ISLAMIC PERSPECTIVE


INDUCED ABORTION FROM AN ISLAMIC PERSPECTIVE: IS IT CRIMINAL OR JUST ELECTIVE?  

Mohammed A. Albar, DM, FRCP ( London), Consultant to Islamic Jurisprudence Council, Jeddah, Saudi Arabia

خلفية البحث:هل لا يزال يعتبر الإجهاض المحدث جنائيا أم صار أمرا اختياريا؟ مع تركيز على النظرة الإسلامية.

ينتشر الإجهاض لأسباب اجتماعية واقتصادية في العالم أجمع .ويقدر أن هناك خمسين مليون حالة إجهاض متعمد سنويا في العالم، وتؤدي إلى وفاة مائتي ألف امرأة نتيجة لذلك، ومعاناة الملايين منهن. إن مضاعفات الإجهاض الجنائي كثيرة وخطيرة. وللأسف فلا يزال الإجهاض يستعمل كوسيلة من وسائل تحديد النسل.

إن الأسباب الطبية الداعية للإجهاض محدودة ولا تشكل سوى نسبة بسيطة من جملة حالات الإجهاض المتعمد التي تحدث في العالم.

تناقش هذه الورقة مختلف وجهات النظر حول الإجهاض، وكيف تطورت هذه النظرة عبر التاريخ، وما هو الموقف القانوني من الإجهاض المتعمد. وتركز على وجهة النظر الإسلامية ومختلف المواقف الفقهية من هذه القضية.

الكلمات المرجعية:الإجهاض المحدث، الإجهاض الجنائي، تحديد النسل، الإسلام. 

Background:Induced Abortion for social reasons is spreading all over the world. It is estimated that globally 50 million unborn babies are killed annually, resulting in the deaths of 200,000 pregnant women and the suffering of millions. The compli­ca­tions of illegal abortion are very serious. Abortion is still used in many countries as a means of family planning. The medical reasons for abortion are limited and con­sti­tute a small proportion of all abortion cases. This paper discusses the different views on abortion, its history, its evolution over time, and the present legal circumstances. The emphasis is on the situation in Islamic countries and the effect of Islamic Fatwas on abortion.

Key Words: Induced abortion, illegal abortion, family planning, Islam.


 

A number of conflicting views on induced abortion from various religious groups, secu­lar humanists, liberals and feminists have created divisions and conflict, culmin­ating in acts of violence and loss of life. Indeed, abortion is the most controversial area of family planning, and the least under­stood and socially accepted. However, it is the most important method employed by the advocates of fertility regulation and family planning.1

DEFINITION OF ABORTION 

There is a surprising diversity of definitions in law in different countries and even in medicine. Sir Stanley Clayton and John Newton in their booklet: A Pocket Obstetrics2 define abortion as the expulsion of the conceptus before the 28th week of pregnancy. This is a view still held by British law.3 Ralph Benson in a “Handbook of Obstetrics and Gynecology”4 defines abortion as “the termination of pregnancy


 

Correspondence to:

Dr. Mohammed A. Albar, P.O. Box 11639, Jeddah 21463


 

before the fetus is viable. Technically, via­bility is reached at 23-24 weeks, when the fetus weighs slightly more than 600 grams.” The law in the United Statesvaries from state to state, in general allowing abortion on demand in the first trimester of preg­nancy, with more restrictions on certain medi­cally indicated cases in the second tri­mester. The World Health Organization (WHO) defines abortion as “the expulsion or extraction of a fetus or embryo weighing 500 grams or less from its mother.”5

                Medical opinion nowadays defines abor­tion as the expulsion of conceptus prior to viability, defined as 20 weeks of pregnancy or a fetus weighing 500 grams or more. Re­cently, some states have lowered the weight of viability to 300 grams.5

                Such terms as miscarriage are usually used by the public to denote spontaneous abortion, while the term abortion denotes induced abortion, whether legalized or not.5

                The Encyclopedia Britannica of 1982 defined abortion as the termination of preg­nancy before viability, in turn defined as a 1000-gram fetus by weight or more than 20 weeks of pregnancy.3

INCIDENCE OF INDUCED ABORTION

In his book "The Pill", Dr. Guilleboud estimates that the incidence of induced abor­tion in the early eighties of the twentieth century was 40 million annually, half of which were performed legally, the other half illegally. This resulted in the death of about 200,000 women and affected hundreds of thou­sands of others with many serious complications, including pelvic inflamma­tory disease, recurrent abortions and steri­lity.6 Hawkins and Elder claim in their book “Human Fertility Control”, that induced abortion is the most effective method used for family planning and curbing population growth.7 Time Magazine of August 6, 1984 puts the number of induced abortions glo­bally at an annual 50 million.8 Legal and illegal induced abortions in Japan have sta­bilized at three million annually and have reduced the annual birth rate to 13.5 per thou­sand.9,10 The pill is still not available in Japan.

                The incidence of induced abortion is very high in Russia, Chinaand the former East European block countries, mainly because of the absence of the pill, and the use of abor­­tion as a means of birth control. In Bela­rus, there are 200 abortions for each 100 live births, i.e. two-thirds of all preg­nancies end in abortion.11

                Similarly in the predominantly Roman Catholic Latin American countries, where contraceptive methods, except for “the safe period” are frowned on by the church, the incidence of induced criminal abortion is estimated at three million annually. In the Iberian Peninsula (Spain and Portugal), another Roman Catholic area, the incidence of criminal abortion is the highest in Western Europe, an estimated one million annually, the result of which is the death of 3500 women per year. In Manila, the Philippines, with a population of five million, it is estimated that illegal abortions are provided for 100,000 women annually. This figure is similar to the number of abor­tions carried out in the whole of Great Britainwith a population of 55 million.1,12

                Since abortion was legalized in 1973, the figures for induced abortion have stabilized at 1.5 to 1.6 million annually in the USA. More than 60% of all induced abortions in the USA, Canadaand Europeare carried out on young unmarried girls under the age of 20, one quarter of whom were under the age of 17. The prestigious medical journal Pedi­a­trics (supplement 1985) on “Sex, Drugs, Rock ‘N’ Roll, and Understanding Teen­agers’ Behavior”13 stated that annually 1.2 million unmarried teenage girls between 12 and 17 years of age get pregnant in the USA. Forty-nine percent of them carry their pregnancies to term and are dubbed “Virgin mothers,” 13% have spontaneous abortions and stillbirths, while the remaining 400,000 get aborted. Time Magazine claims that an­nually half of the one-third of all unmarried high school girls who get pregnant abort the fetuses, while the rest carry them till term.14

                By 1982, 80% of all pregnancies in girls under 20 in Britainwere out of wedlock, and about half of them procured induced abortion.15

                It is evident that promiscuity and the sexual revolution constitute the major cause of unwanted pregnancies that result in induced legal and illegal abortions. The latter are fraught with serious and some­times fatal complications. Despite the avail­a­bility of contraceptive methods for young school girls in the USA, the rate of preg­nancy there is very high indeed. Time Magazine (December 9, 1985)14 gave a figure of 30,000 pregnancies for those under 15. This figure jumped to 1,200,000 (also confirmed by the medical journal, Pedi­atrics) by age 17.13 By age 20, there are two million pregnancies outside wedlock, a million of which result in abortion annually.

                All the studies show that both pregnancies and abortions are higher in Afro-Americans than in Caucasians,1,12 at the ratio of 2.5 to 1. In the last part of the twentieth century, abortions for teenage girls decreased in the USA, as girls became more adept at using contraceptive methods.16,17 A new wave of female infanticide is now spreading in many countries, especially Chinaand India, after the spread of ultrasonography. If ultrasound shows that the conceptus is a female, the parents resort to an abortion, which is unfortunately done in the second trimester and often results in serious compli­ca­tions, especially if done illegally.18

                The medical indications for an abortion are broadened to include not only physical ailments, but also supposed psychological disturbances that may result from the con­tinuation of pregnancy. Similarly, if the continuation of pregnancy will somehow affect any member of the family, then abortion is resorted to (The British Law of 1967 regarding Abortion).

                A new type of indication is called “reduc­tion of pregnancy,” in which the expectant mother treated for infertility with hormones or by in-vitro fertilization gets pregnant with multiple fetuses, when the treating physician had reintroduced more than three fertilized ova (pre embryos) into the uterus. This practice was deprecated by Islamic Jurists in their meeting in Kuwait in 198719 and Amman 1986 (Jordan).20 Later, gynecolo­gists all around the world passed a regula­tion limiting the reintroduction of fertilized ova to two or a maximum of three in each cycle in the management of fertility by in-vitro fertilization  (IVF) methods.

THE HISTORICAL ASPECT OF THE LEGALITY OF INDUCED ABORTION

The medical profession took a stand many centuries ago against induced abortion. Imhotep of Egypt (3000 B.C; deified as the god of medicine) instituted an oath to be taken by all practicing physicians, which prohibited them from prescribing an aborti­ficient drug or pessary. Similarly, the well-known Hippocratic oath enjoins doctors not to induce abortion by drugs, pessaries or any other means.21,.22

                The Declaration of Geneva of 1968, as amended in Sydney, reiterated the Hippo­cratic oath and pledged “to maintain the utmost respect for human life from the time of conception.”23 However, the Declaration of Oslo, while retaining this moral principle, recognized the different opposing opinions on the question of abortion: “The Diversity of opinion is he result of the varying atti­tudes towards the life of the unborn child. This is a matter of individual convic­tion and conscience.”24 This profound change in attitude is the result of cumulative change in the fabric of many societies, where mores and lifestyles have completely changed.

                Although ancient civilizations prohibited and even harshly pun­ished those who com­mitted abortion, they were lax in some stages of their development and condoned clan­destine acts of abortion. Potts and Diggory, in their Textbook of Contraceptive Practice, stated that abortion was practised in the Middle Kingdom of Egypt (2133–1786 BC), and the excavations at Pompeii re­vealed a vaginal speculum suitable for per­for­mance of abortion.1 The Roman Poet Ovid lamented, “There are few women nowadays who bear all the children they conceive.”1 The same seems equally true of the majority of women in many societies today, which have legalized abortion on demand, or for tenuous social or psycho­logical reasons.

                The Bible considered induced abortion a crime but not murder; the husband of the offending wife determined the punishment, which was a compensation to him. The judge could also punish the perpetrator by strapping or imprisonment.1

                The Catholic church was more stringent, and in the 7th century instituted a canon for capital punishment of women who had abortions.25

                Laws were passed making abortion punishable by death, in Englandin 1524; in Germanyin 1531; in Francein 1562; and in Russiain 1649.25

                With the advent of the industrial revolution and social upheavals in the 18th and 19th centuries, European countries gradu­ally revoked the previous harsh laws and replaced them with less drastic penalties, e.g. imprisonment, fines and with­drawal of the license to practice medicine.

                By 1929, the law in Britainallowed abortion if continuation of pregnancy was expected to endanger the health of the expectant mother. The previous law had allowed abortion only if continuation of pregnancy endangered her life and not her health.1,3

                From 1929 to 1967, induced abortion with­out a clear medical indication was con­sidered a criminal act and was punished by imprisonment, fine and withdrawal of the license to practice medicine. The 1967 amend­ment issued by the British Parliament authorized physicians to abort a fetus if there was likelihood of: (a) a threat to the life of the mother if pregnancy continued; (b) a threat to her physical or psychological health, or the health of children of the family (whether her own children, her husband’s children or adopted children) if pregnancy continued; (c) the presence of con­­genital anomalies in the fetus.

                The abortion should be performed in an institution recognized by The Ministry of Health, but not necessarily by a specialist.1,21

The first country in the world to legalize abortion on demand was communist Russia, which passed a law on 18 November 1920, “permitting abortion to be performed freely without charge in Soviet hospitals.”1 This resulted in the decline of the family and the population. Stalin saw the dangers clearly and hence passed a new law in 1935, which restricted abortion to medically indicated reasons. Pravda ap­plauded the new law and wrote: “Our Soviet women have been given the bliss of motherhood. We must safeguard our families.” In 1955 however, the 1920 law on abortion was reinstated.1,25 The East Euro­pean satellite countries soon followed suit, with minor changes. Several Scandi­navian countries liberalized abortion laws in the 1930s. In 1935 Icelanddid the same, and then Swedenand Denmarkin 1938. Japanallowed abortion on demand and as a means of contraception in 1948, and Chinafol­lowed suit during the cultural revolution of the 1960s. Haitiand Great Britainpassed their laws in 1967, Indiain 1971, and the USAin 1973. By 1980, over 70% of the world’s popu­lation lived in countries where abortion was allowed on demand or with minor restrictions.

                Countries allowing abortion on demand include: Russia, China, Japan, the Scan­dinavian countries, Eastern Europe, Viet­nam, North Korea, the USAand Tunisia(the only Muslim country).25

                Countries allowing abortion with some re­strictions are: Great Britain, Canada, India, France, Germany, Holland, Italy, Switzer­land, Turkeyand South Africa.

                Countries allowing abortion only for strict medical reasons are: the Catholic coun­tries such as those of Latin America; Ireland, Spain, Portugal, Malta, Belgium, the Philippines, and all Muslim countries except Tunisiaand Turkey. The Zaidi School of Jurisprudence ( Yemen) is very lenient and allows abortion in the first 120 days of pregnancy (computed from the start of con­ception and not LMP) for both medical and social reasons.25

                It is unfortunate that induced abortion is used in many societies as a means of birth control. Many gynecologists, policy makers, Planned Parenthood organizations, and others related to the United Nations advo­cate the use of induced abortion as a means of birth control. They also indicate that the available methods, including sterilization of both males and females, be used for birth control.

                The Encyclopedia Britannica mentions some contemporary views on birth control and the means of controlling popula­tions, including strict government controls such as compulsory sterilization. This was en­forced on 40 million people by the Mao Tse Tung regime in Chinaand on 24 million in Indiaby Indira Ghandhi.3,25 As the law in Chinapermitted couples to have only one child,3 millions in Chinawere also forced to abort.

                Potts and Diggory claim in their “Textbook of Contraceptive Practice” that “Both contraception and abortion are essential for controlling fertility. A society cannot meet its fertility goals purely by the use of contraception. Therefore, the combi­na­tion of reversible methods of contra­ception (and sterilization), and induced abortion will remain necessary elements in fertility control. Throughout history, and with increasing force over the past 100 years, societies have used a combination of contraception and abortion to control ferti­lity. The moral and political benefits of abor­tion services outweigh such factors as proven mortality rates or the evidence indicated in cost benefit studies. Abortion will occur in societies with low fertility, and is likely to be most common in those societies where the birth rate is falling in response to socioeconomic pressures.”1

                The paragraph quoted above contains many contradictory and illogical statements in support of abortion where it is employed despite dangers to the health and life of the expectant mother, and in societies where ferti­lity is low; where instead every effort should be made to improve fertility, pro­hibiting abortion and encouraging the birth of as many children as possible.

                American and European societies en­cour­age third world countries to curb fer­tili­ty and population increase, even by resorting to methods unacceptable in their own socie­ties. Governments of third world countries are encouraged to implement laws and take certain measures to enforce the policy of birth control, even if it involves compulsory sterilization, the use of unsafe contra­cep­tives or even forced abortion.1, 3, 25

                The medical reasons for the so-called therapeutic abortion constitute a very small proportion of the number of abortions carried out globally for social reasons. Potts and Diggory claim, “Few abortions are carried out because continuation of preg­nancy threatens the woman’s life, and a small proportion because of congenital anomalies of the fetus.”1 If a woman wishes to carry her pregnancy to term and delivery, almost all obstetricians will try their best to fulfill this desire. They will do this despite the fact that she may be suffering from a disease considered an indication for abor­tion, e.g. advanced renal, hepatic, cardiac problems, poorly controlled diabetes, hyper­tension, blood dys­criasis, or the use of im­muno­supressive drugs.

                Hawkins and Elders, in their book “Human Fertility Control,” emphasize that “Countries with a population problem have found it politically expedient, at least tacitly, to support increased facilities for abortion. The public in general is aware that abortion is either wrong or at least a medically and psychologically unsatisfactory solution to social problems. The church is faced with the difficulty that it cannot enforce its views without losing its adherents… Few doctors are happy with those aspects of society which produce the need for abortions; fewer still are satisfied with an environment which generates defects in motivation to employ effective contraceptive measures.”7

                The majority of medical practitioners and gynecologists agree that since criminal abor­tion is fraught with serious complica­tions including loss of life, then for prag­matic reasons, if abortion is to be carried out, it should be done by a licensed pro­fessional in a safe environment. The compli­cations of such a procedure are much reduced and the mortality rate in first trimester abortions is very low indeed, especially after the introduction of an anti- progesterone agent, e.g. RU 486 or mife­pris­tone and misoprostol which act success­fully (90%) if given to women less than nine weeks pregnant (computed from LMP).26 The morality rate of illegal abor­tions is around 50 per 100,000, while that of legal abortions in the first trimester is approximately one or two per 100,000. Inthe second trimester, the mortality rate reaches 40 per 100,000.1,5 It is estimated that globally, 200,000 women die annually as a result of illegal abortions.6

                Abortions should not be used as a means of birth control. The social causes leading to un­wanted pregnancy should be dealt with, and if the need arises, temporary means of con­traception should be made available to couples. Abortion should be strictly limited to medically indicated cases, which con­sti­tute a small proportion of all abortions car­ried out on demand and for social reasons.

Religious Aspects of Abortion

                Islam, Christianity and Judaism view pro­cre­ation as an integral part of marriage. In the book of Genesis, God said to both Adam and Eve, “Be fruitful and increase in numbers, fill the earth and subdue it.”27

                In Islam, procreation is not only an integral part of matrimony, it is an act of worship. Even the sexual act with one's wife is considered to be an act of charity as pro­claimed by the Prophet Mohammed (PbuH).28 The Holy Quran proclaims: “Oh man­kind, be conscious of your Sustainer, who has created you out of one living entity, and out of it created its mate, and of the two spread abroad a multitude of men and women.”29

                “And God has given you mates of your kind, and has given through your mates children and grand children.” 30 The Prophet Mohammed said to all Muslims: “Get mar­ried, beget and multiply because I will be proud of you among nations.”26 He also said: “Marry the kind and fertile, for I will be proud of your numbers among other nations.” 32

                Though Islamic teachings encourage procreation within matrimony, it does not altogether prohibit the temporary means of contraception. The Prophet himself (PbuH) allowed his companions to practice 'aazel,' i.e. coitus interruptus (Onanism).33-35

                His teachings stand in stark contrast to what is found in the Old Testament, the Book of Genesis. Onan, the son of Judahand the grandson of Jacob, spilled his seed on the ground to avoid producing offspring for his deceased brother when he married his brother's widow Tamar. (The Jewish teaching then gave the offspring to the de­ceased husband if he left no children, rather than the actual father.) God was furious and caused the death of Onan.36

                The Catholic church holds the most conservative and stringent position against any means of contraception except absti­nence during and before ovulation, i.e. using the safe period. Similarly, it holds the most conservative point of view against abortion at any stage of pregnancy, since it views human life as beginning at the point of fertilization. The fertilized ovum is given the status of a human being, and hence killing it by any means is tantamount to the crime of manslaughter.

                In Islam, temporary means of contra­cep­tion are allowed, provided they cause no harm, and are done with mutual consent of the partners.37 Steriliza­tion is not allowed, except for clear medical indications, where pregnancy would seri­ously endanger the health or life of the expectant mother.37

                Similarly, abortion is allowed only if con­tinu­ation of pregnancy would endanger the life or health of the expectant mother; or if there is proven serious congenital anomaly in the embryo or fetus. The performance of abortion should be done prior to elapse of 120 days from the start of conception, which is considered the time of ensoulment according to the Hadith (sayings) of the Prophet. However, if both the life and health of the expectant mother are endangered, abortion or pre-term delivery can be per­formed at any time of pregnancy. The decision with clear medical indication for abortion should be agreed upon by three spe­cialist physicians.38-40

               This was the Fatwa (decision) of the Islamic Council of Jurists of Makkah Al-Mukaramah (Islamic World League) held in Makkah from 10 to 17th February 1990. The decision was passed by the majority of votes, but with abstentions of the late presi­dent Shaikh Abdulaziz Bin Baz, and Shaikh Bakr Abu Zaid.40

                Many Islamic jurists are more stringent and would allow abortion only in the first 40 days of conception (computed from fertilization and not LMP). In fact, this was the official Fatwa in Saudi Arabia, until the Fatwa of the Council of Islamic Jurists of Makkah in 1990 extended it to 120 days from start of conception.

                More conservative jurists like the Maliki Schooland Imam Al Gazali (from Shafii School of Jurisprudence) do not allow abor­tion at any time of pregnancy except to save the life of the expectant mother.41,42

                Nevertheless, there are some jurists who would allow abortion for social reasons, e.g. rape, or where continuation of pregnancy would affect a nursing child, or where a wet nurse was not available or the father was too poor to afford a wet nurse.25,41 Prominent among those permitting abortion is the Zaidi School of jurisprudence which allows abortion for social and minor medical reasons in the first 120 days of conception.25 Some jurists of the Hanafi, Hanbali and Shafii Schools also permit abortion with minor restrictions.25  However, the majority of Islamic jurists throughout history, because of Islam's respect for life, do not allow abortion except for strong medical reasons. There are a lot of Quaranic ayas and Hadiths on the sanctity of life. “We decreed upon the children of Israelthat who­soever kills a soul for other than man­slaughter or corruption in the land; it shall be as if he killed all mankind, and who­soever saves the life of one, it shall be as if he saved the life of mankind.43

                The Quran deplores killing children for want, or fear of want, “Kill not your children on a plea of want. We provide sustenance for you and for them. Come not near to shameful deeds whether open or secret. Take not life, which God has made sacred, except by ways of justice and law. Thus does He command, that you may learn wisdom.”44

                “Kill not your children for fear of want. We shall provide sustenance for them as well as for you. Verily the killing of them is a great sin.”45

                        Ibn Massoud (a companion of the Prophet) asked the Prophet: What is the gravest sin? The Prophet (PBUH) answered: “That you associate partners with God who created you.” Ibn Massoud asked: What is next to this? And the Prophet answered “That you kill your offspring for fear of them sharing your food with you” (Bukhari and Muslim).46,47

                Though Muslims generally consider the embryo from its earliest stages as “living,” they do not give it the status of full human life except after ensoulment. Ibn Al Qaiyim, in his book Attibian Fi Aksam Al Quran, brings up this question by asking: "Does the embryo before ensoulment (breathing of the spirit into it) have a life?" He answers that the embryo has the life of growth and nou­rish­ment like a growing plant, but once the spirit is breathed in he acquires perception and volition.”48

                Similarly, Ibn Hajar Al Asqalani, in his voluminous Fateh ul Bari, on the first organ to be formed in the embryo says, “The liver is the first organ formed as it is the site of nu­trition and growth. Voluntary movement and perception are acquired only after ensoulment.”49

                Ensoulment only occurs after many stages through which the embryo passes. The Holy Quran says: “We created man from the quin­­tessence of mud. Thereafter, we cause him to remain as a drop of fluid (Nutfa) in a firm lodging (the womb). Thereafter, we fashion the Nutfa into something that clings (Alakah), which we fashion into a chewed lump (Modgha). The chewed-like lump is fashioned into bones, which are then covered with flesh. Then we nurse him into another act of creation. Blessed is God, the best of artisans.”50

                All the ulema and commentators of the Holy Quran agree that the other act of crea­tion mentioned above is the time of ensoul­ment, where the spirit is inspired into the body of the fetus.

                The Hadith (sayings) of the Prophet narrated by Ibn Massoud state: “The crea­tion of each one of you is collected in the womb of his mother in forty days. And something that clings (Alakah) he becomes for forty days, and then he becomes Modgha (a chewed lump) for forty days. The angel is sent to him and the angel writes four things: his provision (sustenance), his life span, his deeds and whether he will be wretched or blessed. Then the spirit is breathed into him” (AlBukhari, Muslim, others).51,52

                This simply means that ensoulment occurs at 120 days computed from the beginning of conception. However, there is another Hadith narrated by Huzaifa Ibn Aseed which made some ulema (jurists of the Islamic nation) decide that forty days computed from the beginning of conception is the line of demarcation and the beginning of human life.

                “When the Nutfa enters the womb and stays there for 42 nights, God sends an angel to give it a form and create its hearing, sight, skin, bone and flesh. Then the angel asks, “O God, is it a boy or a girl ? and God determines whatever He decides. He then asks what is his livelihood and God determines (Muslim).52

                It is interesting to note that organogenesis (formation of organs in the embryo) takes place between the fourth and eighth week of conception (computed from fertilization) and reaches its zenith in 42 days. The embryo has an unidentified gonad until that period after which the gonad differentiates into either a testes or an ovary. Similarly, the brain stem forms and starts to function in an embryo of 42 days. However, the higher functions of the brain are still forming and the cerebral cortex does not have synapses with the lower centers before the beginning of the 20th week computed from the last menstrual period, which is equivalent to 120 days computed from fertilization (viz. beginning of conception). Dr. Koren J. presented a paper at the Con­fer­ence on Ethics of Organ Transplantation in Ottawa, Canada August 20 – 24, 1989, in which he proved with dissection of many aborted fetuses that synapses between the higher centers of the cerebrum and the lower centers do not start to work before the beginning of the 20th week of pregnancy, computed from the LMP; which is equi­valent to 120 days, computed from the moment of conception (fertilization).53

                It is evident that both sayings of the Prophet Mohammad (PbuH) speak of different times of development of the CNS of the fetus; the Hadith of 42 days refers to the development and functioning of the brain stem, while the Hadith of 120 days speaks about the higher centers and their control over the lower ones in the CNS.

                There are a lot of Hadith which assign to the conceptus an important status that gradually increases with the time of preg­nancy.  If a lady commits a crime punish­able by death, the execution of the penalty is postponed until after delivery and until after the baby has been nursed for two years. However, if a wet nurse is available for the mother's nursing period, it is much shorter. This applies even if the pregnancy is illegitimate.21,25,41,54

                The fetus has the right of the lineage of his father, and if his father dies while he is in utero, his share of the inheritance will be kept for him/her until delivery.

                Killing the fetus, intentionally or uninten­tionally, is penalized by the payment 1/20 of the diyha (blood fine), which is equivalent to 500 golden dinars. Another penalty is determined by the magistrate for inten­tionally induced abortion.25,41,54

                Sheikh Mohmoud Shaltout (Grand Imam of Al Azhar in the 1940s and early 1950s) wrote: “ Old scholars are agreed that after quickening takes place (120 days from con­ception), abortion is prohibited to all Muslims, for it is a crime perpetrated against a living being. Therefore, blood ransom is due if the fetus is delivered alive and then dies immediately after delivery, and ghorra (1/20 of the diyah) if delivered dead.” (Shaltout Islam: Creed and Law).55

                Imam Ghazali (died 505 H = 1122 AD), in his well-known book Ihyia Oloom addin, considered abortion at all stages of conception as “Haram,” with a gradation of the sin according to the length of pregnancy. It is tantamount to manslaughter if the child is deli­vered alive and then dies because of the abor­ti­ficient act or drug. However, the Imam recog­nized that the gravity of the crime is less if the abortion is of Nutfa (at 40 days) than the abortion of Alakah (40 to 80 days), which is less than the abortion of Modgha (80 to 120 days).  It becomes a grave crime after en­soul­ment, i.e. after 120 days. In his opinion, abortion should be avoided at all stages of pregnancy except if the life of the expectant mother is en­dangered.25,41,54

                The Muslim physician Abubaker Al Rhazi (died 313 H/925 AD) mentioned in his book Al Mansouri and in his encyclo­pedic Al Hawi many abortificient drugs and methods to be used if continuation of preg­nancy would endanger the health or life of the expectant mother. Similarly, Ibn Sina (Avi­cinna) wrote in his well-known (Al Kanoon fi Tibb) a chapter on medical indi­ca­tions of abortion and how to perform them.25

                I think that their recognition of the need for abortion in certain cases where continua­tion of pregnancy would endanger the health or life of the expectant mother is more realistic and humane than the stance of the church in medieval Europe, and the Catholic church at this moment.

                Abortion on demand, as carried out in many countries, with liberal abortion laws, will never be condoned by Shariah (Islamic Law). Unfortunately, Tunisiapassed a law 65/24 dated 1st July 1965, which allowed abor­tion for tenuous reasons. The situation became worse when law no. 73-75 dated 19th November 1973came into effect. It allowed abortion on demand in the first tri­mester of pregnancy, and on flimsy reasons in the second half of pregnancy.25

                Tunisiais the only Muslim country with a law that defies all the recognized Fatwas from all Islamic Jurists and Islamic conferences and meetings of jurists. Turkeyallows abortion with some restrictions based on some medical or social reasons. The remaining Islamic countries allow abortion to safeguard the expectant mother from serious problems in pregnancy that might put her health or life at risk. Many permit abortion when there is a seriously mal­formed embryo or fetus. The time limit for carrying out such abortions is 120 days computed from fertilization, which is equivalent to 134 days from the LMP.25,41

REFERENCES

1.     Potts M, Diggory P: Textbook of Con­tra­ceptive Practice. Cambridge Univer­sity Press, 2nd edition, 1983: Abortion. pp 274-367.

2.     Clayton S, NewtonJ: A Pocket Ob­stetrics. Churchill Livingstone, Edin­burgh, Londonand New York, 8th edition 1976. pp 35.

3.     Encyclopedia Britannica, 15th edition, 1982, vol. 2: 1069-72.

4.     Benson R. Handbook of Obstetrics and Gynecology. Lange Medical Publication, Middle East Edition, Lebanon, 6th edition, 1977 p 260.

5.     Bennett M. Abortion. In: Hacker N, Moore JG. Essentials of Obstetrics and Gynecology, 3rd ed. Saunders Co. Philadelphia, 1998 pp 477-86.

6.     Guilleboud G. The Pill. Oxford UniversityPress, Oxford. 3rd edition, 1987:15.

7.     Hawkins D, Elders M: Human Fertility control, Butterworths, London, 1979: 237-60.

8.     Time magazine, Aug 6, 1984.

9.     News week December 10, 1979p 29.

10.   Goto A, Fujiyama-Kiriyama C, Fukoo A, etal: Abortion trends in Japan1975-95 Stud Fam Plann 2000 ,31(4):301-8.

11.   Kovasc L: Abortion and contraceptive practice in Eastern Europe Int J Gynaecol Obstet 1997 ,58, (1): 69-75

12.   News week July 17, 1989: The Future of Abortion pp 32-40.

13.   Straburger V: Sex, Drugs, Rock “N” Roll. Understanding Teenagers Behavior. Pediatrics (supplement), 76, (4), Oct 1985: 659-63.

14.   Time magazine, cover story: Children having children, December 9, 1985: 28-31.

15.   Tindall VR: Jeffcoats Principle of Gynecology. Butter worths, London, 5th edition, 1985:28-31.

16.   Kaufman R, Spitz A , Moris Letal: The Decline in US Teen Pregnancy Rates 1990-95. Pediatrics 1998;102(5):1141-7

17.   Henshaw SK: Abortion Incidence and Services in the US, 1995-96 Fam Plann Perspect 1998, 30: 263-270 and 287.

18.   Tifts: Curse Heaven for little girls. Time magazine Jan 4, 1988:46-7.

19.   Ibrahim M.A: what to do with excess fertilized ova? (Arabic) and discussions 3rd Symposium on some medical practices, April 18, 1987. Islamic Organization for Medical Sciences, Kuwait, pp 450-455 and 666-78.

20.   The complete works of the 3rd meeting of the International Islamic jurists council OIC, October 11-16, Amman, Jordanvol. 1, pp 425-515.

21.   Hathout H: Topics in Islamic Medicine. Is­lamic Medicine Organization, Ku­wait, 1984; pp 93-135.

22.   Ahmed WD. Oath of Muslim Physician JIMA, 1988, 20:11-4.

23.   Phillips M, DawsonJ. Doctors’ Dilemma, The Harvester Press, Brighton(G. Britain), 1985, Appendix: The Declaration of Genevapp 211.

24.   ibid pp 45-9.

25.   Albar M: Policy and methods of Birth control (Arabic: Siyasat wa wasayil Tahdid Annasl) Al Asr AlHadith Publication, Beirut1991, pp 119-23.

26.   Jian J, Meckstroth K,Mishell D:Early pregnancy termination with intravaginally administered moistened misoprostol tablets. Historical comparison with mifepristone and oral misoprostol . Am J Obstet and Gynecol 1999 (6) : 1386-91.

27.   Holy Bible, Book of Genesis 1:27,28. New International translation, Hodder and Stroughton, London, 1980.

28.   Muslim. Sahih Muslim Bishareh Al Nawawi, Dar Al Fik, Beirut, 2nd ed. 1972, Book of Zakat vol. 7:92.

29.   The Glorious Quran Sura 4, Al Nisa (women), aya 4.

30.   Ibid Sura 16, Al Nahil (The Bee), aya 72.

31.   Ibn Maja: Sunan Ibn Maja, Cairo, Matbaat Issa Al Halabi, (No date mentioned), Kitab Al Nikah, 8.

32.   Ahmed ibn Hanbal: Musnad Ahmed. Comment by Ahmed Shakir, Cairo, Dar Al Maarif (nd) vol. 3:158,245; vol. 4:349,351.

33.   Al Bokhari M: Al Jamie Al Sahih, Cairo, Maktabat Al Nahda Al Haditha 1367 H (1956); Kitab Al Nikah: 96, Kitab Al Maghazi:32.

34.   Muslim (Al Qushairi): Al Jamie Al Sahih, Cairo, Dar Ihya al Kotob Al Arabia, Issa al Babi al Halabi (nd), Kitab Attalaq:15,25,26,27,28.

35.   Ahmed ibn Hanbal (reference 32) vol. 3:51,53,313,388.

36.   Holy Bible, Book of Genesis 38:8-10.

37.   Resolution No 1 concerning Birth Control. The council of Islamic Figh Academy, 5th session, held in Kuwait10-15 December 1988, Islamic Figh Academy. Resolutions and Recommendations 1406-1409 H/1985-1989, 36. Organization of the Islamic conference, Jeddah.

38.   Shaltoot M: Al Fatawa (Arabic), Dar Alshorooq, Cairo, 15th edition 1988 p 289-291.

39.   The Kuwaiti Law No 12 Quoted by Dr. S. Alawadi in 3rd Symposium of Islamic viewpoints on some aspects of Medical Practice held in Kuwait April 18,1987, Complete works and discussions, Islamic organization for Medical Sciences, Kuwait, 1987 pp 456-459.

40.   The 4th Resolution on Aborting a congenital malformed fetus, Islamic jurist council of Islamic World League, Makkah Al Mukaramah, 12th session 10-17th February 1990 and also quoted appendix No 1, in M.Albar: Al Ganin Al Mushawah (The congenitally malformed fetus), Dar Al Qalam Damascus and Dar Al Manara Jeddah 1991 pp 439.

41.   Al Bar M: Mushkilat Al Ijhadh (The problem of Abortion), Arabic, Saudia Publishing House, Jeddah, 1985 p 37-45.

42.   Al Ghazali M: Ihyia Oloom Al Dein. Dar Al Maarif, Beirut, vol 2:65.

43.   The Glorious Quran: Sura Al Maiydah 5, aya 32.

44.   The Glorious Quran: Sura Al Anaam 6, aya 151.

45.   The Glorious: Sura Al Isra 17, aya 31.

46.   Al Bokhari M: Al Jamie Al Sahih, Cairo, Maktabat Al Nahda Al Haditha, 1956, Kitab Al Tafsir, Sura: Al Bakara (2), Kitab Al Adab 22, Kitab Al Diyat 1, Kitab Al Hodood 19, Kitab Al Tawheed 40,60.

47.   Muslim: Sahih Muslim Bishareh Al Nawawi, Dar Al Fikr, Beirut, 2nd edition 1972, Kitab Al Iman vol. 2: 79,80.

48.   Ibn Al Qaiyim: Attibian fi Aksam Al Quran, Maktabat Al Kahira, Cairo(No date mentioned), p 255.

49.   Ibn Hajar Al Askalani: Fathu Al BariFi Shareh Sahihu Al Bokhari Al Malktabh Assalafiyah, CairoKitab Al Qadar vol. 11:481.

50.   The Glorious Quran: Sura Al Moominoon 23, aya 12-14.

51.   Al Bokhari M: Al Jamie Al Sahih, Cairo, Maktabat Al Nahda Al Haditha 1956, Kitab Bidu Al Khalq, Kitab Al Tawhid, Kitab Al Anbiya, bab Khalq Adam, Kitab Al Qadar.

52.   Muslim: Sahih Muslim Bishareh Al Nawawi, Dar Al Fikr, Beirut2nd edition; 1972, Kitab Al Qadar.

53.   Koren J: Symposium on Ethics of Organ transplantation Ottawa( Canada) Aug. 20-24, 1989. Abstracts.

54.   Hathout H: Islamic Perspectives in obstetrics & Gynecology. Islamic Medicine organization, Kuwait, 1986 pp 61-89.

55.   Shaltoot M: Islam: Creed and Shariah, Dar al Qalam, 1966. Quoted in reference 54.


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HEALTH CARE


HEALTH CARESERVICES IN SAUDI ARABIA: PAST, PRESENT AND FUTURE

Zohair A. Sebai, PhD,* Waleed A. Milaat, PhD,† Abdulmohsen A. Al-Zulaibani, MBCHB‡

*­Shourah Council, Riyadh, † Medical School, King Abdulaziz University, Jeddah and ‡Joint Program of Family and Community Medicine, Jeddah, Saudi Arabia

لقد تطورت الخدمات الصحية في المملكة العربية السعودية بشكل كبير خلال العقدين الماضيين وامتدت إلى كل أرجاء البلاد الشاسعة البعيدة وبينما تقوم وزارة الصحة في المملكة بتقديم ما يزيد على 60% من هذه الخدمات، تتقاسم جهات حكومية أخرى مع القطاع الخاص تقديم باقي الخدمات الصحية للمواطنين. ومن المؤكد أن خطط  التنمية  الخمسية للدولة  قد أفلحت بشكل كبير في إنشاء البني التحتية المطلوبة لتقديم الخدمات العلاجية في المملكة كما أن مجالي التعليم الطبي والتدريب للكوادر الفنية في المجال الصحي قد شهدا تقدما ملحوظا. ومع كل هذا فانه لا بد من النظر في العديد من التحديات المستقبلية التي تواجه النظام الصحي في السعودية والتي لا مناص من دراستها والتعامل معها لتحقيق أهداف الخطة الخمسية الحالية. وتتمثل هذه التحديات في القدرة على الاستخدام الأمثل للموارد والإمكانات البشرية والمادية في القطاع الصحي بالتخطيط الجيد والإدارة الفاعلة الكفء كما يمثل البحث عن مصادر أخرى للإنفاق على الخدمات الصحية غير القطاع الحكومي أحد أهم هذه التحديات. وتشكل الحاجة إلى إيجاد التوازن المفترض في تقديم الخدمات الصحية بشقيها العلاجي والوقائي وكذلك التطبيق الأمثل لبرنامج الرعاية الصحية الأولية والتوسع في تدريب القوى العاملة السعودية في المجالات الفنية الصحية تحديات أخرى تواجه المخططين للخدمات الصحية في المملكة.

الكلمات المرجعية: النظام الصحي، إحصائيات صحية، الرعاية الصحية الأولية، المملكة العربية السعودية.

Health services in Saudi Arabiahave developed enormously over the last two decades, as evidenced by the availability of health facilities throughout all parts of the vast Kingdom. The Saudi Ministry of Health (MOH) provides over 60% of these services while the rest are shared among other government agencies and the private sector. A series of development plans in Saudi Arabiahave established the infra­structure for the expansion of curative services all over the country. Rapid development in medical education and the training of future Saudi health manpower have also taken place. Future challenges facing the Saudi health system are to be addressed in order to achieve the ambitious goals set by the most recent health development plan. These include the optimum utilization of current health resources with competent health managerial skills, the search for alternative means of financing these services, the maintenance of a balance between curative and preventive services, the expansion of training Saudi health manpower to meet the increasing demand, and the implementation of a comprehensive primary health care program.

Key Words: Health system, health statistics, primary health care, Saudi Arabia.

Correspondence to:

Dr. Waleed Milaat, P.O. Box 984, Jeddah 21421, Saudi Arabia


 

THE PAST

The history of health care services in Saudi Arabiadates back to 1949, when a small number of medical staff (111 doctors) and fewer than 100 hospital beds were documented.1 Since then, the Kingdom has made huge advances in the organization of its health care system. Major developments have brought health services to every corner of the vast kingdom. Compared to 1949, the number of doctors and nurses has multiplied 25 times and 20 times (1172 to 30281 and 3261 to 64790 in 1998) respectively, in more than 300 hospitals and 1700 primary health care centers around the country. Government spending on health rose sharply as the budget of the Ministry of Health (MOH) increased sixty fold to 12044 million SR (3.2 billion US$) in 1998, about 6.2% of the national budget.2,3

                This remarkable development in the health care system has been accompanied by an improvement in the quality of health services, especially in curative medicine. Hos­pi­tals have become fully equipped and are able to perform a variety of advanced procedures in cardiovascular and cancer surgery, as well as all types of transplant operations. 

          Preventive services started in early 1950s when the ARAMCO oil company, in collaboration with the WHO, helped the MOH to control malaria in the eastern re­gion of the kingdom.4 Programs to control bilharziasis, leshmianisis, trachoma, tuber­cu­losis and other endemic diseases followed suit in the various regions of the country on both vertical and horizontal levels.5-7 The country also adopted the new concept of Primary Health Care (PHC) developed in 1978 and in 19838,9 began to promote it as the basis of its health delivery system. This strategic step has been most fruitful with the immunization of over 90% of the children in Saudi Arabiaagainst infectious childhood diseases in the EPI system.10

                       Medical education has also developed considerably with over 340 doctors and 89 dentists graduating from five medical colleges and two dental schools in 1998.3 Another four government colleges in Madi­nah, Qassim, Gizan and Hassa are to be opened in due course and ambitious plans for private medical colleges are under dis­cus­sion. Local literature on health in Saudi Arabiahas also developed. A large number of health research projects have been con­ducted in various fields of medi­cine and allied sciences over the last fifteen years and the results published in more than 10 Saudi medical journals.

THE CURRENT SITUATION

The MOH provides around 60% of the health services, free of charge, through 13 health directorates. Twenty per cent of the health service is delivered free through other government agencies3 and the remaining 20% is provided by the non-government sector, which is growing rapidly (Table 1).


 

Table 1:Distribution of health services in Saudi Arabiaby type of providers (1998)

Item

Ministry of Health

Other Govern. Agencies

Private Sector

Total

Hospitals

    182

    39

      87

    308

Hospital beds

27428

9119

  8485

45032

PHC centers

  1751

-

-

   1751

Private center

-

-

     622

    622

Private clinic

-

-

     785

    785

Pharmacies

-

-

   3208

  3208

Doctors

14407

  6853

   9021

30281

Nursing staff

36101

17080

11609

64790

Technicians

19743

  9686

  3846

33275

Source: Reference 3.


 

                In 1998, the total budget of the MOH reached over 12000 million SR, with an average expenditure of 400 SR (108 US$)per capita per year. In other government agencies the expen­diture also increased (200 US$ per capita). The relatively high health expen­diture in this country compared to that of many developing countries has made the extensive coverage with curative services in Saudi Arabiapossible. Nevertheless, this progress has not been equally commen­surate with other important issues, such as: (1) The develop­ment of the health infor­mation system for the purpose of effec­tive plan­ning, moni­toring and systematic evalua­tion; (2) The training of personnel in various medical fields and health administra­tion; and (3) The enhancement of preventive services.

FUTURE CHALLENGES

These can be grouped into four interrelated domains:

1. Management and financing of health services

Government services are currently pro­vided by more than 10 agencies, including the MOH. The management of these ser­vices is not uniform, and some managed by private contractors are still expensive. However, the diversity of administrative systems could be a source of enrichment, especially in health administration and the management of re­sources. Better coordina­tion among these agencies would result in more judicious use of available resources and expertise, to the greatest advantage. Health services are largely publicly financed, and in spite of an increased budget allocation for these free services, the actual average expenditure per capita is expected to decrease. This is a re­sult of a rapidly growing population and declining government revenues.11 Thus, other sources of financing are essential. The govern­ment, therefore, is proceeding with its plan for the implementation of the co­opera­tive health insurance scheme, which is already being applied to non-Saudis. Further plans for privatization of health services and facilities are on the drawing board, but there are still many issues to be resolved. There is a definite need for competent health man­age­ment and an innovative approach to health administration and financing.

2. Curative versus preventive services

An official report by the Ministry of Planning on the utilization of health services was conducted on the PHC center level in 1984.12 The report documented a heavy focus on providing curative services, with over 90% of its acti­vities directed towards individual patient care. This trend was noted in further studies in several regions of the country.13 Health planners for the fifth national health plan (1990-1995), thus felt the need to emphasize preventive services in PHC centers and shift interest towards re­ducing endemic disease, combating com­mun­i­ty health problems, and raising the health level of the population through application of all curative, preventive and promotive elements in PHC. The impact of these measures was evident in the exten­sive coverage of the children's immun­i­za­tion pro­­­gram, a 29% reduction in hospital atten­dance, and a 42% increase in PHC visitors for all types of services during the five-year period (1989-1994).14

3. Training and development of Saudi manpower

Official estimates show that the percentages of Saudi doctors, nurses and paramedics were 18.7, 18, and 43% respectively, of the working force of the health services in 1998.3 In view of the rapid population growth in the country, these figures pose a challenge to the smooth running of the health system by Saudi manpower. It is calculated that there will be a total of 15226 Saudi doctors in the Saudi health force by the year 2020, representing only 32% of the total health manpower. This is a rather con­servative estimate, based on the present number of Saudi doctors (5699 in 1998), together with the projected 500 graduates per year, allowing a 15% dropout rate for various reasons. Hence, the country’s dependence on expatriates to fill physicians’ posts will continue for long time. Similar shortage is also envisaged among Saudi nurses15 and other health personnel, in­dicating an urgent need to accelerate the training of the Saudi work force in all health fields. With the escalation of training costs in the health field all over the world, the involvement of the private sector in training, in conjunction with the privatization of the country’s health system, could be part of the solution. It should be noted that the development and training of health man­power in the country should concentrate not only on the number of health workers trained but also on the assurance of the quality and the performance of those trained. This, undoubtedly, will mean the adoption of better quality assurance pro­grams in all health facilities to maximize the utilization of Saudi manpower and develop medical curricula in medical institutes to meet the required training standards.

4. Health development plans of the country

The provision of free health care to the entire population is enshrined in the constitution of Saudi Arabia.Previous develop­­ment plans had repeatedly empha­sized the right of all Saudi citizens to a healthy life, and the need to develop and organize the health system to achieve this. The sixth development plan (1995-2000) of the country clearly details this and specifies the following points: (1) The development of health manpower in terms of both quan­tity and quality, (2) The assurance of both curative and preventive services to all Saudis, (3) The development of primary health care services as a solid basis of the health delivery system to the entire popu­lation, particularly to mothers and children, (4) The control of all endemic diseases and their possible eradication.

Detailed, measurable objectives noted in this plan were as follows: (1) Maintain the current hospital bed rate of 2.4 beds per 1000 population, (2) Minimize the current rates of childhood infections and diarrheal diseases through immunization programs and other preventive measures, (3) Lower the infection rate of malaria in endemic areas to 200/100,000 and eradicate it from non-endemic areas, (4) Increase antenatal coverage for 97% of all pregnant mothers and increase the tetanus immunization rate of these mothers to 85%, (5) Reduce the rate of preterm babies to less than 2% of all deliveries.

CONCLUSION

The development of health care services in Saudi Arabiahas influenced life in the Kingdom and changed the health map of the country in a very positive way. Previous health plans established most of the infra­structure for the health services with remarkable results. However, for suc­cess­ful implementation of a good health care system to provide adequate, high quality ser­vice to all citizens, a balance between preventive and curative services will have to be established, managerial and adminis­trative skills in health facilities have to be sharpened through application of quality pro­grams, and the quality and quantity of the training of Saudi health manpower should be properly developed.

REFERENCES

1.     Papanikalaou. B. The tuberculosis control pro­gram in Saudi Arabia. WHO/TB/I0; 1949:20-23.

2.     Saudi Arabia Ministry of Planning, Achievements of the development plans (1970-1985), 1986:271.

3.     Ministry of Health. Annual Health Report. King­domof Saudi Arabia, 1998.

3.     Aramco Medical Department. Epidemiology Bulletin, Dhahran, Saudi Arabia: Oct 1972;1-2.

4.     Abdel Azim M.  Gismann A. Bilharziasis survey in south-western Asia Bull WHO 1956; 14:403-456.

5.     Tarizzo ML., Schistosomiasis in Saudi Arabia Vemes, Congres Internationaux de Medi­cine Tropical et du paludisme (Expert) 1956.

6.     Page RC. Progress report on the Aramco trachoma research program.  Med Bull Standard Oil Co (NJ) l959; 19: 68-73.

7.     World Federation of Public Health Association, Inter­national conference on primary health care, Alma Ata, USSR, September 6-12,1978. Conference Bulletin, I 978; 3: 1-2.

8.     Ministry of Planning, Fourth Development Plan 1985 -1990. Saudi Arabia1985: 323-338.

9.     World Health Organization, The world Health Report 1997; Conquering suffering enriching humanity, Geneval997: 44- 156.

10.   Umeh JC. Healthcare financing in the kingdomof Saudi Arabia: a review of the options. World Hosp Health Serv 1995; 31(2) :3-8.

11.   Saudi Arabia: Ministry or Planning, Development of health services and its appropriate manpower (CL Health Planner) 1984: 386.

12.   Sebai Z A. Health in Saudi Arabia–Volume II. King Abdulaziz Cityfor Science and Technology, 1987.

13.   Ministry of Planning, Sixth Development Plan 1995 -2000. Saudi Arabia1995.

14.   Luna L. Culturally competent health care: a challenge for nurses in Saudi Arabia. J Trans­cultural Nursing 1998; 9 (2): 8-14.


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