Review of implementation, barriers and challenges of premarital care program in the middle east countries

Received: 17-Nov-2020 Accepted Date: Dec 21, 2020 ; Published: 28-Dec-2020

Introduction

Premarital Care (PMC) is an emerging concept with reproductive health to help couples to prepare for marriage. The program includes premarital health counseling, medical examination, investigations, and vaccination. It can identify and modify behavioral, medical, and other health risk factors known to impact pregnancy outcomes through prevention and management [1]. Hence, it is recognized as a step towards saving society and allowing people to enjoy life.

Since 1950, Arab countries have made progress in some health-related aspects such as infant mortality, life expectancy, and access to health care [2]. However, the Global Report on Birth Defects in 2006 stated that worldwide, about 7.9 million births occur annually with serious birth defects and 94% of these births occur in the middle and low-income countries [3]. Inherited hemoglobin disorders like thalassemia, and sickle-cell disease still constituting a major public health problem in certain parts of the world including the Middle East. It was estimated that 240 million people are heterozygous and more than 2, 00,000 lethally affected homozygotes are born annually [4]. Demographic factors and population structure as the large family size, late maternal age may contribute to the high prevalence of hemoglobinopathies. Moreover, studies demonstrated stronger evidence of the association of viral hepatitis and HIV with marital contact [5]. Viral hepatitis is highly prevalent in Middle Eastern countries than in Europe and the USA. It was estimated that 2-5 percent of Middle East populations are chronically infected with hepatitis B [6]. The prevalence of Hepatitis C in Egypt had reached 15 percent, the highest in the world [7]. Viral hepatitis is the 5th leading cause of death in North Africa and the Middle East due to associated complications mostly Hepatocellular Carcinoma and cirrhosis [8]. Many of these infections could have been prevented through vaccination or treatment services. HIV/AIDS is transmitted from the mother to her child during pregnancy, delivery, and breast-feeding and sexually transmitted disease as well. Although its prevalence is low (less than 0.2%) in the Middle East and North Africa (MENA), the fear of stigma makes people reluctant to seek testing for this disease [9]. Lack of reality seems to have fuelled this situation and the majority of HIV positive patients do not know they have the virus. On the contrary, antiretroviral therapy decreases greatly the risk of HIV transmission between partners and from mother to her child as well [10]. Without a shadow of a doubt, there is a necessity to introduce sexual and reproductive health education to newly engaged couples before they embark on the journey of marriage. Sociological studies indicated that consanguineous marriages increase the couple’s stability, strengthen family ties, and solidarity [11]. On the other hand, it increases the risk of occurrence of recessive genetic disorders. Consanguineous marriage predates Islam, and the Quran does not encourage this practice though high prevalence (25-60)% of consanguineous marriages, particularly among first cousins in the MENA region [12]. Furthermore, the rate of divorce in new families has been reached 34.5% due to fertility problems that could be identified before marriage [13].

Prevention thus appears to be significantly more cost-effective while reducing the psychosocial implications of these chronic diseases. Premarital screening is recognized as one of the most effective strategies for reducing the burden of hereditary diseases, STD’s, birth defects, divorce rates [14]. Therefore, the Ministry of Health in Arab countries has been made premarital screening mandatory before issuing a marriage certificate. The couples need to provide a certificate stamped by the Department of State of premarital screening to the court to proceed with the wedding [15]. Meanwhile, the benefits, ethical consequences of such programs have been much debated. In the year 2000, the World Health Organization reported that many governments especially in the Arabic-speaking world have been promoting premarital medical examinations since the first half of the 20th century. Yet, the little effect had been detected on hereditary diseases and consanguinity [16].

The objectives of the current review was to explore the process of implementation of premarital care program in the Middle East countries, to highlight the possible barriers and challenges to program effectiveness and to outline recommendations to add momentum to current health care efforts.

Materials and Methods

Relevant literature was retrieved from different journals and web pages. The Science Direct, Embase, Scopus, PubMed, and Web of Science (ISI) databases were searched using keywords. The search terms of premarital testing, counseling, care, or screening, preconception care, thalassemia and sickle cell anemia testing, hepatitis testing were used. Relevant articles were identified, then screened and selected based on title and abstract from the year 1997 up to 2019. Google search was employed to collect relevant information about premarital screening programs in different countries. A review of relevant Arabic literature, booklets, and newspapers was also carried out.

Recommendation

It is necessary to improve the policy environment for the successful implementation and sustainability of premarital care program. Efforts should be directed to policy advocacy for improved premarital care access, acceptability, and quality services. Screening programs must be accessible and understood by the target population, but most importantly, they must comply with the prevailing cultural, ethnic, economic, and social values. Public education through mass media, newspapers, internet websites, awareness campaign, university symposia, incorporation into educational curricula to raise awareness and change behavior about the importance of screening [57]. Adopting a life cycle approaches for identifying health risks and intervening at critical periods during youth, prenatal, and neonatal life stages could be more successful than premarital screening alone [13]. This urge the need to capitalize on NGOs and private sector role through their clinics, role in development activities directed to youth. They could play a major role in the sustainability of demand through BCC and continuation of awareness-raising [62]. Efficient use of limited resources, social insurance, and business community support to overcome financial constraints is essential. Religious leaders should legalize therapeutic abortion in case the fetus is diagnosed with grave congenital malformation. Indeed, ensuring the contribution of different sectors and ministries can play a vital role in developing awareness among the people especially prospective life partners regarding premarital screening programs.

Conclusion

In conclusion, any mandatory screening program does have the potential to succeed as long as the target population is clearly identified and all ethical issues (confidentiality of results), religious, cultural, and human rights, and concerns about post-diagnostic management are fully addressed.

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