U,,{i,i-..._o11_o 9A5‘dbzayb_65 0.3111114 2211 Coding Column 0 211$“, ;1,;11 4 21,15 2,5- 2 U QIQYI 3.31.41 (LEI_ 3 D al..-,1“ 3:1..fll (LEI_ 4 D :5wa 351.31 (51.. 5 D ,{1 ,1 2:91.11 2.1,.111 (121- a 98.99 ....... YgA—‘JIwayb_66 [31}ng YH-JJFI_ Dz-o-JJSIJIY-u_2 D1...JJ31311..._3 DA--~yjIJ11-u_4 u‘....&.y131,\..._5 D"°"&‘J5IJ"““—° nu...yJ;1JIn..._7 D1‘1n1yJiIJHt-1-—8 D1Ao-oyjIJ|n---_9 D;{I,IJL;, 111-”-10 100-101: ...... $3.13,», Job—67 Dyijw'wyyfiwx-l 031,1 21,125,12115... 045,513..3 021,124,311»- 011—1013;.»991511- D 1111‘ 2....151 MAIJxfi Jr— 136445;th J11...— bf'aI .114!" H 31- D JfI ._ 102: ........... ?-_"IdI-fgj.5j.—a,bb_68 0 2115.11, 21,2HJ21,.15 2,5- ' _‘LLLS'I ' MIJJ.” 1+;|_3 c121..,:112.1,.11211.1¢1_4 1:12,,1112..C1,.111g;1_5 0&1,12,.,u,12..1,.111.1.;1_o Coding Column um“ u-’u1-,,u1g Ah- 225 ?~'-L’-?:Jr‘r”—°9 Dumywi_1 Buy/131111-21 DQYAJIY‘—3 DJI,I¢.-Y\_4 91.51 2,:6 .1315 3.2.11 13' 5'11») 14454-15 gJ—"OL-J' w r5-70 S'wlaJIJaaA' 0,512;Jv5;{1,1;11,2;.-_1 01512;.1515'51,331o1,.c,1_2 Dylszwoy¢w_3 091.512,:53315'Jgfdli,-_4 DI4__,1_5 13.1,.“ Ingldjgglyfidd1_n UfTJfléfl131fl3-wg-I 'DgfIlg»Q_2 DSWZQ»E§_3 Dédl'IébIb}—4 DQALJIQ_5 :12st “14.15456257—6 €‘Jfl1:'_72 Do__.16_l D:L....a¢._.,_2 Ugrlocfi_3 02.2.2-4 LofiIC'LLéé‘y Ddf-I_S ¢L__J:i.>>b 226 INTERVIEW QUESTIONS Please answer the following questions by selecting the appropriate answers: 1. To what hospital do you usually take your young children for treatment? a. Public hospital b. Military hospital c. National Guard hOSpital d. Private hospital e. Other. please specify How well do you think the physicians in that hospital try to understand your young children's health problems? a. They try very hard b. They try to some degree c. They try slightly d. They don't try hard enough e. They don't try at all Do you think physicians in that hospital are helpful in relieving your young children's illness? a. Very helpful b. Somewhat helpful c. Slightly helpful d. Not helpful 6. Not helpful at all How many minutes do you think the physicians in that hospital spend with your young child during a routine visit? a. One minute or less b. Two to five minutes c. Six to ten minutes d. Eleven to fifteen minutes 9. More than fifteen minutes Do you usually take your infant to see the same doctor on each visit? a. Always b. Often c. Sometimes d. Seldom e. Never 10. 227 Does the physician usually discuss your young children's illness with you? a. Always b. Often c. Sometimes d. Seldom e. Never From your point of view and based on your experiences with that hospital. how do you evaluate the health services it provides to your young children? a. Excellent b. Very good c. Fair d. Poor e. Very poor In general. are you satisfied with that hospital's health services provided to your young children? a. Very satisfied b. Satisfied c. Slightly satisfied d. Dissatisfied e. Very dissatisfied How many of the physicians in that hospital do you trust for treating your young children? a. All of them b. Most of them c. Some of them d. Few of them e. None of them Do you think if you were to take your young children to another hospital that they would be treated a lot better than in the hospital to which you usually take them? a. Yes. certainly b. Yes. probably c. Maybe d. No. probably not e. No. certainly not The following statements deal with some attitudes and beliefs in regard to modern medicine and folk healing. Remember. there is no wrong or right answer. What you have to do is indicate whether you agree or disagree with each statement. 11. 12. A folk healer is able to cure most diseases. a. Strongly agree b. Agree c. Not sure d. Disagree e. Strongly disagree Modern medicines may harm people instead of curing them. a. Strongly agree b. Agree c. Not sure d. Disagree e. Strongly disagree l3. 14. 15. 16. I7. 18. 19. 20. 228 Vaccinating infants against some diseases can protect them against these diseases. a. Strongly agree b. Agree c. Not sure d. Disagree 9. Strongly disagree There is no risk at all when a woman gives birth at home if her mother or other relatives are present. a. Strongly agree b. Agree c. Not sure d. Disagree e. Strongly disagree It is necessary for all women to seek medical advice during pregnancy. even if they feel well. a. Strongly agree b. Agree c. Not sure d. Disagree e. Strongly disagree A physician may help a woman to deliver a healthy baby. a. Strongly agree b. Agree c. Not sure d. Disagree e. Strongly disagree There is no need for an infant to be physically examined by a physician during the infancy period if the infant is feeling well. a. Strongly agree b.» Agree c. Not sure d. Disagree e. Strongly disagree Folk healing is no more than Jugglery. a. Strongly agree b. Agree c. Not sure d. Disagree e. Strongly disagree Have you ever taken any of your young children to a folk healer for treatment? a. Yes b. No c. Not sure Have you ever taken any of your infants to a folk healer for treatment? a. Yes b. No c. Not sure 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 229 Have any of your young children ever been treated using cautery? a. Yes b. No c. Not sure Have any of your infants ever been treated by medication prepared by a folk healer? a. Yes b. No c. Not sure Have any of your infants ever been treated using cautery? a. Yes b. No c. Not sure Have any of your young children ever been treated using medication prepared by a folk healer? a. Yes D. No c. Not sure Have you ever bought medication from a pharmacy for treatment of your infants without a physician's prescription? a. Yes b. No c. Not sure How many children have you had in all? How many male children have you had in all? How many female children have you had in all? Have you lost any of your children? a. Yes b. No If yes. How many children have you lost? How old was/were the child(ren) when the childiren) died? lst 2nd 3rd 4th 5th 6th Child Child Child Child Child Child TOTAL a. Less than l day b. l-l4 days c. lS-28 days d. One to 2 months e. Two to 6 months f. Six to 12 months 9. One to 2 years h. More than 2 years 32. 33. 34. 35. 36. 37. 38. 39. 230 lst 2nd 3rd 4th 5th 6th Child Child Child Child Child Child TOTAL What was/were the sex(es) of the childiren)? Male _ _ Female ___. ___. :::: ___. ___. .__. ___. Have you had any children born during the past six years? a. Yes b. No If yes. How many children have you had during the past six years? How many male children have you had during the past six years? How many female children have you had during the past six years? How many of these children were breast fed during the early months? a. All of them were breast fed b. Most of them were breast fed c. Some of them were breast fed d. Few of them were breast fed e. All of them were artificially fed Where were these children born? a. All of them were born in a hospital b. Most of them were born in a hospital c. Some of them were born in a hospital d. Few of them were born in a hospital e. All of them were born at home How many of these children were vaccinated during the first year? a. All of them were vaccinated b. Most of them were vaccinated c. Some of them were vaccinated d. Few of them were vaccinated e. None of them were vaccinated 40. 41. 42. 43. 44. 45. 46. 47. 48. 231 In general. how often did you take that child(ren) to the hospital for a check-up during the first year? a. Once every four weeks b. Once every two months c. Once every three to six months d. Once during the first year 9. Never Have you lost any of your children who were born during the past six years? a. Yes b. No If yes. How many children have you lost during the past six years? How old was/were the child(ren) when the child(ren) died? lst 2nd 3rd 4th 5th Child Child Child Child Child TOTAL a. Less than l day b. l-l4 days c. l5-28 days d. 29 days to 1 year 6. More than l year ||||I l|||I |||I| ||I|| ||||| IIIII What was/were the sex(es) of the child(ren)? Mal e __ __ __ _._ __ __ Female ___. ___. ___. ___. ___. ___. Have you had any children born during the past three years? a. Yes D. No If yes. How many children have you had during the past three years? How many male children? How many female children? 49. 50. 51. 52. 53. 54. 55. 56. 232 Have you lost any of your children who were born during the past three years? a. Yes b. No If yes. How old was/were the child(ren) when the child(ren) died? lst 2nd 3rd Child Child Child Total a. Less than l day b. l-l4 days 0. 15-28 days d. 29 days to l year e. More than l year What was/were the sex(es) of the child(ren)? Male Female Have you had any children born during the past l2 months? a. Yes b. No If yes. What is the sex of this child? a. Male b. Female Where was he/she born? a. In a hospital b. At home Was he/she vaccinated? a. Yes b. No How often do you take that child to the hospital for a check-up? a. Once every two weeks b. Once every three weeks c. Once every four weeks d. Once every two months e. Once every three to six months f. Never 57. S8. 59. 60. 61. 62. 63. 64. 233 Is he/she still alive? a. Yes b. No If no. How old was he/she when he/she died? a. Less than one day b. One day to 14 days c. Fifteen to 28 days d. More than one month How many bedrooms are there in your house? How many persons presently live in this house? Do you have the following items in your house? a. Refrigerator 1 Yes 2 b. Washing machine 1 Yes 2 c. Air-conditioner 1 Yes 2 d. Television set 1 Yes 2 e. Telephone 1 Yes 2 What is the type of house ownership? a. Rented b. Private ownership c. Provided by the employer d. Other. please specify How old are you? a. Less than 18 years b. 19 to 28 years 3. 29 to 38 years d. 39 to 48 years e. 49 to 58 years f. 59 years or older What is your level of education? a. Illiterate b. Limited experience in reading and writing c. Elementary school completed d. Middle school completed e. High school completed f. College or higher-level education completed No No No No No 65. 66. 67. 68. 69. 234 What is your monthly income? a. b. c. d. e. f. g. h. J. Less than SR 2000 SR 4.000 to SR 8.000 SR 8.000 to SR 10.000 SR 10.000 to SR 12.000 SR 12.000 to SR 14.000 SR 14.000 to SR 16.000 SR 16.000 to SR 18.000 SR 18.000 or more What is your occupation? a. b. c. d. e. f. g. h. J. k. Governmental official. grade 14 or above Officer. Colonel or above Wholesaler Officer below the rank of Colonel Governmental official. grade 6-13 Governmental official. grade 5 or below Soldier Retailer Driver or unskilled worker Other. please specify What is your wife's level of education? a. b. c. d. e. f. How a. b. c. d. Illiterate Limited experience in reading and writing Elementary school completed Middle school completed High school completed College or higher-level education completed old is your wife? Less than 18 years 19 years to 28 years 29 years to 38 years 39 years or older During your wife's pregnancy. how often did she go to the hospital for a check-up? a. b. c. d. 6. Six times during the pregnancy Four times during the pregnancy Three to five times during the pregnancy One to two times during the pregnancy Never 70. 71. 235 Where did you live before you moved to this house? a. b. c. d. e. f. In the city of Riyadh but in another house In another city In a small town In a village In the desert Other. please specify Type of house? a. b. c. d. e. Villa Concrete house Clay house Apartment Other. please specify APPENDIX 8 ADDITIONAL TABLES 236 237 Table Bl.--Intercorrelation matrix among independent variables. Independent Variable 1 2 3 4 5 6 7 1 SES .. 2 Mother's education .48 .. 3 Age of mother -.11 -.35 .. 4 Use of health facilities .35 .40 -.22 .. 5 Quality of housing .52 .36 -.01 .27 .. 6 Proportion of arti- ficially fed infants -.09 -.04 -.01 -.02 .07 .. 7 Use of folk healing -.09 —.16 .14 -.11 -.11 .12 .. 8 Number of children -.23 -.47 .64 -.28 -.11 .05 .20 238 Table BZ.--Distribution of householders according to the type of folk healing used in the treatment of infants. Type of Folk Hea1ing Use of Folk Healing Folk Medicine Cautery Number Percent Number Percent Never used 1.048 88.7 945 80.0 Used 128 10.8 231 19.6 Not sure 5 .4 5 .4 Total 1.181 100.0 1.181 100.0 Table 83.--Distribution of mothers and fathers according to their educational level. Educational Mothers Fathers Level Number Percent Number Percent Illiterate 563 47.7 223 18.9 Limited experience in reading and writing 207 17.5 194 16.4 Elementary school 188 15.9 257 21.8 Middle school 117 9.9 191 16.2 High school 81 6.9 162 13.7 College or higher 23 1.9 154 13.0 Total 1.179 100.0 1.181 100.0 ‘ 239 Table B4.--Distribution of householders according to father's monthly income. Income in Saudi Riyals Number Percent Less than 2.000 66 5.6 2.000 to less than 4.000 423 ' 35.8 4.000 to less than 6.000 311 26.3 6.000 to less than 8.000 194 16.4 8.000 to less than 12.000 ' 82 6.9 12.000 to less than 14.000 57 4.8 14.000 to less than 16.000 15 1.3 16.000 to less than 18.000 7 .6 More than 18.000 26 2.2 Total 1.181 100.0 240 o.oo. 55... o.oo_ 55... o.oo. 55... o.oo. m5... o.oo_ 55... _muo5 m.m_ omu o.~ _m m.m o: 5.. ON o. 5 0: m.om 5.5 5.55 .5... ..mm .5... m.mm . mm... {.mm 05... mo» acouLom .oz acouLom .oz acoucom .02 5:66.05 .02 acouLom .oz oco;ao_oh co_m5>o_oh Loco_u_nc0u1u_< oc_;umz m:_;mm3 Leumcom_umom awmwmwwzo Emu. Loanm:0u .mEou5 Lusamcou uo amsmuoczo cu mc_ocouum moot—ocomao: 50 co_u:n_gum_oii.mm o_nmk 241 Table 86.--Percentage distribution of deceased children according to ages at death for the past six years. Age at Death Number Percent Under one day 32 18.9 One to fourteen days 29 17.5 Fifteen to twenty-eight days 24 14.2 Over 28 days _ 84 49.4 Total 169 100.0 Table B7.--Distribution of householders according to their infants' place of birth. Place of Birth Number Percent All born in hospital 790 66.9 Most of them born in hospital 109 9.2 Some of them born in hopsital 95 8.0 Few of them born in hospital 46 39.0 All of them born at home 141 11.9 Total 1.181 100.0 Table B8.--Re1ationship between attitudes toward health facilities and infant mortality during the last three years (in percent). Attitudes Toward Health Facilities Mortality Status Negative Neutral Positive Total (N=432) (N=639) (N=274) Survived 96.1 91.9 93.8 93.6 (N=l.259) Died 3.9 8.1 6.2 6.4 (N=86) Total 32.1 47.5 20.4 100.0 (N=l.345) x2 = 7.63. df = 2. p > .05. G = .16 Table B9.--Re1ationship between attitudes toward folk healing and infant mortality during the last three years (in percent). Attitudes Toward Folk Hea1ing Mortality Status Negative Neutral Positive Total (N=323) (N=668) (N=339) Survived 95.4 93.1 92.6 93.5 (N=12244) Died 4.6 6.9 7.4 6.5 (N=86) Total 24.3 50.2 25.5 1000.0 (N=l.330) k x2 = 2.43. df = 2. p = .29. G = .14 243 Table BlO.--Re1ationship between attitudes toward modern medicine and infant mortality during the last three years (in percent). Attitudes Toward Modern Medicine Mortality Status Negative Neutral Positive Total (N=432) (N=639) (N=274) Survived 89.3 94.7 97.3 93.7 (N=19274) Died 10.7 5.3 2.7 6.3 (N=86) Total 31.0 44.2 24.9 100.0 (N=l.360) x2 = 22.2. df = 2. p > .001. G = -.43 APPENDIX C REGULATIONS ON BIRTHS AND DEATHS REGISTRATIONS IN THE KINGDOM OF SAUDI ARABIA 21111 245 Regulations on Births and Deaths Registrations in the Kingdom of Saudi Arabia* In the Name of God Royal Decree Regulations on Births and Deaths No. 2 Date: 1-1-1382 H in the Kingdom of Saudi Arabia We. Saud Ben Abdul Aziz Al-Saud. King of the Kingdom of Saudi Arabia. Considering Articles 19 and 20 of the Regulations of the Council of Ministers issued by our Decree No. 38 of 22-10-1377 H. Pursuant to the decision of the Council of Ministers No. 11 date 4-1-1382 H. Considering the proposition of the Prime Minister. Doom 1. We ratify the regulations with respect to Births and Deaths as provided for in the text herewith attached. 2. These regulations cancel all provisions provided for in the previous regulations and decisions dealing with Births and Deaths. 3. The Prime Minister and the Minister of Health shall enforce our present Decree as soon as it is published in the Official Gazette. Royal Signature *Source: C. K. Chu. S. K. Djazar. and M. H. Adham (1963). 246 Births and Deaths Regulations No. 11 date 4-1-1382 H EaLLI .Binths .Antigla_1 - Births in the Kingdom of Saudi Arabia shall be notified within fifteen days with effect from the date of delivery. The notifi- cation shall be made on the specific form. AW - The notification shall be made to the Health Office of the locality where the delivery occurred. in case there is such an office. Otherwise it shall be made to the Administrative Governor. .Actlglg41 - Health offices or Administrative Governors (in the localities where health offices are not available). as well as the representatives of the Saudi Government abroad. shall be provided with registers for births registration. These registers shall be in two originals of the form specified by an arrete of the Minister of Health. They shall be paginated and pages shall bear the seal of the Ministry of Health. The registration shall be assumed by officials and persons assigned by arrete of the Minister of Health to this effect. jujflgfljLA - No blank spaces shall be left during the registration and no abbreviated words shall be used. ‘The dates shall be written in full. Any addendum. crossing-out. or rectification to be made during the registration. must be referred to in the margin. Such notes are to be ratified by the notifier and by the official in charge of the registration. Amjdglg_5 - Persons required to notify deliveries are: l - The father of the infant if present. 2 - Adult male relatives who attended the delivery. or the nearest female relatives to the infant. 3 - Adult male persons living in the same home with the mother. otherwise. the females. 4 - The administrative governor of the locality. 5 - Directors of institutions. i.e.. hospitals. maternities. prisons and quarantines with respect to deliveries which may have occurred in each of them. 247 None of the aforesaid categories shall be responsible for the notification. except in case of absence of any of the preceding categories. Notification could not be accepted from those who are not concerned. In all cases the physician or midwife shall notify the deliveries they carry out. to the Health Office within the period provided for in Article 1. However. the receipt of this notification does not suffice to record the event in the special register. .A11191§_6 - The notification shall comprise the following information: 1 - The day. date. time and place of birth. 2 - Sex. name and surname of the born. 3 - Names. surnames. nationality. religion. residence and profession of the parents. .A211g1§_1 - The official in charge of the registration in births register. shall draw up birth certificate on the form prepared to this purpose. and submit it. free of charge. to the notifier. The birth certificate includes the information provided for in Article 6. fimjfiglg_§ - If the born is dead before he has been registered. the official in charge of the registration shall record his birth and his death. But if he is still-born after the sixth month of pregnancy. he shall be recorded only in the register of deaths. .An1191e_2 - If a delivery occurred during travel. it shall be notified to the Health Office of the first Saudi port within fifteen days with effect from the date of arrival at this port. or to the representative of the Saudi Government in the locality of destination. .A111g1e_10 - The police stations in towns. the administrative governors in villages. the institutions and orphanages admitting new borns (foundlings). shall notify to the Health Office concerned. any new born found by or admitted in one of those institutions or orphanages. The . notification shall include the date and time at which the child has beam found or consigned and the name. surname. age. profession and resddence of the person who may have found or handed him. unless he refuses. as well as the sex of the child and his age according to the evaluation of the medical officer concerned. The official in charge of the registration shall denominate the child in full and then record him in the birth register without mentioning that he is a foundling. and he shall leave in blank the two columns provided for the parents. unless one of them submits an acknowledgement of his/her paternity to the infant. The column of residence is then to be filled in. 248 EaLLZ Deaths ‘A51191§_11 - Notification of deaths in the Kingdom of Saudi Arabia. including still-born after the sixth month of pregnancy. whether the death is pre-natal or during the delivery. shall be made on the special form. to the Health Office in the locality where the death occurred. should such an office exist. Otherwise. the notification shall be made to the administrative governor of the locality within twenty-four hours from the time at which the death occurred or [was] confirmed. fimjugflgL12_- Health Offices. the Administrative Governors in the localities where there are no health offices. as well as representa- tives of the Saudi Government abroad. shall be provided with registers for death recording. These registers shall be in two originals of the form specified by an arrete of the Minister of Health. They shall be paginated and the pages shall bear the seal of the Ministry of Health. The registration shall be assumed by officials and persons assigned by arrete of the Minister of Health to this respect. .ALIlQl§_L1‘- No blank spaces shall be left during the registration and no abbreviated words are to be used. 'The dates shall be written in full. Any addendum. crossing-out or rectification to be made during the registration. must be referred to in the margin. Such notes are to be ratified by the notifier and by the official in charge of the registration. fluidsflgLJA - Persons required to notify deaths are: 1. Parents. ascendants. husbands or wives of the deceased. 2. Adult male relatives who attended the death. otherwise. the nearest female relative to the deceased. 3. Adult male persons living in the same home with the deceased. otherwise the females if the death occurred at home. 4. The administrative governor of the locality. 5. The medical officer or the health officer required to confirm the death. 6. The owner of the place. its manager or the person in charge of its management. if the death occurred in a hospital. a nursing home. an Institution. a hotel. a school. a camp. a prison or any other place. 311's includes the "Mutawefin" (Pilgrims guides) in case of deaths among grims. 249 Notification could not be accepted from persons other than those required to do so. None of the aforesaid categories shall be respon- sible for the notification. except in case of absence of any of the preceding categories. £flfld£fl£LlE.- The notification shall comprise the following information: 1. The day. date. time and place of death. 2. The name. surname. sex. nationality. religion and profession of the deceased. 3. Age. place and date of birth and residence of the deceased. 4. Names. surnames of his/her father and mother. if they were known to the notifier. .ALIinfi_l§ - The official in charge of death registration shall draw up a copy of the record on the special form and issue it free of charge. in the same day. to the applicant on request. The copy of the record shall include the information provided for in the previous article. Injdsflijl,- Provisions of Article 9 are applicable to death notifications occurring during any outward travel. mm - Any persons who finds a dead human body (corpse) shall notify police station in towns and to the administrative governor in villages. fiujdsflgLJQ - If the name. residence or country of origin are unknown. the deceased shall be examined by the medical officer in towns where there are health offices or by the health officer in villages. The police in towns and the administrative governor in villages must draw up a report giving a description of the deceased and mentioning the circumstances in which he/she was found. as well as the time and place. and any other useful information. A photo of the deceased shall be taken and kept in the health office after having been endorsed with the information extracted from the death record. 'The inhumation shall not take place in this case except by authorization from the police or the administrative governor as the case may be. The registration shall be done in the deaths record. accordingly. .A11191§_ZQ - No corpse shall be buried without authorization from the Inedical officer of the health office in towns where health offices exist. and from the health officer in villages. Such authorization shall not be delivered except on submission of a death certificate Inentioning the causes of death. issued by an authorized practitioner in the Kingdom of Saudi Arabia. If the medical certificate is not 250 available. the health medical officer in towns where health offices exist or the health officer in villages. shall make the necessary statement to certify the death before issuing the inhumation authorization. Autism - If there is evidence of a criminal death or if there are other causes of suspicion. the inhumation shall not be authorized unless the police or the administrative governor are notified. Then. the inhumation authorization shall be obtained from any of them as the case may be. W - No corpse shall be buried unless eight hours in summer. and ten hours in winter. have elapsed. Anyhow. it shall be buried before twenty-four hours have elapsed. from the time of death. How- ever. the health medical officer may exempt from this restriction if there were strong reasons Justifying this. .A:11§J§L23_- The persons required to obtain the inhumation authoriza- tion are those required to notify the death according to the provisions of Article 14. The grave-digger. and the person in charge of the supervision of the transport of the corpse. must ascertain that the inhumation has been issued. The guard of the graveyard or the grave- digger. in case of absence of the guard. shall receive the aforesaid authorization before proceeding to the burial. EaLtj. W W - Any person may apply for an official copy of birth certificates concerning him and of death certificates concerning his parents. descendants. wives/husbands. The public authorities could apply for an official copy of these certificates. In addition to the aforesaid persons and authorities. any person recognized by the Ministry of Health as concerned in the matter. may obtain such a copy. The Minister of Health defines the procedures to be followed in applying for certificate extracts. and determines the fees to be paid. ALIJSJLZS. - Births and deaths records. when terminated. shall be kept. They shall be kept and handed over in accordance with the procedures provided for by an arrete of the Minister of Health. 251 2211:1225 - The Health Medical Officer in the localities where health offices exist. and the administrative governor in other localities. shall verify and sign births and deaths records once a month. at least. W - When recording births and deaths. the name. surname. age. profession and residence of the notifier. as well as the capacity in which he/she is making the notification. are to be recorded in "AD HOC" registers. The notification must be signed by the notifier and the official in charge of the registration. If the notifier abstains from signing. his/her abstention shall be stated in the record. W - Every citizen living abroad. shall notify to the repre- sentative of the Saudi Government. births and deaths he has to notify in accordance with this regulation. within fifteen days as from the date of delivery of death. .An1151§_22 - The Minister of Health determines the forms of certificates. records and printed matters required for implementing this regulation. and the action to be taken in this respect. .A11191g_30_- Births and deaths not notified during the year following the birth or death. shall not be recorded in the special register except by a decision taken by the committee provided for in Article 31. mm - A committee is to be set up in the district of each area. composed as follows: The administrative governor Chairman A delegate from the Ministry of Health ) in the area ) ) Delegates A delegate from the Ministry of Interior ) This committee is concerned with taking decisions with regard to requests for recording births and deaths as provided for in the previous Article. .AntjsflgLaz - The following measures are to be enforced before taking a decision regarding requests for recording births and deaths provided for in Article 30: l. The person concerned shall submit a request for registration. to the1administrative governor of the area. the district of which includes the locality where the registration is required. 2. In addition to the information needed for the registration. the request shall include evidence in support of the validity of the request. 252 3. The administrative governor shall investigate into the request. and when adequate information is collected. he shall submit the subject to the committee provided for in Article 31. 4. If the committee considers that the request is acceptable. it shall publish a notice in its respect in the Official Gazette and stick up a copy of this notice on the door of the area administrative gover- nor directorate and on the door of the administrative governor of the locality where the delivery or death occurred. The applicant shall be required to publish the same notice in one of the daily newspapers. If no opposition is made during the three months following the publication of the notice. as mentioned before. or if an opposition is made and the committee provided for in Article 31 considers. after inquiry. that it is not Justified. the aforesaid committee shall take a decision author- izing the registration of the birth or death in the respective records and submit it to the Minister of Health for approval and enforcement. 253 Births and Deaths Regulations No. 11 date 4-1-1382 H EanLl 81.13115 .ALI1£19_1 - Births in the Kingdom of Saudi Arabia shall be notified within fifteen days with effect from the date of delivery. The notifi- cation shall be made on the specific form. Autism - The notification shall be made to the Health Office of the locality where the delivery occurred. in case there is such an office. Otherwise it shall be made to the Administrative Governor. .A:11g1§;1 - Health offices or Administrative Governors (in the localities where health offices are not available).1as well as the representatives of the Saudi Government abroad. shall be provided with registers for births registration. These registers shall be in two originals of the form specified by an arrete of the Minister of Health. They shall be paginated and pages shall bear the seal of the Ministry of Health. The registration shall be assumed by officials and persons assigned by arrete of the Minister of Health to this effect. mm - No blank spaces shall be left during the registration and no abbreviated words shall be used. The dates shall be written in full. Any addendum. crossing-out. or rectification to be made during the registration. muSt be referred to in the margin. Such notes are to be ratified by the notifier and by the official in charge of the registration. .A311g1e_5 - Persons required to notify deliveries are: l - The father of the infant if present. 2 - Adult male relatives who attended the delivery. or the nearest female relatives to the infant. 3 - Adult male persons living in the same home with the mother. otherwise. the females. 4 - The administrative governor of the locality. 5 - Directors of institutions. i.eu. hospitals. maternities. prisons and quarantines with respect to deliveries which may have occurred in each of them. 254 None of the aforesaid categories shall be responsible for the notification. except in case of absence of any of the preceding categories. Notification could not be accepted from those who are not 'concerned. In all cases the physician or midwife shall notify the deliveries they carry out. to the Health Office within the period provided for in Article 1. However. the receipt of this notification does not suffice to record the event in the special register. Amidslg_§ - The notification shall comprise the following information: 1 - The day. date. time and place of birth. 2 - Sex. name and surname of the born. 3 - Names. surnames. nationality. religion. residence and profession of the parents. £u:dgle_1 - The official in charge of the registration in births register. shall draw up birth certificate on the form prepared to this purpose. and submit it. free of charge. to the notifier. The birth certificate includes the information provided for in Article 6. mm - If the born is dead before he has been registered. the official in charge of the registration shall record his birth and his death. But if he is still-born after the sixth month of pregnancy. he shall be recorded only in the register of deaths. .A:11§1§_2 - If a delivery occurred during travel. it shall be notified to the Health Office of the first Saudi port within fifteen days with effect from the date of arrival at this port. or to the representative of the Saudi Government in the locality of destination. AW - The pol ice stations in towns. the administrative governors in villages. the institutions and orphanages admitting new borns (foundlings). shall notify to the Health Office concerned. any new born found by or admitted in one of those institutions or orphanages. The notification shall include the date and time at which the child has been found or consigned and the name. surname. age. profession and residence of the person who may have found or handed him. unless he refuses. as well as the sex of the child and his age according to the evaluation of the medical officer concerned. ‘The official in charge of the registration shall denominate the child in full and then record him in the birth register without mentioning that he is a foundling. and he shall leave in blank the two columns provided for the parents. unless one of them submits an acknowledgement of his/her paternity to the infant. The column of residence is then to be filled in. 255 EarLZ Deaths .A:t1g1g_11,- Notification of deaths in the Kingdom of Saudi Arabia. including still-born after the sixth month of pregnancy. whether the death is pre-natal or during the delivery. shall be made on the special form. to the Health Office in the locality where the death occurred. should such an office exist. Otherwise. the notification shall be made to the administrative governor of the locality within twenty-four hours from the time at which the death occurred or [was] confirmed. W - Health Offices. the Administrative Governors in the localities where there are no health offices. as well as representa- tives of the Saudi Government abroad. shall be provided with registers for death recording. These registers shall be in two originals of the form specified by an arrete of the Minister of Health. ‘They shall be paginated and the pages shall bear the seal of the Ministry of Health. The registration shall be assumed by officials and persons assigned by arrete of the Minister of Health to this respect. .An:1g13_13,- No blank spaces shall be left during the registration and no abbreviated words are to be used. 'The dates shall be written in full. Any addendum. crossing-out or rectification to be made during the registration. must be referred to in the margin. Such notes are to be ratified by the notifier and by the official in charge of the registration. ' £fljfl£fljLJA,- Persons required to notify deaths are: 1. Parents. ascendants. husbands or wives of the deceased. ’ 2. Adult male relatives who attended the death. otherwise. the nearest female relative to the deceased. 3. Adult male persons living in the same home with the deceased. otherwise the females if the death occurred at home. 4. The administrative governor of the locality. 5. The medical officer or the health officer required to confirm the death. 6. The owner of the place. its manager or the person in charge of its management. if the death occurred in a hospital. a nursing home.«an institution. a hotel. a school. a camp. a prison or any other place. This includes the "Mutawefin" (Pilgrims guides) in case of deaths among pilgrims. 256 Notification could not be accepted from persons other than those required to do so. None of the aforesaid categories shall be respon- sible for the notification. except in case of absence of any of the preceding categories. fiujdsflgL15_- The notification shall comprise the following information: 1. The day. date. time and place of death. 2. The name. surname. sex. nationality. religion and profession ‘of the deceased. 3. Age. place and date of birth and residence of the deceased. 4. Names. surnames of his/her father and mother. if they were known to the notifier. .Antig1g_1§ - The official in charge of death registration shall draw up a copy of the record on the special form and issue it free of charge. in the same day. to the applicant on request. The copy of the record shall include the information provided for in the previous article. .A£11£l§_ll - Provisions of Article 9 are applicable to death notifications occurring during any outward travel. .A:11g1g_18,- Any persons who finds a dead human body (corpse) shall notify police station in towns and to the administrative governor in villages. Am - If the name. residence or country of origin are unknown. the deceased shall be examined by the medical officer in towns where there are health offices or by the health officer in villages. The police in towns and the administrative governor in villages must draw up a report giving a description of the deceased and mentioning the circumstances in which he/she was found. as well as the time and place. and any other useful information. A photo of the deceased shall be taken and kept in the health office after having been endorsed with the information extracted from the death record. ‘The inhumation shall not take place in this case except by authorization from the police or the administrative governor as the case may be. The registration shall be done in the deaths record. accordingly. W - No corpse shall be buried without authorization from the Inedical officer of the health office in towns where health offices exist. and from the health officer in villages. Such authorization shall not be delivered except on submission of a death certificate Inentioning the causes of death. issued by an authorized practitioner in ‘the Kingdom of Saudi Arabia. If the medical certificate is not 257 available. the health medical officer in towns where health offices exist or the health officer in villages. shall make the necessary statement to certify the death before issuing the inhumation authorization. £u11g13_21 - If there is evidence of a criminal death or if there are other causes of suspicion. the inhumation shall not be authorized unless the police or the administrative governor are notified. Then. the inhumation authorization shall be obtained from any of them as the case may be. M - No corpse shall be buried unless eight hours in summer. and ten hours in winter. have elapsed. Anyhow. it shall be buried before twenty-four hours have elapsed. from the time of death. How- ever. the health medical officer may exempt from this restriction if there were strong reasons Justifying this. AM - The persons required to obtain the inhumation authoriza- tion are those required to notify the death according to the provisions of Article 14. The grave-digger. and the person in charge of the supervision of the transport of the corpse. must ascertain that the inhumation has been issued. The guard of the graveyard or the grave- digger. in case of absence of the guard. shall receive the aforesaid authorization before proceeding to the burial. Band. Waldo: fiujusfljng,- Any person may apply for an official copy of birth certificates concerning him and of death certificates concerning his parents. descendants. wives/husbands. The public authorities could apply for an official copy of these certificates. In addition to the aforesaid persons and authorities. any person recognized by the Ministry of Health as concerned in the matter. may obtain such a copy. The Minister of Health defines the procedures to be followed in applying for certificate extracts. and determines the fees to be paid. W - Births and deaths records. when terminated. shall be kept. They shall be kept and handed over in accordance with the procedures provided for by an arrete of the Minister of Health. 258 8121111125. - lhe Health Medical Officer in the localities where health offices exist. and the administrative governor in other localities. shall verify and sign births and deaths records once a month. at least. AW - When recording births and deaths. the name. surname. age. profession and residence of the notifier. as well as the capacity in which he/she is making the notification. are to be recorded in "AD HOC" registers. The notification must be signed by the notifier and the official in charge of the registration. If the notifier abstains from signing. his/her abstention shall be stated in the record. W - Every citizen living abroad. shall notify to the repre- sentative of the Saudi Government. births and deaths he has to notify in accordance with this regulation. within fifteen days as from the date of delivery of death. o‘Ant1g1§_22 - The Minister of Health determines the forms of certificates. records and printed matters required for implementing this regulation. and the action to be taken in this respect. W - Births and deaths not notified during the year following the birth or death. shall not be recorded in the special register except by a decision taken by the committee provided for in Article 31. W - A committee is to be set up in the district of each area. composed as follows: The administrative governor Chairman A delegate from the Ministry of Health ) in the area ) ) Delegates A delegate from the Ministry of Interior ) This committee is concerned with taking decisions with regard to requests for recording births and deaths as provided for in the previous Article. W - The following measures are to be enforced before taking a decision regarding requests for recording births and deaths provided for in Article 30: l. The person concerned shall submit a request for registration. to the administrative governor of the area. the district of which includes the locality where the registration is required. 2. In addition to the information needed for the registration. the request shall include evidence in support of the validity of the request. 259 3. The administrative governor shall investigate into the request. and when adequate information is collected. he shall submit the subject to the committee provided for in Article 31. 4. If the committee considers that the request is acceptable. it shall publish a notice in its respect in the Official Gazette and stick up a copy of this notice on the door of the area administrative gover- nor directorate and on the door of the administrative governor of the locality where the delivery or death occurred. The applicant shall be required to publish the same notice in one of the daily newspapers. If no opposition is made during the three months following the publication of the notice. as mentioned before. or if an opposition is made and the committee provided for in Article 31 considers. after inquiry. that it is not justified. the aforesaid committee shall take a decision author- izing the registration of the birth or death in the respective records and submit it to the Minister of Health for approval and enforcement. _.&m__;w BIBLIOGRAPHY 260 BIBLIOGRAPHY Abdulla. M. A.: Sebai. Z. A.; and Swailem. A. R. 1982. "Health and Nutritional Status of Pre-School Children." In Community Health in Saudi Arabia. pp. ll-18. Edited by Z. A. Sebai. The Riyadh Al-Kharj Hospital Programme. Great Britain: Stanhope Press. Abou-Gamrah. H. M. 1983. "Model Life Tables for the Gulf Countries." h Paper presented at the Cairo Demographic Center Annual Seminar. 18-20 December. Cairo. Egypt. Adamchak. D. 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