Awareness of Chorioamnionitis and Its Complications: A Cross-Sectional Study Among Women in Makkah City.

Chorioamnionitis (CA) is a common pregnancy complication involving inflammation of the placental membranes and chorion. It is also known as intra-amniotic infection, often caused by ascending bacterial infection, typically occurring with membrane rupture but sometimes without it. Clinical and histologic CA often overlap, with histologic CA being more common and identified through microscopic placental abnormalities [ 1 ]. Several studies have identified various risk factors associated with CA. These include an extended duration of membrane rupture, prolonged labor, being a first-time mother (nulliparity), and African American ethnicity. Other contributing factors include the use of internal labor monitoring, frequent vaginal examinations during labor, the presence of meconium-stained amniotic fluid, and lifestyle factors such as smoking, alcohol consumption, or drug abuse. Additionally, conditions like immune system compromise, the use of epidural anesthesia, and infections such as group B streptococcus colonization, bacterial vaginosis, sexually transmitted genital infections, and vaginal colonization with Ureaplasma have been linked to an increased risk of developing CA [ 2 - 12 ]. CA has been reported in 2-4% of full-term pregnancies [ 3 ] and 40-70% of preterm pregnancies [ 13 , 14 ]. Another retrospective cohort study conducted in 2009 at Moffitt-Long Hospital, San Francisco, reported that CA affects 1% of term and 13-60% of preterm premature rupture of membranes (PPROMs) [ 15 ]. In addition, a study conducted in Korea in 2013 identified CA as one of the risk factors for adverse neonatal outcomes [ 16 ]. This was supported by a retrospective cohort study conducted in 2017 in Washington, which reported a definite connection between CA and fetal complications, specifically respiratory distress syndrome and perinatal death [ 17 ]. Moreover, another study found that CA was associated with an increased risk of adverse maternal outcomes following cesarean section [ 18 ]. Unfortunately, only one study was conducted in Jeddah, Saudi Arabia, in 2021 to assess knowledge of CA and its complications. It showed poor knowledge about CA and its complications among 49.1% of participants [ 19 ]. Therefore, this study aims to evaluate the awareness of CA and its complications among women living in Makkah City, Saudi Arabia, and their effects on mothers and newborns.

Sociodemographic characteristics, pregnancy history, and medical conditions of participants The study included a total of 702 participants, with a mean age of 36.63 years (SD: 9.74). The majority were Saudi nationals (N=638, 90.9%), while non-Saudis accounted for a smaller proportion (N=64, 9.1%). In terms of education, most participants held a bachelor's degree (N=409, 58.3%), followed by postgraduate studies (N=101, 14.4%), diplomas (N=84, 12.0%), high school (N=87, 12.4%), medium education (N=16, 2.3%), and elementary education (N=5, 0.7%). Regarding family income, the highest proportion earned was 10,000-20,000 SAR (N=276, 39.3%), followed by 3,000-10,000 SAR (N=263, 37.5%), more than 20,000 SAR (N=105, 15.0%), and less than 3,000 SAR (N=58, 8.3%). In terms of employment status, employees constituted the largest group (N=346, 49.3%), followed by housewives (N=315, 44.9%) and students (N=41, 5.8%). The mean total number of pregnancies was 3.70 (SD: 2.26), with a mean of 1.85 births at ≥24 weeks (SD: 2.22) and a mean of 0.74 miscarriages at <24 weeks (SD: 1.30). The majority of participants reported having no chronic diseases (N=522, 74.4%), while urinary tract infections were the most commonly reported condition (N=86, 12.3%), followed by diabetes (N=59, 8.4%) and vaginitis or sexually transmitted infections (N=18, 2.6%). Other conditions, including high blood pressure, lupus erythematosus, weak ovum, uterine fibroids, placenta previa, polycystic ovary syndrome/obesity, hypothyroidism, glandular disorders, epilepsy, elevated liver enzymes during pregnancy, and anemia, were each reported by only one or two participants (≤0.3%). Regarding PROM, 72.9% (N=512) had never experienced it, while 27.1% (N=190) had a history of PROM/PPROM (Table 1 ). PROM, preterm rupture of membrane; PPROM, preterm premature rupture of membrane Awareness, experience, and sources of information regarding chorioamnionitis Among the participants, 375 (53.4%) had heard of CA, while 327 (46.6%) were unaware of the condition. Among those who had knowledge of CA (N=375), the most common sources of information were healthcare workers (N=110, 29.3%), followed closely by social media (N=105, 28.0%), relatives and friends who had experienced the disease (N=77, 20.5%), scientific lectures (N=45, 12.0%), and books, newspapers, and magazines (N=38, 10.1%). Regarding personal experience with CA, 110 participants (15.7%) reported having had the condition, whereas the majority (N=592, 84.3%) had not. Among those who had experienced CA (N=110), cesarean section was the predominant method of delivery (N=95, 86.4%), while natural birth was reported in 15 cases (13.6%) (Table 2 ). Perceived risks and complications of chorioamnionitis for mothers and newborns The majority of participants believed that CA increases the risk of various complications. Most respondents associated the condition with bleeding (N=623, 88.7%), emergency cesarean section (N=625, 89.0%), blood poisoning (N=530, 75.5%), high blood pressure during pregnancy (N=576, 82.1%), intrauterine fetal death (N=580, 82.6%), premature birth (N=613, 87.3%), and infection in the baby (N=519, 73.9%). Additionally, a significant proportion linked it to gestational diabetes (N=413, 58.8%), endometriosis (N=414, 59.0%), and blood clots (N=455, 64.8%). Regarding potential complications in the child, most participants believed that CA could lead to premature birth (N=630, 89.7%), sepsis (N=522, 74.4%), low birth weight (N=550, 78.3%), pneumonia (N=482, 68.7%), and death (N=530, 75.5%). Many also associated the condition with meningitis (N=435, 62.0%), retinopathy (N=421, 60.0%), and cerebral palsy (N=375, 53.4%) (Table 3 ). Knowledge and misconceptions about chorioamnionitis among participants The majority of participants recognized that women with a ruptured amniotic sac are at greater risk of CA (N=465, 66.2%), and many identified lower abdominal pain as a symptom (N=434, 61.8%), though a smaller proportion acknowledged an increased heart rate in the mother and fetus as a sign (N=351, 50.0%). More than half believed that inflammation of the reproductive system is a cause (N=391, 55.7%) and that the condition can lead to premature death in newborns (N=401, 57.1%), while a notable portion mistakenly thought premature babies are less likely to develop it (N=271, 38.6%). A majority agreed that CA almost always leads to preterm birth (N=397, 56.6%) and can cause serious complications (N=432, 61.5%). However, opinions were mixed on whether antibiotics alone are sufficient for treatment (N=255, 36.3%) and whether the condition can be transmitted from mother to husband (N=272, 38.7%). Regarding prevalence, only N=218 (31.1%) believed CA is common in Saudi Arabia, while N=282 (40.2%) were uncertain. Most respondents agreed that diagnosis requires specialist review (N=497, 70.8%) and that early treatment of infections can reduce incidence (N=484, 68.9%). There were misconceptions, as N=241 (34.3%) believed women cannot get pregnant again after having CA, and N=323 (46.0%) attributed the condition to poor hygiene. Additionally, N=241 (34.3%) thought it could be resolved without treatment, while N=370 (52.7%) correctly identified that the infection can be transmitted from mother to baby. There was uncertainty about whether medications for CA are more harmful than the disease itself (N=295, 42.0%) and whether it can be treated with herbs or home remedies (N=251, 35.8%). Similarly, a nearly even split existed regarding the belief that cesarean section is the only treatment (N=306, 43.6%) (Table 4 ). Association between awareness of chorioamnionitis and sociodemographic characteristics There was a significant difference in age between those who had heard of CA (median=33.00, IQR: 27.00-40.00) and those who had not (median=40.00, IQR: 31.00-45.00, p<0.001). Awareness was significantly higher among non-Saudis (N=42, 65.6%) compared to Saudis (N=333, 52.2%, p=0.048). Educational level also played a role, with higher awareness among those with postgraduate studies (N=74, 73.3%) and diploma holders (N=55, 65.5%) compared to those with a high school education (N=35, 40.2%) or lower (p<0.001). Family income was significantly associated with awareness, with lower awareness in those earning less than 3000 SAR (N=19, 32.8%) compared to those earning 10,000-20,000 SAR (N=172, 62.3%, p<0.001). Employment status showed a significant correlation, with students (N=30, 73.2%) and employees (N=208, 60.1%) being more aware than housewives (N=137, 43.5%, p<0.001). Women who had heard of CA had fewer pregnancies (median=3.00, IQR: 2.00-5.00) than those who had not (median=4.00, IQR: 2.00-6.00, p<0.001). They also had fewer births ≥24 weeks (median=0.00, IQR: 0.00-2.00) compared to those unaware (median=2.00, IQR: 0.00-4.00, p<0.001) and slightly fewer miscarriages <24 weeks (median=0.00, IQR: 0.00-1.00, p=0.040). Women who had experienced PROM/PPROM were significantly more likely to have heard of CA (N=127, 66.8%) compared to those who had not (N=248, 48.4%, p<0.001). Similarly, nearly all women who had CA (N=104, 94.5%) were aware of it, compared to only 45.8% of those who did not have the condition (N=271, p<0.001). Among those who had CA, cesarean section was significantly more common in those who were aware of the condition (N=93, 97.9%) compared to those unaware (N=2, 2.1%, p=0.003) (Table 5 ). U Independent sample Mann-Whitney U test F Fisher’s exact testand Fisher-Freeman-Halton exact test *p<0.05, significant PROM, preterm rupture of membrane; PPROM, preterm premature rupture of membrane Association between chorioamnionitis and demographic, obstetric, and clinical factors There was a significant difference in age between those who had experienced CA (median=34.00, IQR: 30.00-39.00) and those who had not (median=37.00, IQR: 29.00-45.00, p=0.040). Nationality was not significantly associated with CA, with similar proportions among non-Saudis (N=10, 15.6%) and Saudis (N=100, 15.7%, p=1.000). Educational level showed a significant association, with a higher prevalence among women with postgraduate studies (N=30, 29.7%) compared to those with a bachelor’s degree (N=61, 14.9%) or high school education (N=6, 6.9%, p<0.001). Family income was also significantly associated with lower rates of CA among those earning less than 3000 SAR (N=3, 5.2%) compared to those earning 10,000-20,000 SAR (N=65, 23.6%, p<0.001). Employment status played a role, with employees (N=82, 23.7%) having a significantly higher prevalence than housewives (N=26, 8.3%) and students (N=2, 4.9%, p<0.001). While the total number of pregnancies was similar between groups (p=0.545), those with CA had fewer births ≥24 weeks (median=1.00, IQR: 0.00-1.00) compared to those without the condition (median=1.00, IQR: 0.00-3.00, p<0.001). However, they had more miscarriages <24 weeks (median=1.00, IQR: 0.00-1.00) than those who did not have CA (median=0.00, IQR: 0.00-1.00, p<0.001). PROM/PPROM was significantly associated with CA, as more than half (N=101, 53.2%) of those with PROM/PPROM had experienced CA, compared to only 1.8% (N=9) of those without PROM/PPROM (p<0.001) (Table 6 ). U Independent sample Mann-Whitney U test F Fisher’s exact test and Fisher-Freeman-Halton exact test *p<0.05, significant PROM, preterm rupture of membrane; PPROM, preterm premature rupture of membrane Chorioamnionitis awareness and knowledge scores by demographic, health, and obstetric factors The chorioamnionitis awareness and knowledge score varied significantly across several factors. Educational level showed a significant association (p<0.001), with those having postgraduate studies scoring higher (median=16.00, IQR: 16.00-18.00) compared to those with a high school education (median=14.00, IQR: 9.00-17.00) or medium education (median=11.50, IQR: 7.00-15.50). Family income also played a role (p=0.003), where individuals earning 10,000-20,000 SAR had a higher median score (median=16.00, IQR: 13.00-18.00) compared to those earning less than 3000 SAR (median=14.50, IQR: 10.00-17.00). A significant difference was observed in individuals who had experienced PROM/PPROM, with those who had it scoring higher (median=16.00, IQR: 15.00-18.00) compared to those who had not (median=15.00, IQR: 10.00-17.00, p<0.001). Awareness of CA was also a key factor (p<0.001), as those who had heard of it scored significantly higher (median=16.00, IQR: 15.00-18.00) than those who had not (median=12.00, IQR: 8.00-16.00). The source of information was also important (p<0.001), with individuals who learned about the condition through scientific lectures (median=16.00, IQR: 15.00-19.00) and healthcare workers (median=16.50, IQR: 16.00-18.00) scoring higher compared to those who relied on relatives or friends (median=16.00, IQR: 13.00-17.00). A significant association was found between CA history and knowledge scores (p<0.001), where those who had the condition had a higher median score (median=16.00, IQR: 16.00-18.00) compared to those who had not (median=15.00, IQR: 10.00-17.00). Additionally, among those who had CA, the method of delivery impacted the knowledge score (p<0.001), with those who underwent a cesarean section having a higher score (median=16.00, IQR: 16.00-18.00) compared to those who had a natural birth (median=16.00, IQR: 14.00-17.00) (Table 7 ). K Independent sample Kruskal-Wallis test U Independent sample Mann-Whitney U test *p<0.05, significant PROM, preterm rupture of membrane; PPROM, preterm premature rupture of membrane Correlation between chorioamnionitis awareness and knowledge scores with age and pregnancy history The correlation analysis between the chorioamnionitis awareness and knowledge score and various demographic and reproductive factors revealed a significant negative correlation with the number of births (≥24 weeks) (Spearman’s rho=-0.145, p<0.01), indicating that individuals with more full-term births tended to have lower awareness and knowledge scores. However, no significant correlations were observed with age (Spearman’s rho=-0.053, p=0.159), total number of pregnancies (Spearman’s rho=-0.026, p=0.494), or the number of miscarriages (<24 weeks) (Spearman’s rho=-0.065, p=0.088) (Table 8 ). **Correlation is significant at the 0.01 level (2-tailed)

This study assessed awareness of CA and its complications among women in Makkah, Saudi Arabia. The findings revealed that while more than half of the participants (53.4%) had heard of CA, a significant portion remained unaware of the condition. This lack of awareness is concerning, as CA is a serious infection that can lead to severe complications for both mothers and newborns [ 21 ]. A study conducted in Jeddah reported that 49.1% of participants had poor knowledge of CA and its complications [ 22 ]. These findings indicate a need for better public health education about infections in mothers, especially those with life-threatening conditions. Women with postgraduate studies had the highest awareness levels (73.3%), while those with only a high school education or lower had significantly lower awareness. This trend aligns with previous studies, which have shown that individuals with higher education are more likely to seek health information and better understand medical conditions [ 23 ]. Education and health awareness are closely linked; therefore, health campaigns targeting women with less education are essential to help them obtain accurate information about pregnancy-related health risks. Another significant finding was the role of income and employment status in awareness levels. Women with higher family income (10,000-20,000 SAR) were more aware of CA than those earning less than 3,000 SAR. Employed women and students had significantly higher awareness than housewives. These results suggest that financial stability and professional engagement may provide more opportunities for women to access healthcare information, possibly through workplace wellness programs or increased exposure to digital health resources [ 24 ]. Similar trends have been observed in previous research, where economic factors influenced maternal health knowledge and health-seeking behavior [ 25 ]. Regarding sources of information, healthcare workers (29.3%) and social media (28.0%) were the most common sources of awareness. This finding is consistent with other studies indicating that social media has become a primary channel for health information dissemination [ 26 ]. However, reliance on social media raises concerns, as misinformation can spread easily, leading to misconceptions about medical conditions. A significant proportion of participants (46%) incorrectly believed that poor hygiene was a primary cause of CA, while 34.3% thought the condition could resolve without treatment. These misconceptions highlight the importance of ensuring that health information shared on social media is accurate and evidence-based. This study also explored the relationship between awareness and past obstetric history. Women who had experienced PROM were significantly more likely to have heard of CA than those who had not (66.8% vs. 48.4%). Nearly all women who had previously had CA (94.5%) were aware of the condition. This suggests that personal experience with pregnancy complications plays a crucial role in increasing awareness, which aligns with findings from previous research indicating that individuals are more likely to learn about medical conditions after experiencing them firsthand [ 27 , 28 ]. However, relying on personal experience alone is insufficient for widespread awareness, reinforcing the need for proactive health education. The study also assessed perceptions of the risks and complications associated with CA. Most participants correctly associated CA with increased risks of emergency cesarean section (89.0%), premature birth (87.3%), and intrauterine fetal death (82.6%). However, there were misconceptions regarding treatment options, with 43.6% believing cesarean section was the only treatment and 36.3% thinking antibiotics alone were sufficient. This discrepancy suggests that while women recognize the severity of CA, they may not fully understand the clinical management of the condition. A study in the United States similarly found that although pregnant women were aware of certain pregnancy-related complications, they often lacked a comprehensive understanding of their treatment [ 29 ]. The analysis further revealed that women with a history of CA had a significantly higher rate of cesarean section delivery (97.9%) compared to those without the condition. This finding aligns with previous research indicating that CA is a major risk factor for emergency cesarean delivery due to its association with fetal distress and maternal complications [ 30 ]. The increased rate of cesarean sections among women with CA underscores the need for better preventive measures, as surgical delivery carries its own risks, including infection and prolonged recovery [ 31 ]. Women who learned about CA through healthcare workers or scientific lectures had higher knowledge scores than those who relied on social media or friends. This finding is consistent with research showing that structured educational interventions are more effective in improving health literacy than informal sources [ 32 ]. Women who had experienced PROM/PPROM or CA scored significantly higher on knowledge assessments, reinforcing the impact of direct experience in shaping health awareness. One notable finding was the significant negative correlation between the number of full-term births and awareness scores, suggesting that women with more childbirth experiences were less knowledgeable about CA. This may stem from the perception that prior uncomplicated pregnancies indicate a lower risk of complications in subsequent pregnancies. However, this is a misconception, as multiparous women can still develop pregnancy-related infections [ 32 ]. Public health efforts should address this gap by ensuring that all pregnant women, regardless of previous pregnancy outcomes, receive adequate information about potential risks. Strengths and limitations This study has several strengths. It included a large sample size of 702 participants, which makes the findings more reliable. The study also covered various sociodemographic groups, allowing for a better understanding of how education, income, and employment influence awareness of CA. Additionally, the use of validated questionnaires ensured the accuracy of data collection. However, there are some limitations. Because the study used an online survey, it may have excluded women who do not use social media or have limited internet access. Another limitation is the self-reported nature of the responses, which could lead to recall bias. Furthermore, since the study was conducted in Makkah, the results may not fully represent other regions of Saudi Arabia. Future research and recommendations Future research should focus on developing educational programs to improve awareness of CA. Studies should explore the most effective ways to deliver health information, such as through hospitals, social media, or community workshops. Additionally, researchers should investigate how increased awareness affects pregnancy outcomes by conducting follow-up studies with pregnant women. More research is also needed to understand why misconceptions about CA persist and how they can be corrected. It would also be beneficial to conduct similar studies in other cities or rural areas to compare knowledge levels across different populations.

This study found that while more than half of the women in Makkah had heard of CA, many still lacked detailed knowledge about its causes, risks, and treatment. Women with higher education, income, and previous pregnancy complications were more aware of the condition. However, misconceptions about CA were common, highlighting the need for better public health education. Healthcare professionals and social media play key roles in spreading awareness, but reliable medical information should be promoted to prevent misinformation. Increasing awareness through targeted campaigns can help reduce complications related to CA and improve maternal and newborn health outcomes.

Study design This study employs a quantitative descriptive cross-sectional design to assess the awareness of CA and its complications among women in Makkah City, Saudi Arabia. Conducted between December 2024 and March 2025, the research uses an online questionnaire distributed via social media platforms to reach both Saudi and non-Saudi women who are currently pregnant or have experienced at least one pregnancy. The study received ethical approval from the Biomedical Research Ethics Committee at Umm Al-Qura University (Approval No. HAPO-02-K-012-2025-02-2548, dated 18/01/2025), ensuring adherence to ethical standards in data collection and participant engagement. Sample Size The sample size was calculated using OpenEpi version 3.0 (released in 2013, Atlanta, GA, USA), considering the following: the population size of females living in Makkah City is estimated at more than 1 million, according to the General Authority for Statistics of the Kingdom of Saudi Arabia [ 20 ]. Therefore, the minimum sample size to achieve a 95% confidence interval (CI) and a 5% margin of error was 384. To compensate for potential data loss, the total sample size was increased to 400 participants. Data Collection A validated questionnaire from a previous study was distributed via Google Forms through social media platforms. It was reviewed and translated into Arabic by a certified translator using a back-to-back translation technique [ 19 ]. The questionnaire consisted of four main sections. The first section collected data on participants’ sociodemographic characteristics, pregnancy history, and medical conditions, including age, nationality, educational level, family income, employment status, total number of pregnancies, number of births, number of miscarriages, history of diseases, and experience with preterm rupture of membranes (PROM). The second section assessed participants’ awareness of CA, personal experiences, sources of information about the condition, and the method of delivery. The third section examined participants’ understanding of the potential risks and complications of CA for both the mother and the newborn. The final section evaluated participants’ knowledge of CA and identified common misconceptions. Statistical Analysis Descriptive statistics: Descriptive statistics were used to summarize the study variables. Categorical data were presented as frequencies (N) and percentages (%), while continuous variables were expressed as mean and SD. Inferential statistics: For inferential statistics, the normality of continuous variables was assessed using the Kolmogorov-Smirnov test, which indicated that the data were not normally distributed. Consequently, nonparametric tests were applied. The Mann-Whitney U test was used to compare differences between two-category variables, while the Kruskal-Wallis test was used for comparisons involving multiple categorical variables. Fisher’s exact test or the Fisher-Freeman-Halton exact test was applied for categorical variables with small expected counts. Spearman’s rank correlation was performed to assess the relationship between the chorioamnionitis awareness and knowledge score and other continuous variables. Significance value: A p-value of <0.05 was considered statistically significant for all tests. Software: Data analysis was performed using IBM SPSS Statistics version 27.0.1 (IBM Corp., Armonk, USA). This software was used for all statistical computations, including descriptive statistics, inferential tests, and correlation analyses. Ethical consideration The study received ethical approval from the Biomedical Research Ethics Committee at Umm Al-Qura University (Approval No. HAPO-02-K-012-2025-02-2548, dated 18/01/2025). The questionnaire began with a clear statement assuring participants that their information would remain confidential and be used solely for research purposes. Participants were asked to either consent or decline participation, and only those who agreed were included in the study. Each participant was assigned an individual code number for data analysis to ensure anonymity and confidentiality. There were no incentives, and participation was entirely voluntary.