Abstract
Background:
Obstetrics and gynecology emergency rooms (OB-GYN ERs) are crucial for treating acute women’s health issues. However, utilization of ER services for non-urgent complaints is a challenging issue in the healthcare system and could reflect gaps in the primary healthcare (PHC) setting.
Objectives:
To evaluate the epidemiology of OB-GYN ER visits and identify the patterns and predictors of hospital admissions in a referral university hospital in the Eastern Province of Saudi Arabia.
Design:
A retrospective, record-based, epidemiological study.
Methods:
All OB-GYN ER visits from January to December 2022 were included. Data on patient demographics, triage levels, timing of visits, chief complaints, and admission status were collected. Logistic regression models were used to assess factors associated with hospital admission.
Results:
Among 8781 ER visits, the median patient age was 30 years (Interquartile range: 26–36), and 85.30% were Saudi nationals. The majority of visits were triage level IV (71.84%), with only 12.46% resulting in admission. Obstetric complaints (47.44%) were the most common, followed by gastrointestinal and gynecological symptoms. Older age, higher acuity triage levels, the winter season, and visits during night or morning shifts were significantly associated with increased odds of admission. Most presenting complaints had a lower odd of admission when compared to the obstetrics complaints.
Conclusion:
The study demonstrates a substantial number of non-urgent OB-GYN ER visits, underscoring gaps in continuity of care. Strengthening PHC services and optimizing referral pathways for women’s health may help reduce unnecessary ER utilization and ensure more appropriate use of emergency resources.
Introduction
Emergency rooms (ERs) have a critical role in the healthcare system in providing timely and essential care for patients with acute health issues, particularly those relating to obstetrics and gynecology (OB-GYN). According to Nazzal et al., 1 10.13% of all ER visits among females aged 15–44 in North Carolina between 2016 and 2021 were related to pregnancy, and 15.50% of those visits resulted in hospitalization.
OB-GYN ERs are essential for ensuring maternal and reproductive health, especially in high-load tertiary care centers where a variety of clinical presentations are encountered, from non-urgent gynecological complaints such as menstrual irregularities and vaginal infections to life-threatening conditions such as ectopic pregnancy and postpartum complications. Epidemiological patterns of OB-GYN ER utilization reflect the population’s needs, as well as the accessibility and efficiency of healthcare systems. Utilization of OB-GYN ER services for non-urgent issues is a global challenge and a quality-related public health issue in healthcare systems worldwide. These non-emergency conditions can be managed effectively in an outpatient setting or a primary healthcare (PHC) setting after identification of the gaps and establishing proper strategic plans.2–4
In Turkey, a study showed that 31% of OB-GYN ER visits were for non-emergent complaints. 5 A study from Germany evaluating an ER service for pregnant females found that many patients presented due to misunderstandings in the interpretation of symptoms during pregnancy, with 36% eventually being hospitalized. 6 In Saudi Arabia, demands on OB-GYN ER services are rising with rapid population growth, especially with the large proportion of younger age groups. Therefore, women’s health is a national priority, reinforced by the goals of Vision 2030, which aims to improve accessibility and efficiency of healthcare in the country, as well as preventive care across all levels of the health system. In order to alleviate the burden on ERs and tertiary hospitals, Vision 2030 promotes an initiative toward empowering PHCs as the first point of contact, reducing dependence on hospital-based care, and ensuring timely patient-centered care.7,8 Understanding the epidemiology of utilization and admission determinants in OB-GYN ERs is a critical step for identifying gaps in healthcare services, optimizing triage protocols, and informing policies that support the integration of women’s healthcare into PHC. However, studies focusing on the presentation of women’s health issues are deficient in the region. Therefore, this study’s objectives include evaluating the epidemiology of OB-GYN ER visits as well as measuring the rate of admissions and its determinants in a large university hospital in the Eastern Province of Saudi Arabia.
Methods
Study design and setting
This is a record-based retrospective epidemiological study conducted at Imam Abdulrahman Bin Faisal University’s King Fahd Hospital in Khobar city in the Eastern Province of Saudi Arabia and is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. 9 The study hospital is a large, urban, tertiary-care, teaching hospital that serves as a referral center for a wide catchment area, providing comprehensive OB-GYN services alongside other specialties.
There is one examination room, a waiting area, and three observation beds in the OB-GYN ER. A trained nurse does the triage in the registration area. Patients with a triage level in need of resuscitation are seen in the resuscitation room that is covered by the adult ER staff. Pregnant females with any medical issues, as well as females with complaints that could be related to gynecological issues, are seen at the OB-GYN ER either directly or by a referral from the adult ER or a PHC center in Khobar city. Radiology services, pharmacy, and the option of admitting a patient when necessary are all available in the OB-GYN ER.
The OB-GYN ER is covered by OB-GYN consultants and residents in rotating shifts, and medical students and interns may also be present for training purposes.
Study population
All OB-GYN ER visits from 1 January to 31 December 2022, were included in this study. Therefore, the sample was a full coverage of all patients during this period. The only exclusion criterion was visits with missing or incomplete data in the electronic medical record.
Study variables
A structured data collection sheet was used to collect data from the patients’ electronic medical file. These variables were chosen based on the relevant literature, the study’s objectives, and the availability of the data. Content validity was ensured through consensus among the research team, which included consultants in family medicine, OB-GYN, women’s health, and public health. The variables included the patients’ age, level of triage, nationality, month and time of presentation, chief complaint, and whether the patient was admitted or discharged from the hospital.
Data collection process
The IT department extracted data directly from the hospital’s electronic medical record system and provided the research team with a finalized dataset encompassing all OB-GYN ER visits during the study period. Records containing missing or incomplete information were excluded by the IT department at the extraction stage, ensuring that only complete cases were included for analysis.
Data management and statistical analysis
This study’s main outcome was whether the patient had been admitted to the hospital. Nationality was defined as Saudi or non-Saudi, and the presentation months were divided into the following seasons: Autumn (September, October, November), Winter (December, January, February), Spring (March, April, May), and Summer (June, July, August). Times of patient presentation were categorized as the following shifts: morning (8:00 am–16:00 pm), evening (16:00 pm–00:00 am), and night (00:00 am–8:00 am). The Canadian Triage and Acuity Scale determined the triage levels, according to hospital policy, which are as follows: resuscitation, emergent, urgent, less urgent, and non-urgent for levels I through V. 10 Chief complaints were categorized into 10 main categories: obstetrics (e.g. labor pain, decreased fetal movement, bleeding during pregnancy, etc.), gastrointestinal (e.g. vomiting, constipation, heartburn, etc.), gynecological (e.g. dysmenorrhea, menorrhagia, vaginal discharge, etc.), musculoskeletal (e.g. joint pain, low back pain, leg pain, etc.), respiratory (e.g. cough, sore throat, runny nose), cardiovascular (e.g. palpitation, high blood pressure, and chest pain), neurological (e.g. numbness, seizure, headache), urological (e.g. dysuria and hematuria), psychiatric (e.g. suicidal thoughts, panic attacks, psychosis), and others (e.g. trauma, skin rash, fatigue, etc.). The review and finalization of this categorization were based on consensus agreement among consultants in family medicine, OB-GYN, women’s health, and public health.
Statistical analysis was performed using Stata Software 15. 11 Due to the high positive skewness of the age variable, the median and interquartile range were used to statistically describe it. Frequencies and percentages were used to describe categorical variables. Mann-Whitney U tests and chi-squared tests were used in bivariate analyses to determine the p-values of associations, with a significance level set at less than 0.05. Binary logistic regression models were used to derive 95% confidence intervals (CIs) with unadjusted and adjusted odds ratios (ORs). Variable selection for the multivariable logistic regression was guided by a directed acyclic graph constructed to represent plausible causal relationships between patient demographics, clinical presentation, and admission outcomes. Specifically, we considered age, nationality, triage level, chief complaints, season, and shift as core variables based on their theoretical relationship to admission likelihood. Post-hoc model diagnostics were conducted, and model selection was guided by information criteria, with the final model chosen as the one that minimized both AIC and BIC.
Results
Epidemiology of OB-GYN ER visits
A total of 8781 OB-GYN ER patient visits were included in the study. The median age of patients was 30, with an interquartile range between 26 and 36 years. The majority of visits (85.30%) were for Saudi nationals. Triage level IV was the highest recorded level at 71.84%, and the least was triage level II (0.19%). Only 12.46% of visits had been admitted. Most visits happened during the spring season (27.12%), whereas the least happened during winter (21.17%). Most visits occurred during the evening shift (44.69%) compared to only 20.68% that occurred during the night shift. The most common chief complaint was for obstetrics (47.44%), followed by gastrointestinal (18.44%) and gynecological complaints (14.04%; Table 1). Among the obstetrics, 32.53% had arrived at the ER due to bleeding during pregnancy, 32.19% had arrived due to labor pain, and 11.69% were in their third trimester and required investigations, whereas only 0.07% came to the ER for the induction of labor. Among gynecological visits, 55.90% came in due to dysmenorrhea, followed by 14.43% who were suffering from vaginal discharge and 11.62% due to menorrhagia. The least frequent reason for visits for gynecological complaints was vaginal spasm in 0.09%.
Obstetrics and gynecology emergency room visit characteristics, 2022.
IQR: interquartile range.
Bivariate associations between patient characteristics and admissions
Associations between OB-GYN ER visit characteristics and admissions are presented in Table 2. Patients whose visits concluded with admissions were older than their counterparts (p < 0.001). A higher percentage of admissions was found in non-Saudis compared to Saudis (p = 0.001). The rates of admission were inversely associated with the levels of triage (64.71%, 36.75%, 9.18%, and 1.50% for triage levels II to V, respectively) (p < 0.001). Patient visits with admissions were mostly for visits relating to obstetrics complaints, followed by cardiovascular complaints (19.47% and 18.64%, respectively). On the other hand, admissions due to gynecological complaints were among the second least common causes (2.92%) (p < 0.001). With regard to seasons, admissions were lowest in the spring (11.26%) and highest in the winter (14.69%). The highest percentage of admissions (18.34%) occurred during night shift visits, while the lowest admission rates (9.91%) occurred during evening shift visits.
Associations between admissions and the characteristics of obstetrics and gynecology ER visits in 2022.
ER: emergency room.
Multivariable regression analyses of predictors of admission
The unadjusted and adjusted ORs of admissions in relation to the visit characteristics are presented in Table 3. There are higher odds of admission for older patients (adjusted OR = 1.01, 95% CI = 1.01–1.03). In comparison with triage IV, triage II had a 15.35 OR for admission, followed by triage III (adjusted OR = 4.41, 95% CI = 3.79–5.12). Triage V had the lowest odds of admission and was statistically significant (adjusted OR = 0.18, 95% CI = 0.10–0.30). With regard to the chief complaint, all complaints were found to have lower odds of admission when compared to the reference category that was obstetrics complaints. These are statistically significant for musculoskeletal, gynecological, respiratory, gastrointestinal, and neurological. Winter season visits had higher odds of admission compared to spring (adjusted OR = 1.25, 95% CI = 1.03–1.52). Visits during the night and morning shifts were associated with higher odds of admission compared to evening time (adjusted OR = 1.90, 95% CI = 1.60–2.25 and adjusted OR = 1.29, 95% CI = 1.10–1.52, respectively).
Univariable and multivariable binary logistic regression models of admission of obstetrics and gynecology emergency room patients.
CI: confidence interval; OR: odds ratio.
Pattern of admissions across the months of 2022
Figure 1 plots the prevalence of admission per month during the study period between January and December of 2022. Generally, admissions fluctuated over the months. Admissions peaked in February, with the proportion of visits that had resulted in admission reaching 15.74% of all visits for that month. This was followed by December and November, in which the proportions of visits were 14.74% and 14.69%, respectively. October visits had the lowest admission rates at 3.38% of all visits during that month.
Pattern of admission from obstetrics and gynecology emergency room between January and December 2022.
Discussion
Epidemiology of OB-GYN ER visits
Overcrowding in ERs is a challenging issue for the healthcare management system both locally and worldwide. In Saudi Arabia, studies on ER visits are primarily focused on a specific study population or patient group. 12 To our knowledge, the current study is one of the few that targets all females who visit the OB-GYN ER in Saudi Arabia.
The present study revealed that triage level IV was the most frequently reported category of OB-GYN ER visits, accounting for 71.84% of cases, while triage level II was the least common at only 0.19%. This distribution signifies the fact that the majority of patients presenting to the ER were assessed as having less-urgent conditions and suggests a significant burden on emergency services for less acute cases. The high prevalence of non-emergent cases may be attributed to limited access to PHC, as Alghanim and Alomar found that 51% of frequent ER visits in Saudi public hospitals were due to PHC facilities being closed, and 47% were due to primary care physicians’ inability to adequately address patients’ issues. These factors likely drive patients with non-urgent conditions to seek ER care, contributing to the observed triage distribution. 13
In this study, the most common chief complaint among OB-GYN ER visits was obstetric-related issues (47.44%), a pattern consistent with other studies where labor pain, pain and bleeding during pregnancy, and pelvic pain are frequently reported as leading reasons for ER visits.5,14 The high proportion of visits for bleeding during pregnancy underscores the need for accessible antenatal care and patient education regarding when ER care is necessary versus when alternative care settings may be more appropriate. A significant proportion of patients presenting to the OB-GYN ER in the present study reported gastrointestinal complaints (18.44%). While some gastrointestinal symptoms may overlap with gynecologic or obstetric conditions, many of these cases are more appropriately managed by general emergency or PHC physicians rather than OB-GYN specialists. This finding highlights the challenge of non-specialty cases presenting to specialty emergency services, contributing to unnecessary resource utilization and potential overcrowding. 14 Moreover, the presence of gastrointestinal cases in the OB-GYN ER underscores the need to enhance triage protocols to ensure patients are directed to the most appropriate care provider. Additionally, a large portion of OB/GYN ER visits in the present study involve non-urgent gynecological issues like dysmenorrhea and infections, which are better managed in PHC. This pattern adds to overcrowding and strains emergency resources. Improved triage, PHC staff training on most frequent OB-GYN ER cases, and better integration between emergency and PHC services can help optimize patient flow, reduce the burden on OB-GYN specialists, and ensure that emergency resources are reserved for true OB-GYN emergencies.15,16
Interestingly, the study found that most OB-GYN ER visits occurred during the spring season, whereas the least had occurred during winter. Similarly, a prior study conducted in different locations of Saudi Arabia, as well as a German study, discovered that the peak of ER visits appears during the spring season and holidays.17,18 Improvement in weather makes access to the ER easier, and the number of non-urgent presentations also increases. 19 Moreover, similar to the findings of a Turkish study, the majority of ER visits occurred in the evening, which could be explained by social factors such as the ability of husbands to join their wives after the end of the working hours. 5
Admission from OB-GYN ER rates, patterns, and predictors
This study revealed that the total admission rate of patients attending the OB-GYN ER was 12.46%, which is lower than Abualenain’s study in an academic tertiary care hospital in the western region of Saudi Arabia, which revealed an admission rate of 34.28%. 20 Differences in the population density between two regions could explain the variance in admission rates. 21 However, a further possible explanation could be that Abualenain’s study was conducted in 2017, prior to the COVID-19 pandemic. After the pandemic, healthcare services in Saudi Arabia went through major transformations that encouraged people to engage in PHC services, which would facilitate early recognition of diseases and treatment, therefore resulting in lesser admission rates. 22 On the other hand, the admission rate in a Canadian study was only 7%, which is slightly lower than the rate reported in the current study. This could be due to the difference in the study participants in the Canadian study, which only targeted pregnant females visiting the ER. 23
Older patients had higher odds of admission in the current study, which may be attributed to the increased likelihood of comorbidities and complications in this demographic, especially those related to obstetric issues. This finding is inconsistent with another study that reported a non-significant association between age and ER admissions. 24
Results of the present study showed that admission rates were higher for more urgent triage levels (e.g. level II) and lower for less urgent ones (e.g. level V), consistent with the goals of triage systems. Similar findings in a study using the 4-level obstetric triage acuity scale showed increasing admissions with higher acuity. 25 A Saudi study highlighted the need for a standardized national triage system to reduce variability and enhance emergency care outcomes. 26
Obstetric complaints were the most common reason for admissions, followed by cardiovascular issues. This trend is supported by other research indicating that obstetric emergencies, such as labor complications and pre-eclampsia, are frequent causes of emergency visits and admissions.5,24 The study also highlighted that non-obstetric-related issues, such as gynecological, gastrointestinal, and musculoskeletal, were significantly less likely to require admission, emphasizing the critical nature of obstetric emergencies.
Examining the epidemiology of OB-GYN ER admissions, the observed variations in rates highlights important temporal patterns. Even though OB-GYN ER visits are lowest in the winter, admission rates are higher than in other seasons. Admissions peaked in February, followed by December and November. Several factors may contribute to this epidemiological phenomenon, including the fact that winter is frequently associated with an increase in respiratory infections, which disproportionately impact pregnant females due to immunologic changes during pregnancy. These infections can lead to complications, such as preterm labor or fetal distress, often requiring inpatient care. 27 Additionally, a previous study also found that the winter season is associated with serious ER presentations, which usually require admission. 28 It should be noted that these observations reflect associations only, and causality cannot be inferred; unmeasured factors such as staffing patterns or underlying patient characteristics may also contribute.
In addition to seasonal effects, visits during night and morning shifts had higher odds of admission compared to evening visits. A study of the pediatric population showed that, whereas midnight visits account for a smaller percentage of overall daily visits, they are typically of higher acuity. 29 Among pregnant females, a study found that deliveries during the evening and night shifts were more prone to perinatal mortality, poor perinatal outcomes, and admission to the neonatal intensive care unit. This could be explained by the fact that neonates born in the evening or at night may have been subjected to a prolonged first phase of labor, increasing their risk of detrimental perinatal outcomes. 30 A previous study in the United Kingdom considered factors such as limited access to investigations and equipment along with fewer consultants at nighttime contributing to a higher nighttime admission. 31 Furthermore, morning shift hours often include decisions on admitting patients who were under observation overnight, naturally increasing admission numbers. Furthermore, it coincides with the completion of inpatient rounds and discharges in the morning, which increases bed availability for new admissions. 17
Strengths and limitations
This study is unique in focusing on the epidemiology of OB-GYN ER visits, an area with limited research in the region. Furthermore, it benefits from utilization of data from electronic medical records throughout a full year thereby allowing for epidemiological analyses of visits and admissions. Nonetheless, several limitations should be noted. Records with incomplete information were excluded during data extraction, although the exact number of such records could not be determined; however, the overall dataset remained comprehensive. Chief complaints were categorized through clinical consensus and prior literature, but misclassification is still possible. Important factors such as comorbidities, parity, and socioeconomic status were not available and could not be analyzed. The study was limited to a single tertiary hospital over 1 year, which restricts generalizability. Finally, as the analysis included the complete census of visits, no a priori sample size calculation was undertaken.
Conclusion and implications for women’s health services in PHC
This study provides epidemiologists and policymakers in the healthcare system with an insight into OB-GYN ER utilization patterns. Understanding these patterns is crucial for optimizing resource allocation and improving patient flow within OB-GYN ERs. Moreover, the findings of this study have important implications for enhancing women’s health services within the PHC setting in Saudi Arabia. This is directly in line with Saudi Arabia’s Vision 2030 strategic goals that prioritize healthcare system efficiency and strengthening the role of PHC. 7
The majority of OB-GYN ER visits were by young Saudi females, most commonly for obstetric-related complaints such as labor pain and bleeding during pregnancy. While only 12.46% of visits resulted in hospital admissions, a significant percentage of visits were categorized as less urgent (triage level IV), suggesting that many patients may visit the ER for conditions that can be managed in women’s health services in PHC and outpatient settings with appropriate infrastructure, skilled healthcare providers, efficient triage systems, and better integration of primary and emergency care. Epidemiologically, the winter season, higher acuity triage levels, older age, and visits occurring during night or morning shifts were all found to be associated with higher admission rates. Non-obstetric complaints, such as gynecological, gastrointestinal, and musculoskeletal, were significantly less likely to require admission. These findings highlight the importance of strengthening PHC capacity in women’s health services and improving referral pathways to ensure continuity of care and reduce unnecessary OB-GYN ER utilization. Such measures may help reserve ER resources for true obstetric and gynecological emergencies and optimize women’s healthcare delivery in line with national priorities.
Footnotes
Acknowledgements
The authors gratefully acknowledge the Information Technology Department at King Fahd Hospital of the University for their invaluable support in providing the study data.
Ethical considerations
The study was approved by the Institutional Review Board of Imam Abdulrahman Bin Faisal University (IRB number: IRB-2022-01-443). The study adhered to the Declaration of Helsinki’s principles.
Consent to participate
This study used anonymized retrospective data; therefore, written informed consent was waived.
Author contributions
Data availability statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.