Factors affecting the decision of marriage among incompatible couples in the Saudi premarital screening program, 1425H

Under the Royal decree of 4/1/1423 H (i.e. 8/3/2002 G) the Ministry of Health in Saudi Arabia set organizational arrangements for the Saudi Premarital Screening Program, which started on 1/1/1425 H under the second Royal decree, which made premarital screening for genetic diseases mandatory for all couples who plan to marry. The marriage contract would not be issued until the result of this screening test was submitted. However, couples still have the choice of getting married in spite of incompatible results.

This study aimed to identify the proportion of incompatible results among all the couples who had undergone the premarital screening test during a period of one year (1/1/1425 to 30/12/1425), to ascertain the decision of marriage following incompatible results, and to study factors influencing the decision.

A two-part phone-call based structured questionnaire was designed, the first part to collect information for the descriptive component, and the second for the case-control study. After obtaining the final approval from the concerned authorities, a list of names of couples with incompatible results along with their contact numbers, test results and any information about their marriage decision was obtained from the national premarital screening program. All the couples for whom information about marriage decision was not available in the record were contacted by phone.

After the first six months of starting the program, the total screened were 145593 individuals; Sickle cell trait was found among 3.7%, Sickle cell disease 0.27%, Thalassemia minor 2.7% and Thalassemia major 0.06%. Regions with the highest numbers of trait and cases for both disorders were Al-Ahsa, Eastern province, Qunfudah, Jazan and Makkah, in descending order.

Basic data was available for 1211 couples who were found positive (not compatible) during the selected study period. Among the traceable incompatible couples, 830 were incompatible due to sickle cell disease (791 (95.3%) patients and 39 (4.7%) carriers). Among those 731 (88.1%) had married or decided to marry and 99 (11.9%) had decided not to marry. Among the traceable incompatible couples, 1074 were incompatible due to Thalassemia (1055 (95.3%) patients and 39 (4.7%) carriers). Among those 945 (88.0%) had married or decided to marry and 129 (12.0%) couples had decided not to marry.

Among 582 individuals who were interviewed by phone, 302 were khatibs (males) and 280 were makhtoobas (females). The ages of the khatibs ranged from 17-46 years (mean 27.4, standard deviation SD ± 4.5). The ages of the makhtoobas ranged from 15-44 years (mean 23, SD ± 4.69). Only 8 (2.7%) of the 302 khatibs were illiterate and 89 (29.4%) university level. From the 280 makhtoobas 5 (1.8%) were illiterate, and 89 (31.8%) university level.

Regarding their source of income, 263 (90.4%) khatibs were independent, 19 (6.5%) were fully dependent on their families and 9 (3.1%) were partially dependent on their families. Among makhtoobas 121 (41.6%) were independent regarding their source of income, 154 (52.9%) were dependent on their families, and 16 (5.5%) were partially dependent on their families.

For purpose of the case-control study, all the couples who decided not to marry were identified as cases. For identification of controls, couples were randomly selected among those who decided to marry despite a mismatched screening test result, with a ratio of 5 controls to one case. A total of 291 individuals were selected, among those 52 (17.9%) had decided not to marry (cases) while 239 (82.1%) had either married or decided to marry (controls). Among respondents who decided not to marry (cases) 26 (50%) were males and 26 (50%) females, their ages ranged from 19 to 39 years (mean 25.4, SD± 4.65). Among those who decided to marry (controls), 125 (52.3%) were males and 114 (47.7%) were females; their ages ranged from 15-46 years (mean 25.4, SD ± 5.1 years).

Factors influencing the decision of marriage among incompatible couples are presented in table 1.

Regarding knowledge of the existence of a compulsory Premarital screening program, only 6 (11.5%) of those who decided not to marry had not known about its existence compared to 42 (17.6%) of those who decided to marry.

Regarding knowledge of the main purpose of the Premarital screening program, among those who decided not to marry, 48 (92.3%) thought the purpose was to avoid certain diseases in prospective children, and 4 (7.7%) did not know. Among those who decided to marry, 197 (82.4%) thought the purpose was to avoid certain diseases in prospective children, 23 (9.6%) did not know the purpose, 9 (3.8%) answered that the purpose was to detect certain diseases in the couple, and 10 (4.2%) were not sure.

Among those who decided not to marry, 50 (96.2%) had the premarital screening test before melka (marriage contract), compared to 221 (92.5%) of those who decided to marry (OR=2.04, 95% CI 0.43 €“ 13.14).

Among those who decided not to marry, only 24 (46.2%) were asked by the health facility to visit the counseling clinic compared to 66 (27.6%) of those who decided to marry (OR=2.25, 95% CI 1.16 €“ 4.34). Among them, only 22 (42.3%) of those who decided not to marry, actually visited the counseling clinic compared to 84 (35.1%) of those who decided to marry (OR=1.35, 95% CI 0.70 €“ 2.60).

Among those who decided not to marry only 17 (32.7%) knew about their disease status before they did the premarital screening test; 21 (40.4%) had a known family history of Sickle cell anemia; 12 (23.1%) had a known family history of Thalassemia. Among those who decided to marry 40 (16.7%) knew about their disease status before they did the premarital screening test; 60 (25.1%) had a family history of Sickle cell anemia; and 23 (9.6%) had a Family history of Thalassemia. Among those who were asked to visit the counseling clinic, only 72 (67.9%) actually visited the clinic.

Premarital screening is one of the important measures which can help reduce the incidence of genetic diseases particularly in Middle Eastern countries which are characterized by older paternal and maternal ages and the high frequency of consanguineous marriages.[1]

Saudi Arabia is a large country with different cultures, social, and demographic features between different regions and occasionally within the same region itself. Indeed, the Saudi premarital screening program had a major objective to reduce the prevalence of genetic disorders in Saudi Arabia, thus decreasing the suffering of Saudi families and reducing the burden on health facilities and blood banks through avoidance of marriages among high risk couples. Up to date, the Saudi Premarital Screening Program only covers two blood diseases: Sickle cell disease and Thalassemia, which represent serious medical, social and economic problems to the family and to the public. The majority of incompatible couples in this study due to sickle cell disease and Thalassemia were reported from the Eastern, Western and South-western parts of the country, which conforms to the known disease prevalence pattern. The fact that the majority of participants in the study were related, gives an indication that consanguinity is the root of the problem.[2] These results are similar to a study of the premarital screening program in Bahrain, which is explained by the shared social and demographic characteristics between the two countries. [1]

It was found that if the respondents knew about their disease status before screening they were much more likely to decide against marriage than the ones who did not.

The role of the family in decision making cannot be ignored, as it was observed that the couples related to each other were more likely to continue with the marriage indicating some sort of family pressure. On the other hand when it came to decision making, although most of the decision was done by khateb or makhtooba or both but family members were more in favor of stopping an unsafe marriage; which could be used in promoting the objectives of the program.

The Premarital screening program in its first year has been able to avert only one-eighth of the marriages among incompatible couples. This rate is expected to increase as the test increases in popularity among society. Significant promotive factors in deciding not to marry included knowledge about disease status before screening, family history of thalassemia, and if both of the couples were suffering from sickle cell disease. Health facilities have failed to advise people to visit counseling clinics, which themselves were unable to significantly modify the marital decision of couples.

Timing of premarital screening should be made much earlier than maleka, to avoid social embarrassment by withdrawing from marriage at a late stage of commitment. An option which needs exploration is introduction of screening program at the end of secondary school.