Economic burden of neural tube defects and impact of prevention with folic acid: a literature review

Birth prevalence and determinants of neural tube defects among newborns in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Neural tube defects (NTDs) are complex multifactorial disorders in the neurulation of the brain and spinal cord that develop in humans between 21 and 28 days of conception. Neonates with NTDs may experience morbidity and mortality, with severe social and economic consequences. Therefore, the aim of this systematic review and meta-analysis is to assess the pooled prevalence and determinants for neural tube defects among newborns in Ethiopia.

METHODS

The protocol of this study was registered in the International Prospective Register of Systematic Reviews (PROSPERO Number: CRD42023407095). We systematically searched the databases PubMed, Science Direct, Cochrane Library, Google Scholar and Research Gate. Grey literature was searched on Google. Heterogeneity among studies was assessed using the I2 test statistic and the Cochran Q test statistic. A random effects model was used to estimate the birth prevalence of neural tube defects.

RESULT

Twenty-five articles were included in the meta-analysis to estimate the prevalence and determinants of neural tube defects in Ethiopia. A total of 611,354 newborns were included in the analysis. The pooled birth prevalence of neural tube defects was 83.40 (95% CI: 60.78, 106.02) per 10,000 births. The highest and lowest prevalence rates were 130.9 (95% CI: 113.52, 148.29) in Tigray and 28.60 (95% CI: 18.70, 38.50) per 10,000 births in Amhara regional states. Women's intake of folic acid supplements and planned pregnancy were identified as protective factors for NTDs, while stillbirth history, use of any drugs during pregnancy, exposure to radiation, and pesticides during pregnancy were risk factors for neural tube defects.

CONCLUSION

The pooled birth prevalence of neural tube defects in Ethiopia was found to be high. Effective prevention interventions, especially focusing on periconceptional folic acid supplementation as well as folate fortification, should be prioritized alongside nutrition education, maternal health care, and environmental safety measures.

Association between preconception and early pregnancy exposure to fine particulate matter and nervous system anomalies: a nested case-control study

Although several environmental factors may increase the risk of nervous system anomalies, the association between exposure to particulate matter with an aerodynamic diameter of ≤ 2.5 μm (PM2.5) and nervous system anomalies is not completely understood. This study aimed to examine the association between expoure to PM2.5 and nervous system anomalies, including specific phenotypes during preconception and early pregnancy and determine the crucial time windows. We conducted a nested case-control study from the Taiwan Maternal and Child Health Database between 2004 and 2017. We applied satellite-based models with a 1 km resolution to estimate the weekly average PM2.5 from 13 weeks before conception to the first 8 weeks of pregnancy. We used conditional logistic regression with distributed lag nonlinear models (DLNMs) to assess the effects of weekly average PM2.5 on the risk of nervous system anomalies and exposure-response relationships. We identified 12,383 incident nervous system anomalies cases in 2,571,300 participants. A 10 µg/m³ increase in PM2.5 concentrations from a reference value of 25 µg/m³ was associated with higher risk of nervous system anomalies (adjusted odds ratio [aOR]: 1.21; 95% confidence incidence [CI]: 1.18, 1.25) and encephalocele (aOR: 1.56; 95% CI: 1.33, 1.84) from 13 weeks before conception to the first 8 weeks of gestation. Anencephaly showed a significant association with PM2.5 exposure during the 13 weeks before conception (aOR: 1.48; 95% CI: 1.02, 2.51). In DLNMs, the risk of nervous system anomalies was elevated each week from 8 to 11 weeks before conception to 1-8 weeks of gestation. Our findings suggest that exposure to PM2.5 during preconception and early pregnancy may increase the risk of nervous system anomalies in offspring, particularly neural tube defects such as anencephaly and encephalocele.

The current state of Spina Bifida in low- and middle-income countries: where does Africa stand?

Spina bifida is a congenital neural tube defect that results in abnormal development of the spine and central nervous system. Infants born with this condition face a range of physical disabilities and associated complications. Although the global burden has declined in recent decades due to folic acid fortification and prenatal screening, spina bifida remains a significant public health challenge in many low- and middle-income countries (LMICs), particularly in sub-Saharan Africa. This research aimed to comprehensively assess the current epidemiological trends, clinical management practices, and socioeconomic impacts of spina bifida across African LMICs. Through a systematic analytical search of published literature from major medical databases covering the years 2000-2023, relevant data were extracted on the prevalence, risk factors, clinical presentations, treatment modalities, outcomes, and contextual barriers faced in preventing and caring for spina bifida in these settings. The findings were analyzed and synthesized to provide an overview of the contemporary landscape. The findings highlight the need for collaborative efforts between governments, healthcare providers, nongovernmental organizations, and international stakeholders to address the multifaceted challenges posed by spina bifida in LMICs, particularly within the African continent, and to promote equitable access to comprehensive care and support for affected individuals and their families.

Economic evaluations of neglected tropical disease interventions in low- and middle-income countries: a systematic review protocol

OBJECTIVE

The objective of this systematic review is to provide an overview of economic evaluation studies of interventions for neglected tropical diseases in low- and/or middle-income countries.

INTRODUCTION

The majority of people most susceptible to neglected tropical diseases reside in low- and middle-income countries and suffer significant economic impact due to these diseases. The World Health Organization suggests utilizing a systematic and cross-cutting approach with multiple interventions to lessen the neglected tropical disease burden.

INCLUSION CRITERIA

Studies will be eligible for inclusion if they include economic evaluations of interventions for neglected tropical diseases and are conducted in low- and/or middle-income country settings.

METHODS

A preliminary search of MEDLINE (PubMed) was undertaken using MeSH terms, such as neglected tropical disease, economic evaluation, therapeutics, low- and/or middle-income countries . Two reviewers will screen titles and abstracts independently, followed by a full-text review against the inclusion criteria. Disagreements will be resolved by discussion or with a third reviewer. To assess methodological quality, the JBI checklist for economic evaluations will be used. For economic evaluations, data will be extracted using the standardized JBI data extraction form. The Dominance Ranking Matrix will be used to summarize and compare the results of different types of economic evaluations. Cost per quality adjusted life year gained and cost per disability adjusted life year averted will be measures for economic evaluation. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach will be used to assess the certainty of economic evidence, such as resource use and costs.

REVIEW REGISTRATION

PROSPERO CRD42017070386.

Risk Factors for Neural-Tube Defects Detected in Utero: A Prospective Community-Based Study from Addis Ababa

BACKGROUND

A recent community-based study from Addis Ababa identifying Neural Tube Defect (NTD) cases by ultrasound examination of pregnant women showed a higher prevalence of 17 per 1000 fetuses. The risk factors behind the high prevalence remain unclear.

METHODS

Altogether 891 of the 958 women participated in the ultrasound examination. Thirteen with unaffected twin pregnancies were excluded. Among 878 singleton pregnancies, 15 NTD cases were identified. Serum Folate, vitamin B12, and homocysteine levels were measured in case-mothers and a sub-set of 28 noncase mothers. Because of the modest sample size, exact logistic regression analysis was used to estimate associations between risk factors and NTDs.

RESULTS

Serum vitamin status was generally poor for participants in the study. Still, relatively higher values of folate or vitamin B12 in serum, appeared to be protective for NTD (odds ratio [OR] = 0.61 per ng/ml, 95% Confidence interval [CI]: 0.42-0.85 and OR = 0.67 per 100 pg/ml, 95% CI: 0.41-1.02, respectively). High serum homocysteine was associated with higher risk of NTD (OR = 1.3 per μmol/l, 95% CI: 1.02-1.8). Women aged 30 years or more had an OR of 3.5 (95% CI: 1.1-12) for having a NTD child, and families with NTD children had lower household income. Women in the NTD group also had more spontaneous abortions or stillbirths in previous pregnancies. Self-reported intake of folate did not appear to protect against NTDs.

CONCLUSIONS

Within this high-prevalence community, poor vitamin status was identified as a risk factor for NTDs detected at ultrasound examination. Improving food security and fortification of foods or food ingredients could be alternative measures.

Craniorachischisis in a 33-week-old Female Fetus: A Case Report

We report the case of a 33-week-old female fetus born with craniorachischisis to a gravida 5, para 4 (3104) mother with no previous history of conceiving a child with a neural tube defect. Craniorachischisis is characterized by anencephaly and an open defect extending from the brain to the spine and is the most severe and fatal type of neural tube defect. Although the cause of neural tube defects is hypothesized to be multifactorial and is usually sporadic, the risk is increased in neonates born to mothers with a family history or a previous pregnancy with neural tube defect, both of which are not present in the index case. This case is unique in that only during the fifth pregnancy did the couple conceive a child with a neural tube defect, emphasizing that folic acid supplementation, the sole preventive measure proven to decrease the risk of neural tube defects, remains to be important in the periconceptual period for all women of childbearing age.

Comparative Scoping Review of Prenatal Care Resources for Families of Children With Spinal Dysraphism and Hydrocephalus in High-Income Countries and Low- and Middle-Income Countries

BACKGROUND AND OBJECTIVES

Low- and middle-income countries (LMICs) face higher incidences and burdens of care for neural tube defects (NTDs) and hydrocephalus compared with high-income countries (HICs), in part due to limited access to neurosurgical intervention. In this scoping review, we aim to integrate studies on prenatal care, counseling, and surgical management for families of children with spinal dysraphism and hydrocephalus in LMICs and HICs.

METHODS

PubMed, Embase, Global Index Medicus, and Web of Science electronic databases were searched for English language articles pertaining to prenatal care, counseling, and surgical management for families of children with spinal dysraphism and hydrocephalus in HICs and LMICs. Identified abstracts were screened for full-text review. Studies meeting inclusion criteria were reviewed in full and analyzed.

RESULTS

Seventy studies met the inclusion criteria. Twelve studies (16.9%) were conducted in HICs only, 50 studies (70.4%) were conducted in LMICs only, and 9 studies (12.7%) encompassed both. On thematic analysis, seven underlying topics were identified: epidemiology, folate deficiency and supplementation/fortification, risk factors other than folate deficiency, prenatal screening, attitudes and perceptions about NTDs and their care, surgical management, and recommendations for guideline implementation.

CONCLUSION

NTDs have become a widely acknowledged public health problem in many LMICs. Prenatal counseling and care and folate fortification are critical in the prevention of spinal dysraphism. However, high-quality, standardized studies reporting their epidemiology, prevention, and management remain scarce. Compared with NTDs, research on the prevention and screening of hydrocephalus is even further limited. Future studies are necessary to quantify the burden of disease and identify strategies for improving global outcomes in treating and reducing the prevalence of NTDs and hydrocephalus. Surgical management of NTDs in LMICs is currently limited, but pediatric neurosurgeons may be uniquely equipped to address disparities in the care and counseling of families of children with spinal dysraphism and hydrocephalus.

Birth prevalence and risk factors of neural tube defects in Ethiopia: a systematic review and meta-analysis

OBJECTIVE

This study aims to estimate the prevalence of neural tube defects (NTDs) and to identify potential risk factors in the Ethiopian context.

STUDY DESIGN

Systematic review and meta-analysis.

STUDY PARTICIPANTS

A total of 611 064 participants were included in the review obtained from 42 studies.

METHODS

PubMed (Medline), Embase and Cochrane Library databases in combination with other potential sources of literature were systematically searched, whereby studies conducted between January 2010 and December 2022 were targeted in the review process. All observational studies were included and heterogeneity between studies was verified using Cochrane Q test statistics and I2 test statistics. Small study effects were checked using Egger's statistical test at a 5% significance level.

RESULT

The pooled prevalence of all NTDs per 10 000 births in Ethiopia was 71.48 (95% CI 57.80 to 86.58). The between-study heterogeneity was high (I2= 97.49%, p<0.0001). Birth prevalence of spina bifida (33.99 per 10 000) was higher than anencephaly (23.70 per 10 000), and encephalocele (4.22 per 10 000). Unbooked antenatal care (AOR 2.26, 95% CI (1.30 to 3.94)), preconception intake of folic acid (AOR 0.41, 95% CI (0.26 to 0.66)), having chronic medical illness (AOR 2.06, 95% CI (1.42 to 2.99)), drinking alcohol (AOR 2.70, 95% CI (1.89 to 3.85)), smoking cigarette (AOR 2.49, 95% CI (1.51 to 4.11)), chewing khat (AOR 3.30, 95% CI (1.88 to 5.80)), exposure to pesticides (AOR 3.87, 95% CI (2.63 to 5.71)), maternal age ≥35 (AOR 1.90, 95% CI (1.13 to 3.25)), maternal low educational status (AOR 1.60, 95% CI (1.13 to 2.24)), residing in urban areas (AOR 0.75, 95% CI (0.58 to 0.97))and family history of NTDs (AOR 2.51, 95% CI (1.36 to 4.62)) were associated with NTD cases.

CONCLUSION

The prevalence of NTDs in Ethiopia is seven times as high as in other Western countries where prevention measures are put in place. Heredity, maternal and environmental factors are associated with a high prevalence of NTDs. Mandatory fortification of staple food with folic acid should be taken as a priority intervention to curb the burden of NTDs. To smoothen and overlook the pace of implementation of mass fortification, screening, and monitoring surveillance systems should be in place along with awareness-raising measures.

PROSPERO REGISTRATION NUMBER

CRD42023413490.

Delays in care for hydrocephalus and spina bifida at a tertiary hospital in Somaliland

Background

Childhood neurosurgical conditions such as hydrocephalus and spina bifida represent a significant burden of death and disability worldwide, particularly in low and middle-income countries. However, there are limited data on the disease prevalence and delays in care for pediatric neurosurgical conditions in very low-resource settings. This study aims to characterize the delays in access to care for pediatric neurosurgical conditions in Somaliland.

Methods

We performed a retrospective review of all children with congenital hydrocephalus and spina bifida admitted to the Edna University Hospital (EAUH) in Somaliland between 2011 and 2018. Patient demographics were analyzed with descriptive statistics and χ2 test statistics. We defined delays in care for each condition based on standard care in high-income settings. Univariate and multivariate logistic regression were performed to evaluate predictors of delay in care. Statistical significance was set at p<0.05.

Results

A total of 344 children were admitted to EAUH with neurosurgical conditions from 2011 to 2018. The most common condition was congenital hydrocephalus (62%). Delays in care were found for 90% of patients and were associated with the type of diagnosis and region. The longest delay among children with spina bifida was 60 months, while the longest delay for children with congenital hydrocephalus was 36 months. Children with congenital hydrocephalus or spina bifida traveling from foreign countries had the highest waiting time to receive care, with a median delay of 8 months (IQR: 5-11 months) and 4 months (IQR: 3-7 months), respectively.

Conclusion

We found significant delays in care for children with neurosurgical conditions in Somaliland. This country has an urgent need to scale up its surgical infrastructure, workforce, and referral pathways to address the needs of children with hydrocephalus and spina bifida.

Prevented cases of neural tube defects and cost savings after folic acid fortification of flour in Brazil

Anencephaly, encephalocele, and spina bifida are congenital neural tube defects and are the main causes of neonatal morbidity and mortality and impose a heavy economic burden on health systems. This study to estimates the direct costs of neural tube defects from the perspective of the Brazilian Ministry of Health, and the prevented cases and cost savings during the period in which mandatory folic acid fortification was in effect in the country (2010-2019). It is a top-down cost-of-illness oriented study based on the prevalence of the disorders in Brazil. Data were collected from the Brazilian Ministry of Health's outpatient and hospital information system databases. The direct cost was estimated from the total patient-years, allocated by age and type of disorder. Prevented cases and cost savings were determined by the difference in the prevalence of the disorders in the pre- and post-fortification periods based on the total number of births and the sum of outpatient and hospital costs during the period. The total cost of outpatient and hospital services for these disorders totaled R$ 92,530,810.63 (Int$ 40,565,896.81) in 10 years; spina bifida accounted for 84.92% of the total cost. Hospital costs were expressive of all three disorders in the first year of the patient's life. Between 2010 and 2019, mandatory folic acid fortification prevented 3,499 live births with neural tube defects and resulted in R$ 20,381,586.40 (Int$ 8,935,373.25) in hospital and outpatient cost savings. Flour fortification has proved to be a valuable strategy in preventing pregnancies with neural tube defects. Since its implementation, there has been a 30% decrease in the prevalence of neural tube defects and a 22.81% decrease associated in hospital and outpatient costs.

The role of neurosurgeons in global public health: the case of folic acid fortification of staple foods to prevent spina bifida

OBJECTIVE

The global neurosurgery movement arose at the crossroads of unmet neurosurgical needs and public health to address the global burden of neurosurgical disease. The case of folic acid fortification (FAF) of staple foods for the prevention of spina bifida and anencephaly (SBA) represents an example of a new neurosurgical paradigm focused on public health intervention in addition to the treatment of individual cases. The Global Alliance for the Prevention of Spina Bifida-F (GAPSBiF), a multidisciplinary coalition of neurosurgeons, pediatricians, geneticists, epidemiologists, food scientists, and fortification policy experts, was formed to advocate for FAF of staple foods worldwide. This paper serves as a review of the work of GAPSBiF thus far in advocating for universal FAF of commonly consumed staple foods to equitably prevent SBA caused by folic acid insufficiency.

METHODS

A narrative review was performed using the PubMed and Google Scholar databases.

RESULTS

In this review, the authors describe the impact of SBA on patients, caregivers, and health systems, as well as characterize the multifaceted requirements for proper spina bifida care, including multidisciplinary clinics and the transition of care, while highlighting the role of neurosurgeons. Then they discuss prevention policy approaches, including supplementation, fortification, and hybrid efforts with folic acid. Next, they use the example of FAF of staple foods as a model for neurosurgeons' involvement in global public health through clinical practice, research, education and training, and advocacy. Last, they describe mechanisms for involvement in the above initiatives as a potential academic tenure track, including institutional partnerships, organized neurosurgery, neurosurgical expert groups, nongovernmental organizations, national or international governments, and multidisciplinary coalitions.

CONCLUSIONS

The role of neurosurgeons in caring for children with spina bifida extends beyond treating patients in clinical practice and includes research, education and training, and advocacy initiatives to promote context-specific, evidence-based initiatives to public health problems. Promoting and championing FAF serves as an example of the far-reaching, impactful role that neurosurgeons worldwide may play at the intersection of neurosurgery and public health.

An evaluation of adherence to folic acid supplementation in pregnant women during early gestation for the prevention of neural tube defects

OBJECTIVE

Neural tube defects (NTD) are potentially preventable by periconceptual folic acid supplementation. Women with obesity are at higher risk of NTD, therefore, are recommended a higher dose of 5 mg folic acid to mitigate this risk. The aim of this study was to evaluate maternal practice of folic acid supplementation amongst the antenatal population in relation to maternal obesity status.

DESIGN

Prospective observational study.

SETTING

Women ≤18 weeks' gestation at their first antenatal appointment attending University Maternity Hospital Limerick (Ireland) were recruited. Maternal height and weight were measured. Obesity was defined at a threshold of ≥30·0 kg/m2 and ≥27·5 kg/m2 when adjusting for ethnicity. A two-part questionnaire captured maternal characteristics and assessed supplementation compliance, commencement and dosage. Fisher's exact test for independence analysed differences in variables. A P value of <0·05 was considered significant.

PARTICIPANTS

A total of 328 women participated over a duration of 6 weeks.

RESULTS

Mean gestational age was 12·4 ± 1·4 weeks and mean BMI 26·7 kg/m2 ± 5·2 kg/m2. 23·8 % (n 78) were classified as obese. 96·5 % (n 315) were taking folic acid and 95·7 % (n 314) supplemented daily. 30·2 % (n 99) commenced supplementation 12 weeks prior to conception. Overall, 57·9 % (n 190) of women met folic acid supplementation dose requirements. 89·1 % (n 55) of women with obesity did not. Women with obesity were less likely to meet the higher folic acid supplementation dose requirements (P =< 0·001).

CONCLUSION

Folic acid supplementation practices within this cohort were suboptimal to prevent their risk of NTD. This study showed inadequate compliance of folic acid supplementation, and inadequate dosage for women with obesity. Increased patient education and awareness are needed within the antenatal period of pregnancy to bring folic acid supplementation practices in line with best practice guidelines.

LATS1/2 control TGFB-directed epithelial-to-mesenchymal transition in the murine dorsal cranial neuroepithelium through YAP regulation

Hippo signaling, an evolutionarily conserved kinase cascade involved in organ size control, plays key roles in various tissue developmental processes, but its role in craniofacial development remains poorly understood. Using the transgenic Wnt1-Cre2 driver, we inactivated the Hippo signaling components Lats1 and Lats2 in the cranial neuroepithelium of mouse embryos and found that the double conditional knockout (DCKO) of Lats1/2 resulted in neural tube and craniofacial defects. Lats1/2 DCKO mutant embryos had microcephaly with delayed and defective neural tube closure. Furthermore, neuroepithelial cell shape and architecture were disrupted within the cranial neural tube in Lats1/2 DCKO mutants. RNA sequencing of embryonic neural tubes revealed increased TGFB signaling in Lats1/2 DCKO mutants. Moreover, markers of epithelial-to-mesenchymal transition (EMT) were upregulated in the cranial neural tube. Inactivation of Hippo signaling downstream effectors, Yap and Taz, suppressed neuroepithelial defects, aberrant EMT and TGFB upregulation in Lats1/2 DCKO embryos, indicating that LATS1/2 function via YAP and TAZ. Our findings reveal important roles for Hippo signaling in modulating TGFB signaling during neural crest EMT.

Medical, behavioural and social preconception and interconception risk factors among pregnancy planning and recently pregnant Canadian women

OBJECTIVES

The objective of this study is to describe the clustering of medical, behavioural and social preconception and interconception health risk factors and determine demographic factors associated with these risk clusters among Canadian women.

DESIGN

Cross-sectional data were collected via an online questionnaire assessing a range of preconception risk factors. Prevalence of each risk factor and the total number of risk factors present was calculated. Multivariable logistic regression models determined which demographic factors were associated with having greater than the mean number of risk factors. Exploratory factor analysis determined how risk factors clustered, and Spearman's r determined how demographic characteristics related to risk factors within each cluster.

SETTING

Canada.

PARTICIPANTS

Participants were recruited via advertisements on public health websites, social media, parenting webpages and referrals from ongoing studies or existing research datasets. Women were eligible to participate if they could read and understand English, were able to access a telephone or the internet, and were either planning a first pregnancy (preconception) or had ≥1 child in the past 5 years and were thus in the interconception period.

RESULTS

Most women (n=1080) were 34 or older, and were in the interconception period (98%). Most reported risks in only one of the 12 possible risk factor categories (55%), but women reported on average 4 risks each. Common risks were a history of caesarean section (33.1%), miscarriage (27.2%) and high birth weight (13.5%). Just over 40% had fair or poor eating habits, and nearly half were not getting enough physical activity. Three-quarters had a body mass index indicating overweight or obesity. Those without a postsecondary degree (OR 2.35; 95% CI 1.74 to 3.17) and single women (OR 2.22, 95% CI 1.25 to 3.96) had over twice the odds of having more risk factors. Those with two children or more had 60% lower odds of having more risk factors (OR 0.68, 95% CI 0.52 to 0.86). Low education and being born outside Canada were correlated with the greatest number of risk clusters.

CONCLUSIONS

Many of the common risk factors were behavioural and thus preventable. Understanding which groups of women are prone to certain risk behaviours provides opportunities for researchers and policy-makers to target interventions more efficiently and effectively.

Whole exome sequencing identifies potential candidate genes for spina bifida derived from mouse models

Spina bifida (SB) is the second most common nonlethal congenital malformation. The existence of monogenic SB mouse models and human monogenic syndromes with SB features indicate that human SB may be caused by monogenic genes. We hypothesized that whole exome sequencing (WES) allows identification of potential candidate genes by (i) generating a list of 136 candidate genes for SB, and (ii) by unbiased exome-wide analysis. We generated a list of 136 potential candidate genes from three categories and evaluated WES data of 50 unrelated SB cases for likely deleterious variants in 136 potential candidate genes, and for potential SB candidate genes exome-wide. We identified 6 likely deleterious variants in 6 of the 136 potential SB candidate genes in 6 of the 50 SB cases, whereof 4 genes were derived from mouse models, 1 gene was derived from human nonsyndromic SB, and 1 gene was derived from candidate genes known to cause human syndromic SB. In addition, by unbiased exome-wide analysis, we identified 12 genes as potential candidates for SB. Identification of these 18 potential candidate genes in larger SB cohorts will help decide which ones can be considered as novel monogenic causes of human SB.

Trend and burden of neural tube defects among cohort of pregnant women in Ethiopia: Where are we in the prevention and what is the way forward?

Introduction

Neural tube defect is one of the top five most serious birth defects in the world. In Ethiopia an accurate estimate of the trend and burden of neural tube defects is still unknown. There hasn’t been much research done on the prevalence and trend of neural tube defects in Eastern Ethiopia. To complement previous efforts of studies, the purpose of this study is to estimate the trend and burden of neural tube defects in Eastern Ethiopia as well as to investigate the epidemiological implications of the findings.

Methods

A facility-based retrospective cohort study was carried out from cohort pregnant women who delivered in selected hospitals. File records of all babies who were found to have neural tube defects could be reached between 2017 and 2019. A structured checklist was used to collect data. The incidence of each case was calculated by dividing the number of cases per year by the total number of live births in each hospital. To determine the linear trend of neural tube defects over time, linear trend of Extended Mantel-Haenszel chi-square was performed. Data were presented using frequencies and percentages. Data were analyzed using SPSS for windows version 25.

Results

A total of 48,750 deliveries were recorded during the three years of the study considered for analyses with 522 women having neural tube defect giving an incidence rate of 107.5 per 10,000 live births in the three years. The most common types of neural tube defects found in the area were anencephaly and spina bifida accounting for 48.1% and 22.6%, respectively. The distribution of neural tube defects varied across the study hospitals, with Adama Medical College Hospital having the highest proportion (46.6%). Over half of the mothers (56.7%) live in cities. Mothers in the age group 25–34 (46.9%) and multigravida mothers had higher proportions (64.4%).of neural tube defects. None of the mothers took folic acid before conception, and only 19% took iron folic acid supplementation during their pregnancy.

Conclusion and recommendation

The findings showed that an increasing trend and burden of neural tube defects and preconception folic acid supplementation is insignificant in the region which showed that where we are in the prevention of neural tube defects. The finding suggests that preconception folic acid supplementation in conjunction with health care services should be considered to reduce the risk of neural tube defects in the region. Aside from that, intensive prevention efforts for long-term folate intake through dietary diversification and appropriate public health interventions are required. Furthermore, data must be properly recorded in order to address disparities in neonatal death due to neural tube defects, and the determinants of neural tube defects should be investigated using large scale prospective studies with biomarkers.

Cost-effectiveness of mandatory folic acid fortification of flours in prevention of neural tube defects: A systematic review

BACKGROUND

Neural tube defects (NTDs) constitute the most frequent group among congenital malformations and are the main cause of neonatal morbimortality. Folic acid (FA) can reduce the risk of pregnancies affected by NTDs.

OBJECTIVE

We aimed to investigate whether mandatory folic acid (FA) fortification of flours is cost-effective as compared to non-mandatory fortification, and to verify whether FA dosage, cost composition, and the quality of economic studies influence the cost-effectiveness of outcomes.

METHODS

We conducted a systematic review. The protocol was registered on PROSPERO (CRD 42018115682). A search was conducted using the electronic databases MEDLINE/PubMed, Web of Science, Embase, Scopus, and EBSCO/CINAHL between January 2019 and October 2020 and updated in February 2021. Eligible studies comprised original economic analyses of mandatory FA fortification of wheat and corn flours (maize flours) compared to strategies of non-mandatory fortification in flours and/or use of FA supplements for NTD prevention. The Drummond verification list was used for quality analysis.

RESULTS

A total of 7,859 studies were identified, of which 13 were selected. Most (77%; n = 10) studies originated from high-income countries, while three (23%) were from upper-middle-income countries. Results of a cost-effectiveness analysis showed that fortification is cost-effective for NTD prevention, except for in one study in New Zealand. The cost-benefit analysis yielded a median ratio of 17.5:1 (0.98:1 to 417.1:1), meaning that for each monetary unit spent in the program, there would be a return of 17.5 monetary units. Even in the most unfavorable case of mandatory fortification, the investment in the program would virtually payoff at a ratio of 1:0.98. All FA dosages were cost-effective and offered positive health gains, except in one study. The outcomes of two studies showed that FA dosages above 300 μg/100 g have a higher CBA ratio. The studies with the inclusion of "loss of consumer choice" in the analysis may alter the fortification cost-efficacy ratio.

CONCLUSION

We expect the findings to be useful for public agencies in different countries in decision-making on the implementation and/or continuity of FA fortification as a public policy in NTD prevention.

Association of maternal folate use and reduced folate carrier gene polymorphisms with the risk of congenital heart disease in offspring

Although it is generally recognized that genetic and environmental factors are associated with the risk of congenital heart disease (CHD), the mechanism remains largely uncertain. This study aimed to investigate the association of maternal folate use, the time when folate use was started, and polymorphisms of the reduced folate carrier (RFC1) gene with the risk of CHD in offspring of Chinese descent, which can help provide new insight into the etiology of folate-related birth defects. A case-control study of 683 mothers of CHD patients and 740 mothers of healthy children was performed. The present study showed that mothers who did not use folate were at a significantly increased risk of CHD (OR=2.04; 95% CI: 1.42-2.93). When compared with those who started using folate prior to conception, mothers who started using folate from the first trimester of pregnancy (OR=1.90; 95% CI: 1.43-2.54) or from the second trimester of pregnancy (OR=8.92; 95% CI: 4.20-18.97) had a significantly higher risk of CHD. Maternal RFC1 gene polymorphisms at rs2236484 (AG vs AA: OR=1.79 [95% CI: 1.33-2.39]; GG vs AA: OR=1.64 [95% CI: 1.15-2.35]) and rs2330183 (CT vs CC: OR=1.54 [95% CI: 1.14-2.09]) were also significantly associated with CHD risk. Additionally, the risk of CHD was significantly decreased among mothers who had variant genotypes but used folate when compared with those who had variant genotypes and did not use folate.Conclusion: In those of Chinese descent, maternal folate use and the time when use started are significantly associated with the risk of CHD in offspring. Furthermore, maternal folate supplementation may help to offset some of the risks of CHD in offspring due to maternal RFC1 genetic variants. What is Known: • Folate use could help prevent CHD, but the relationship between the time when folate use is started and CHD has not received sufficient attention. • Studies have assessed the associations of folate metabolism-related genes with CHD, but genes involved in cellular transportation of folate, such as the RFC1 gene, have not garnered enough attention. What is New: • In those of Chinese descents, the time when folate use is started is significantly associated with the risk of CHD in offspring. • Maternal RFC1 polymorphisms were significantly associated with the risk of CHD. • Folate supplementation may help to offset some risks of CHD due to RFC1 genetic variants.

Knowledge, attitude and practice of physicians regarding periconceptional folic acid for women at low risk of a neural tube defect affected pregnancy

Canadian expert guidelines recommend low-risk women to consume a daily multivitamin supplement containing 400 µg of folic acid (FA) to prevent neural tube defects. Mandatory food fortification coupled with intake of prenatal vitamin/mineral supplements (PVS), most of which contain ≥ 1000 µg-FA, has resulted in an unprecedented shift in Canadian pregnant women folate status. This study assessed the knowledge, attitude and practice (KAP) of physicians regarding periconceptional FA recommendations, intake and health related outcomes, since they play an essential role in promoting appropriate FA intake. Seventy-seven physicians answered the self-administered KAP survey. Only half of physicians knew the correct dose and duration of FA for low-risk women. Approximately 70% were unsure of, or unfamiliar with the most recent guidelines and 60% of physicians most often recommend a ≥ 1000 µg-FA supplement. Knowledge score 1 (KS1), which related to low-risk women, was associated with physicians' attitude toward believing that most PVS contain the recommended amount of FA (p = 0.004). Significant correlations were also found between KS1 and the total practice score (TPS) (r = 0.45, p < 0.0001) as well as between the total knowledge score and TPS (r = 0.38, p = 0.0007). Our findings show that physicians lacking knowledge regarding periconceptional FA is associated with their attitude and practice. Despite a vast majority of physicians being unsure or uncomfortable recommending PVS that are not in line with recommendations, a lack of knowledge and a widely accessible 400 µg-FA PVS, enables a contradictory practice in reality.

Risk factors associated to neural tube defects among mothers who gave birth in North Shoa Zone Hospitals, Amhara Region, Ethiopia 2020: Case control study

INTRODUCTION

Neural tube defects affect the brain and the spinal cord of the developing embryo. The defects occur due to incomplete or failure of closure of the neural tube. The condition eventually causes death and lifelong disability. Worldwide, more than 300,000 babies are born with neural tube defects each year. The highest burden is in low- and middle-income countries. Therefore, this study aims to identify the risk factors associated with neural tube defects among mothers who gave birth in North Shoa Zone Hospitals.

METHODS

A hospital based unmatched case-control study was conducted among 243 (81 cases and 162 controls) study participants in North Shoa Zone Hospitals. The hospitals were selected using simple random sampling and all cases and randomly selected controls in the selected hospitals were included in the study. The data were collected by using pre-tested structured questionnaire.

RESULTS

Different factors were identified to have association with neural tube defect. Family annual cash income less than 24000ETB (AOR: 3.73, 95%CI: 1.35, 10.26), history of still birth (AOR: 3.63, 95%CI: 1.03, 12.2), history of abortion (AOR: 6.15, 95%CI: 2.63, 18.56), preconception tea use (AOR: 2.36, 95%CI: 1.15, 4.86) and pesticides/chemical exposure (AOR: 5.34, 95%CI: 1.77, 16.05) were positively associated factors. In contrast, preconception care (AOR: 0.14, 95%CI: 0.05, 0.39) and taking iron/folic acid/multivitamin during the current pregnancy (AOR: 0.16, 95%CI: 0.07, 0.33) showed a protective effect.

CONCLUSION

Family annual income less than 24000ETB, history of still birth, history of abortion, preconception tea uses and pesticides/chemical exposure were associated factors of neural tube defects. Preconception counseling and screening should be recommended for women who plan for pregnancy.

The role of Vitamin B12 and genetic risk factors in the etiology of neural tube defects: A systematic review

Neural tube defects (NTDs) are birth defects that arise during embryogenesis when normal neural tube closure fails to occur. According to the World Health Organization, NTDs are detected annually in approximately 300,000 neonates worldwide. The exact etiology of NTDs remains complex and poorly understood. It is generally agreed that most NTD cases are of multifactorial origin, having a combination of multiple genes and a number of environmental risk factors. The role of folic acid, vitamin B12 deficiency, genetics and other risk factors, in the etiology of NTDs, has also been extensively studied. This knowledge synthesis brings together different types of evidence to update the role of vitamin B12 deficiency, genetics and other risk factors, in the etiology of NTDs. Following a PubMed search and screening for relevant articles, we included 40 studies in our review (30 case-control studies, 3 cross-sectional studies, 5 cohort studies, and 2 case reports). The available data showed that vitamin B12 levels were decreased in mothers and infants in NTD groups compared with control groups. Holo-transcobalamin, the active form of vitamin B12, was also found in lower levels in mothers with NTD-affected infants. Several studies reported elevated homocysteine levels in mothers and infants in NTD groups. Additionally, numerous studies reported links between genetic variants and increased NTD risk. These genes include GIF, LRP2, CUBN, TCb1R, MTHFR, and others. Several maternal factors have also been linked with significant NTD risk such as BMI, maternal diet, air pollutants, low maternal age, and many others. The majority of studies on NTDs have focused on the role of folic acid, hence there is a need for well-designed studies on the role of other risk factors like vitamin B12 deficiency in the etiology of NTDs.

Birth prevalence of neural tube defects and associated risk factors in Africa: a systematic review and meta-analysis

Background

Neural tube defects are common congenital anomalies that result from early malformation in the development of the spinal cord and brain. It is related to substantial mortality, morbidity, disability, and psychological and economic costs. The aim of this review is to determine the pooled birth prevalence of neural tube defects and associated risk factors in Africa.

Methods

The first outcome of this review was the pooled birth prevalence of the neural tube defects and the second outcome was the pooled measure of association between neural tube defects and associated risk factors in Africa. We systematically searched PubMed, PubMed Central, Joanna Briggs Institute, Google Scopus, Cochrane Library, African Journals Online, Web of Science, Science Direct, Google Scholar, and Medline databases. The heterogeneity of studies was assessed using the Cochrane Q test statistic, I² test statistic, and, visually, using Forest and Galbraith’s plots. A random-effect model was applied to get the pooled birth prevalence of neural tube defects. Subgroup, sensitivity, meta-regression, time-trend, and meta-cumulative analyses were undertaken. The fixed-effect model was used to analyze the association between neural tube defects and associated risk factors.

Results

Forty-three studies with a total of 6086,384 participants were included in this systematic review and meta-analysis. The pooled birth prevalence of the neural tube defects was 21.42 (95% CI (Confidence Interval): 19.29, 23.56) per 10,000 births. A high pooled birth prevalence of neural tube defects was detected in Algeria 75 (95% CI: 64.98, 85.02), Ethiopia 61.43 (95% CI: 46.70, 76.16), Eritrea 39 (95% CI: 32.88, 45.12), and Nigeria 32.77 (95% CI: 21.94, 43.59) per 10,000 births. The prevalence of neural tube defects has increased over time. Taking folic acid during early pregnancy, consanguineous marriage, male sex, and substance abuse during pregnancy were assessed and none of them was significant.

Conclusions

The pooled birth prevalence of neural tube defects in Africa was found to be high. The risk factors evaluated were not found significant.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02653-9.

Effects of Periconceptional Multivitamin Supplementation on Folate and Homocysteine Levels Depending on Genetic Variants of Methyltetrahydrofolate Reductase in Infertile Japanese Women

Methylenetetrahydrofolate reductase (MTHFR) has various polymorphisms, and the effects of periconceptional folic acid supplementation for decreasing neural tube defects (NTDs) risk differ depending on the genotypes. This study analyzed the effectiveness of multivitamin supplementation on folate insufficiency and hyperhomocysteinemia, depending on MTHFR polymorphisms. Of 205 women, 72 (35.1%), 100 (48.8%) and 33 (16.1%) had MTHFR CC, CT and TT, respectively. Serum folate and homocysteine levels in women with homozygous mutant TT were significantly lower and higher, respectively, than those in women with CC and CT. In 54 women (26.3% of all women) with a risk of NTDs, multivitamin supplementation containing folic acid and vitamin D for one month increased folate level (5.8 ± 0.9 to 19.2 ± 4.0 ng/mL, p < 0.0001) and decreased the homocysteine level (8.2 ± 3.1 to 5.8 ± 0.8 nmol/mL, p < 0.0001) to minimize the risk of NTDs in all women, regardless of MTHFR genotype. Regardless of MTHFR genotype, multivitamin supplements could control folate and homocysteine levels. Tests for folate and homocysteine levels and optimal multivitamin supplementation in women with risk of NTDs one month or more before pregnancy should be recommended to women who are planning a pregnancy.

Folate fortification and supplementation in prevention of folate-sensitive neural tube defects: a systematic review of policy

OBJECTIVE

Neural tube defects (NTDs) are common congenital neurological defects, resulting in mortality, morbidity, and impaired quality of life for patients and caregivers. While public health interventions that increase folate consumption among women who are or plan to become pregnant are shown to reduce folate-sensitive NTDs, public health policy reflecting the scientific evidence lags behind. The authors aimed to identify the types of policies applied, associated outcomes, and impact of folate fortification and supplementation on NTDs worldwide. By identifying effective legislation, the authors aim to focus advocacy efforts to more broadly effect change, reducing the burden of NTDs in neurosurgery.

METHODS

A systematic review was conducted exploring folate fortification and supplementation policies using the PubMed and Scopus databases. Titles and abstracts from articles identified were read and selected for full-text review. Studies meeting inclusion criteria were reviewed in full and analyzed for study design, aim, population, interventions, and outcomes.

RESULTS

Of 1637 resultant articles, 54 were included. Mandatory folate fortification was effective at reducing folate-sensitive NTDs. Mandatory fortification also decreased hospitalization rates and deaths after discharge and increased 1st-year survival for infants with NTDs. Recommended folate supplementation also resulted in decreased NTDs; however, issues with compliance and adherence were a concern and impacted effectiveness. Folate fortification and/or supplementation resulted in decreased NTD prevalence, although more change was attributed to fortification. Dual policies may hold the most promise. Furthermore, reductions in NTDs were associated with significant cost savings over time.

CONCLUSIONS

Both mandatory folate fortification and recommended supplementation policies were found to effectively decrease folate-sensitive NTD rates when applied. A comprehensive approach incorporating mandatory folate fortification, appropriate folate supplementation, and improved infrastructure and access to prenatal care may lead to decreased NTDs worldwide. This approach should be context-specific, emphasize education, and account for regional access to healthcare and social determinants of health. With wide implications for NTDs, associated health outcomes, quality of life of patients and caregivers, and economic impacts, policy changes can drastically improve global NTD outcomes. As caretakers of children with NTDs, the authors as neurosurgeons advocate for a comprehensive policy, the engagement of stakeholders, and a broader global impact.

The Global Burden of Neural Tube Defects and Disparities in Neurosurgical Care

BACKGROUND

Despite the success of folic acid fortification programs, neural tube defects (NTDs) such as spina bifida, encephalocele, and anencephaly remain among the most substantial causes of childhood morbidity and mortality worldwide. Although these are complicated conditions that require an interdisciplinary approach to care, definitive treatment of survivable NTDs is often neurosurgical.

METHODS

Using Global Burden of Disease data, we examined the global burden of NTDs as related to a nation's wealth, health care quality, and access to neurosurgical care. We abstracted data for death by cause, years lived with disability (YLD), gross domestic product (GDP), United Nations geoscheme, Food Fortification Initiative participation, and Healthcare Access and Quality Index. We compared means using 1-way analysis of variance and proportions using Fisher exact tests, with statistical significance as α = 0.05.

RESULTS

Seventeen of 20 (85%) nations with the most deaths caused by NTDs (P < 0.0001) and 15/20 (75%) nations with the highest YLD (P < 0.0001) were in the lowest GDP quartile. Deaths and YLD were negatively correlated with increasing GDP and Healthcare Access and Quality Index (P < 0.0001). The nations with the highest disease burdens also had the fewest neurosurgeons per capita.

CONCLUSIONS

Despite the success of folic acid fortification programs, greater global public health efforts should be placed on improving access to neurosurgical care in low and middle-income nations through sustainable initiatives such as surgeon exchange programs and the establishment of neurosurgery residency training programs.

Prevention of Neural Tube Defects by Folic Acid Supplementation: A National Population-Based Study

Folic acid supplementation is recommended for neural tube defect prevention during pregnancy. We conducted an observational, retrospective national registry study to determine the rate of dispensing of periconceptional folic acid after prescription in a sample of French women representative of the general population. Our study population (n = 186,061) was a representative sample of the French population, recorded in the Health Data System database on pharmacy dispensing of medication and mandatory reporting of pregnancy. Between 2006 and 2016, 14.3% of pregnant women had a prescription for folic acid supplementation during the month preceding conception and for the first 12 weeks of pregnancy. Of these prescriptions, 30.9% were issued before the start of pregnancy. This percentage was lower for first pregnancies. The rate of pharmacy dispensing during the preconception period increased progressively from 3.8% to 8.3% between 2006 and 2016. In France, the rate of pharmacy dispensing of periconceptional folic acid after medical prescription is very low and does not follow international recommendations. It seems essential to implement awareness-raising policies targeting the general population and physicians regarding effective periconceptional supplementation, particularly starting in the preconception period. Clarification of international recommendations and fortification of flour could improve the efficacy of folate supplementation at population level.

Prevalence of Spina Bifida among Newborns in Africa: A Systematic Review and Meta-Analysis

Spina bifida is an abnormal closure of the neural tube during the fourth week of development. It is the major cause of fetal loss and considerable disabilities in newborns. The aim of this review is to determine the pooled prevalence of spina bifida among newborns in Africa. PubMed/Medline, Google Scholar, Science Direct, Joanna Briggs Institute (JBI) Library, Cochrane Library, Web of Science, African Journals Online, and Embase databases were systematically searched. Cochran Q test and I ² test statistics were applied to assess heterogeneity across studies. A random-effect model was applied to calculate the pooled prevalence of spina bifida. Forest plot and Galbraith's plot were used to visualize heterogeneity. Subgroup, sensitivity, meta-regression, and meta-cumulative analyses were performed. All essential data were extracted using a standardized data extraction format, and the JBI quality appraisal checklist was used to assess the quality of studies. Egger's test and Begg's test were used in order to detect the publication bias. In the present systematic review and meta-analysis, 6,587,298 births in twenty-seven studies were included. The pooled birth prevalence of spina bifida in Africa was 0.13% with a range between 0.12% and 0.14%. In Africa, the highest burden of spina bifida was detected in Algeria (0.43%), Ethiopia (0.32%), Tanzania (0.26%), Cameron (0.12%), Egypt (0.10%), and South Africa (0.10%). The lowest burden of spina bifida was detected in Libya (0.006%) and Tunisia (0.009%). The high birth prevalence of spina bifida was detected in Africa. There was a significant variation in the prevalence of spina bifida among study countries in Africa. The authors recommend that special awareness creation with the help of health education intervention should be provided for mothers to focus on prevention in order to reduce the burden of spina bifida.

Detecting New Allies: Modifier Screen Identifies a Genetic Interaction Between Imaginal disc growth factor 3 and combover, a Rho-kinase Substrate, During Dorsal Appendage Tube Formation in Drosophila

Biological tube formation underlies organ development and, when disrupted, can cause severe birth defects. To investigate the genetic basis of tubulogenesis, we study the formation of Drosophila melanogaster eggshell structures, called dorsal appendages, which are produced by epithelial tubes. Previously we found that precise levels of Drosophila Chitinase-Like Proteins (CLPs), encoded by the Imaginal disc growth factor (Idgf) gene family, are needed to regulate dorsal-appendage tube closure and tube migration. To identify factors that act in the Idgf pathway, we developed a genetic modifier screen based on the finding that overexpressing Idgf3 causes dorsal appendage defects with ∼50% frequency. Using a library of partially overlapping heterozygous deficiencies, we scanned chromosome 3L and found regions that enhanced or suppressed the Idgf3-overexpression phenotype. Using smaller deletions, RNAi, and mutant alleles, we further mapped five regions and refined the interactions to 58 candidate genes. Importantly, mutant alleles identified combover (cmb), a substrate of Rho-kinase (Rok) and a component of the Planar Cell Polarity (PCP) pathway, as an Idgf3-interacting gene: loss of function enhanced while gain of function suppressed the dorsal appendage defects. Since PCP drives cell intercalation in other systems, we asked if cmb/+ affected cell intercalation in our model, but we found no evidence of its involvement in this step. Instead, we found that loss of cmb dominantly enhanced tube defects associated with Idgf3 overexpression by expanding the apical area of dorsal appendage cells. Apical surface area determines tube volume and shape; in this way, Idgf3 and cmb regulate tube morphology.

Lower rates of neural tube defects in Israel following folic acid supplementation policy

Neural tube defects (NTDs) are common and disabling congenital malformations that remain a public health challenge despite prevention efforts. In 2000, The Israeli Ministry of Health published recommendations on daily folic acid (FA) supplementation for women of reproductive age and established a national NTD registry. This study aims to evaluate the long-term impact of the FA supplementation policy on NTD rates in Israel and the need for further intervention. In this descriptive report, we present the rate of NTD-affected pregnancies recorded in the registry between 2000 and 2012, their subtype (anencephaly, spina bifida or other), outcome (live birth, stillbirth or pregnancy termination), ethnic group (Jewish, Bedouin and non-Bedouin Muslim) and years of maternal education. The final analysis included 2374 NTD cases reported between 2000 and 2012, compared with 1,668,073 live births. During this period NTD rates decreased from 20.3 to 11.2 cases per 10,000 live births, a 45% reduction. Reductions were seen in rates of spina bifida, anencephaly and encephalocele. NTD rates decreased in all pregnancy outcomes and in all ethnic groups, though rates among Bedouins remain high. Women with higher levels of education tended to have lower NTD rates, and were more prone to choose termination of an affected pregnancy. Following the institution of FA supplementation in Israel, a substantial reduction was seen in NTD rates. Nonetheless, Israeli NTD rates remain higher than in other developed countries. FA interventions should continue to be vigorously implemented, especially in vulnerable populations. The global success of mandatory fortification of grain strongly advocates its consideration in Israel.

Concentrations of rare earth elements in maternal serum during pregnancy and risk for fetal neural tube defects

Rare earth elements (REEs) are ubiquitous in the environment. Animal experiments have shown that many REEs have adverse impacts on the health of fetuses. However, data from humans are scarce. In this study, we examined the associations between concentrations of 10 REEs in maternal serum and the risk for fetal neural tube defects (NTDs). The study included 200 pregnant women with pregnancies affected by NTDs and 400 pregnant women with healthy fetuses/infants. Fifteen REEs in maternal serum were assessed; 10 of them were detectable in over 60% of samples and were included in statistical analyses, including lanthanum (La), cerium (Ce), praseodymium (Pr), neodymium (Nd), samarium (Sm), europium (Eu), terbium (Tb), dysprosium (Dy), lutetium (Lu), and yttrium (Y). When the elements were considered individually with the use of Logistic regression model, the risk for NTDs increased by 2.78-fold (1.25-6.17) and 4.31-fold (1.93-9.62) for La, and 1.52-fold (0.70-3.31) and 4.73-fold (2.08-10.76) for Ce, in the second and third tertiles, respectively, compared to the lowest concentration tertile. When Bayesian kernel machine regression was used to examine the joint effect of exposure to all 10 REEs, the risk for NTDs increased with overall levels of these REEs and the association between La and NTD risk remained when other nine elements were taken into consideration simultaneously. Taken together, this study shows that the risk for NTDs increases with La concentrations when single REEs are considered and with concentrations of all 10 REEs when these REEs are considered as a co-exposure mixture.

The Use of Dietary Supplements Among African and Caribbean Women Living in the UK: A Cross-Sectional Study

Previous studies have shown that the use of dietary supplements is associated with the prevention of birth defects, negative pregnancy outcomes and cardiovascular diseases. However, there might be some ethnic disparities in supplement usage suggesting that women who could benefit from it are not frequent users. This study aimed to characterise the use of dietary supplement among Black African and Black Caribbean women living in the United Kingdom (UK). Furthermore, it evaluated possible associations between the use of dietary supplements and health and diet awareness. A total of 262 women self-ascribed as Black African and Black Caribbean living in the UK completed a comprehensive questionnaire on socio-demographic factors, diet, use of supplements and cultural factors. The main outcome variable was the regular use of any type of dietary supplement. Use of vitamin D and/or calcium was also explored. A stepwise logistic regression analysis was applied to identify predictors of regular use of dietary supplements. A total of 33.2% of women reported regular use of any dietary supplements and 16.8% reported use of vitamin D and/or calcium. There were no significant ethnic differences in the use of dietary supplements. Reporting use of the back of food packaging label (odds ratio (OR) 2.21; 95% CI 1.07–4.55); a self-rated healthy diet (OR 2.86; 95% CI 1.19–6.91) and having cardiovascular disease (CVD), hypertension and/or high cholesterol (OR 3.81; 95% CI 1.53–9.49) increased the likelihood of using any dietary supplement. However, having poorer awareness decreased the likelihood (OR 0.94; 95% CI 0.88–0.99) of using any dietary supplement. For the use of vitamin D and/or calcium supplements, the main predictor was having CVD, hypertension and/or high cholesterol (OR 4.43; 95% CI 1.90–10.35). The prevalence of dietary supplement use was low among African and Caribbean women. Thus, awareness of potential benefits of some dietary supplements (e.g., vitamin D) among the Black population should be promoted.

Infant hydrocephalus in sub-Saharan Africa: Impact of perioperative care in the Zanzibar archipelago

INTRODUCTION

Child hydrocephalus in low- and middle-income countries represents one of the most sensitive ethical and health problems facing international health development. The most optimistic estimates indicate that 200,000 newborns annually will develop hydrocephalus or be born with a neural tube defect in East, Central and South Africa (ECSA). It is estimated that less than 10% of these children will be operated by ventriculoperitoneal shunts, and in general in poor quality conditions or with a very high complication rate.

OBJECTIVE

To describe the general characteristics, epidemiology and demographic data of childhood hydrocephalus of patients treated at the NED Institute in the Zanzibar archipelago, and assess the clinical details and medium-term results of the impact of the set-up nursing care.

MATERIAL AND METHODS

This is a descriptive and analytical observational study of a retrospective nature, in patients diagnosed and treated with childhood hydrocephalus, in the period from September 2016 to September 2018. With the implementation of a series of perioperative nursing protocols in these patients, the results obtained were described and analyzed.

RESULTS

A total of 96 patients were treated for childhood hydrocephalus. 51% (n=49) of these patients were male, with a mean age of 9.25 months. All the mothers of the patients were monitored during pregnancy, but only 8% were treated with folic acid during pregnancy. 81% of children were born through vaginal delivery or uncomplicated spontaneous delivery. Regarding the etiology, 27.1% of treated hydrocephalus was associated with an infectious cause and 35.4% with an unknown cause. 67 ventriculoperitoneal shunt surgery and 15 endoscopic ventriculostomies were performed. The complication rate was 23.17%.

CONCLUSIONS

The results of this research indicate that childhood hydrocephalus in Zanzibar has etiology, evolution and complications that are similar to or less than those described to date in East Africa. Implementing a series of perioperative protocols and standardized nursing care positively influences the results obtained. Currently, the Mnazi Mmoja Surgical NED Institute is one of the few centers in East Africa with an exhaustive record of healthcare activity and is the first health center that offers further training to nurses.

The role of maternal diet on offspring gut microbiota development: A review

In offspring, an adequate maternal diet is important for neurodevelopment. One mechanism by which maternal diet impacts neurodevelopment is through its dynamic role in the development of the gut microbiota. Communication between the gut, and its associated microbiota, and the brain is facilitated by the vagus nerve, in addition to other routes. Currently, the mechanisms through which maternal diet impacts offspring microbiota development are not well-defined. Therefore, this review aims to investigate the relationship between maternal diet during pregnancy and offspring microbiota development and its impact on neurodevelopment. Both human and animal model studies were reviewed to understand the impact of maternal diet on offspring microbiota development and potential consequences on neurodevelopment. In the period after birth, as reported in both human and model system studies, maternal diet impacts offspring bacterial colonization (e.g., decreased presence of Lactobacillus reuteri as a result of a high-fat maternal diet). It remains unknown whether these changes persist into adulthood and whether they impact vulnerability to disease. Therefore, further long-term studies are required in both human and model systems to study these changes. Our survey of the literature indicates that maternal diet influences early postnatal microbiota development, which in turn, may serve as a mechanism through which maternal diet impacts neurodevelopment.

Trends of folate, vitamin B12 , and homocysteine levels in different trimesters of pregnancy and pregnancy outcomes

OBJECTIVE

To evaluate the effect of folate and vitamin B₁₂ levels on pregnancy progression and outcomes.

METHODS

The present study is a prospective follow up study of 100 pregnant women. Biochemical investigations (plasma homocysteine, folate, and vitamin B₁₂ levels) were performed on all pregnant women in first, second, and third trimesters. Nonparametric tests were used to compare the differences in median levels and odds ratio analysis for the assessment of the risk between the selected biomarkers and adverse pregnancy progression and outcomes.

RESULTS

The pregnant women at their first antenatal care visit were found to be predominantly folate replete (97%) and vitamin B₁₂ deficient (60%). Hyperhomocysteinemia in first and second trimesters was found to pose more than 3-fold increased risk for adverse pregnancy outcomes (P = .006 and .0002, respectively). Low birth weight (LBW) was found to be the most common adverse pregnancy outcome (52%), and was significantly associated with vitamin B₁₂ deficiency in the first and second trimesters (82%, P < .0001; 71.4%, P = .04, respectively).

CONCLUSION

The vitamin B₁₂ deficiency is more common among Indian pregnant women as compared to folate deficiency. Hyperhomocysteinemia is an independent risk factor for pregnancy complications. Vitamin B₁₂ deficiency in first and second trimesters is associated with LBW babies.

A perspective in the management of myelomeningocoele in the KwaZulu-Natal Province of South Africa

BACKGROUND

Myelomeningocoele (MMC) is common in the developing world. The purpose of this study was to investigate the clinical characteristics and management of myelomeningocoele and to identify factors contributing to outcomes.

METHODS

This was a retrospective, observational study of consecutive children diagnosed with MMC managed in the Paediatric Neurosurgery Unit at Inkosi Albert Luthuli Central Hospital. Multiple logistic regression analysis identified clinical characteristics, demographics and surgical variables that were associated with outcome.

RESULTS

A total of 309 children were managed during this period (M:F 1.3:1). The most common sites were lumbar, lumbo-sacral and sacral. Mean age at surgical repair was 4.7 ± 15.6 months. Two hundred and eight children had ventriculomegaly, of whom 158 had symptomatic hydrocephalus, requiring CSF diversion. Fifty-eight (21%) patients developed wound sepsis, of whom 13 (22%) developed meningitis (p = 0.001). The time to wound sepsis was 9.5 ± 3.6 days. The commonest organism isolated was Staphylococcus aureus followed by MRSA. Thirty-two patients (23%) developed shunt malfunction and three (11%) developed ETV malfunction. Twenty children (9%) demised during the admission period. Death was associated with meningitis (p < 0.0001), and meningitis itself was associated with wound sepsis (p < 0.0001). Hospital stay was 20.4 ± 16 days. Wound sepsis (p = 0.002) and meningitis (p < 0.0001), respectively, were associated with prolonged hospital stay.

CONCLUSION

There was a slight male preponderance and hydrocephalus occurred in two thirds of cases. Wound sepsis and meningitis were associated poor outcomes.

Maternal oversupplementation with folic acid and its impact on neurodevelopment of offspring

Folic acid, a B vitamin, is vital for early neurodevelopment and is well known for its protective effect against neural tube defects. Various national health agencies worldwide recommend that women of childbearing age take approximately 0.4 to 1 mg of supplemental folic acid daily to reduce the risk of neural tube defects in offspring. Several countries have tried to promote folic acid intake through mandatory fortification programs to reduce neural tube defects. Supplementation combined with mandatory fortification of foods has led to high levels of folic acid and related metabolites in women of childbearing age. Recent studies have reported that oversupplementation, defined as exceeding either the recommended dietary allowance or the upper limit of the daily reference intake of folic acid, may have negative effects on human health. This review examines whether maternal oversupplementation with folic acid affects the neurodevelopment of offspring. Data from animal studies suggest there are behavioral, morphological, and molecular changes in the brain of offspring. Additional studies are required to determine both the dosage of folic acid and the timing of folic acid intake needed for optimal neurodevelopment in humans.

Failures in reproductive health policy: overcoming the consequences and causes of inaction

It is assumed that long-established research findings and internationally accepted evidence should, and will, be translated into policy and practice. Knowledge about what prevents harm and promotes health has, in fact, guided and resulted in numerous beneficial public health actions. However, such is not always the case. The authors examine three notable, and unwelcome, exceptions in the UK-all in the field of reproductive health and all focused on the period prior to pregnancy. The three examples of counterproductive inaction discussed are: fortifying flour with Vitamin B9 (folic acid); preventing foetal alcohol spectrum disorders; and reducing risks and better regulating a highly teratogenic medication (valproate). The adverse consequences, as well as the causes, of inaction are analysed for each example. Reasons for optimism, and recommendations for overcoming inaction, are also offered, in particular, greater priority should be accorded to preconception health, education and care.

A case-control analysis of maternal diet and risk of neural tube defects in Bangladesh

OBJECTIVES

Mothers need a nutrient-rich diet for healthy neural tube development. Neural tube defect risk can be reduced through fortifying grain products with folic acid and taking folic acid supplements. Fortification is not required in Bangladesh. Maternal supplement use rates are low, similar to other countries. This study evaluates maternal dietary intake during pregnancy to identify possible interventions.

METHODS

A food frequency questionnaire (FFQ) assessed maternal diet. The primary aim compared dietary intake (calories, fat, carbohydrate, protein, fiber, vitamins, and minerals) between mothers of infants with myelomeningocele (cases) and mothers of controls. Secondary aims included (i) comparing foods consumed and (ii) evaluating if rice intake correlated with arsenic exposure. Paired t-tests, Wilcoxon signed rank tests, McNemar's chi-squared test, and linear regression were used.

RESULTS

This study included 110 matched mother-infant pairs (55 cases/55 controls). Mothers of cases and mothers of controls had similar caloric intake [median 2406 kcal/day vs. 2196 kcal/day (p = 0.071)]. Mothers in both groups consumed less than half the daily recommended 600 μg of folate. Diets were potentially deficient in vitamins A, D, E, potassium, sodium, and iron. Steamed rice was the primary food consumed for both groups, and this rice intake was not associated with toenail arsenic.

CONCLUSIONS

Dietary interventions should increase folate, vitamins A, D, E, potassium, sodium, and iron intake in Bangladeshi mothers. Folic acid fortification of grain products maybe the only viable strategy to achieve adequate folate intake for mothers. Given the central role of rice to the Bangladeshi diet, fortifying rice may be a viable option.

Effects of folic acid food fortification scenarios on the folate intake of a multi-ethnic pregnant population

OBJECTIVE

To simulate effects of different scenarios of folic acid fortification of food on dietary folate equivalents (DFE) intake in an ethnically diverse sample of pregnant women.

DESIGN

A forty-four-item FFQ was used to evaluate dietary intake of the population. DFE intakes were estimated for different scenarios of food fortification with folic acid: (i) voluntary fortification; (ii) increased voluntary fortification; (iii) simulated bread mandatory fortification; and (iv) simulated grains-and-rice mandatory fortification.

SETTING

Ethnically and socio-economically diverse cohort of pregnant women in New Zealand.ParticipantsPregnant women (n 5664) whose children were born in 2009-2010.

RESULTS

Participants identified their ethnicity as European (56·0 %), Asian (14·2 %), Māori (13·2 %), Pacific (12·8 %) or Others (3·8 %). Bread, breakfast cereals and yeast spread were main food sources of DFE in the two voluntary fortification scenarios. However, for Asian women, green leafy vegetables, bread and breakfast cereals were main contributors of DFE in these scenarios. In descending order, proportions of different ethnic groups in the lowest tertile of DFE intake for the four fortification scenarios were: Asian (39-60 %), Others (41-44 %), European (31-37 %), Pacific (23-26 %) and Māori (23-27 %). In comparisons within each ethnic group across scenarios of food fortification with folic acid, differences were observed only with DFE intake higher in the simulated grains-and-rice mandatory fortification v. other scenarios.

CONCLUSIONS

If grain and rice fortification with folic acid was mandatory in New Zealand, DFE intakes would be more evenly distributed among pregnant women of different ethnicities, potentially reducing ethnic group differences in risk of lower folate intakes.

Fetal myelomeningocele surgery: Only treating the tip of the iceberg

OBJECTIVE

Fetal myelomeningocele (fMMC) surgery improves infant outcomes when compared with postnatal surgery. Surgical selection criteria and the option of pregnancy termination, however, limit the number of cases that are eligible for prenatal surgery. We aimed to quantify what proportion of cases could ultimately benefit from fetal therapy.

METHODS

We retrospectively reviewed all cases of fMMC referred to a large tertiary care center over a 10-year period and assessed their eligibility for fetal surgery, pregnancy termination rates, and actual uptake of the surgery.

RESULTS

Of 158 cases, 67 (42%) were ineligible for fetal surgery based on surgical exclusion criteria. Eleven fetuses (7%) had chromosomal anomalies, 10 of which (91%) had other anomalies on ultrasound. Thirty-four patients had a combination of maternal and fetal contraindications. Of the remaining 91 eligible cases (58%), 45 (49%) pregnancies were terminated, leaving only 46 (29% of initial 158 cases) as potential candidates for fetal repair. Actual uptake of fetal surgery was 15% (n = 14 of 91), but this increased after a national program was started.

CONCLUSION

Only a minority of fMMC cases will ultimately undergo fetal surgery. These numbers support the centralization of care in expert centers.

[Fetal surgery for myelomeningocele: Obstetric evolution and short-term perinatal outcomes of a cohort of 21 cases]

Objetivo:

Describir la técnica quirúrgica, evolución obstétrica y resultados perinatales de una cohorte de pacientes sometidas a cirugía intrauterina para reparación de una disrafia fetal abierta (DFA).

Métodos:

Análisis prospectivo de 21 casos consecutivos de DFA con diagnóstico y tratamiento quirúrgico prenatal en nuestra institución entre 2015 y 2017. La técnica de la cirugía fetal (QF) fue similar a la descripta en el estudio MOMS, excepto que se utilizó histerotomía con asa bipolar. Los cuidados postoperatorios, nacimiento y cuidados neonatales se realizaron en la misma institución. Se analizaron complicaciones perioperatorias de la QF, la evolución obstétrica y los resultados perinatales.

Resultados:

La QF se realizó a una edad gestacional media de 25.8 semanas (24.1-27.6). La edad gestacional media al nacer fue 34.2 semanas (29.2-37.1). El tiempo quirúrgico medio fue 138 min (101-187) con tendencia descendente y el tiempo de internación medio, 7.1 días (4-32). El 52% (11/21) de las pacientes experimentó rotura prematura de membranas (RPM). Ninguna paciente requirió transfusiones postcesárea. No hubo casos de desprendimiento placentario, rotura uterina ni muertes maternas. La cicatrización de la histerorafia fue normal en 95% de las pacientes. La sobrevida perinatal fue del 95% (20/21, una muerte intrauterina secundaria a banda amniótica). La necesidad de cierre cutáneo postnatal (CCP) fue del 5%. Ninguno de los casos (20) reparados con tejidos fetales requirió CCP. El 70% (14/20) de los pacientes no requirió ningún tratamiento para hidrocefalia. Cuatro pacientes (20%) requirieron una derivación ventriculoperitoneal (DVP) y dos adicionales, una tercer ventriculostomía endoscópica (ETV) (10%). El nivel funcional motor neonatal (NFN) fue mejor que el nivel anatómico prenatal (NAP) en 45% (9/20), igual en 50% (10/20) y peor en 5% (1/20).

Conclusiones:

El presente estudio confirma que la cirugía fetal de disrafias abiertas se asocia a un mayor riesgo de parto prematuro y rotura prematura de membranas, pero reduce significativamente la necesidad de tratamiento postnatal de hidrocefalia y mejora la función motora a corto plazo. Nuestros resultados son similares a los publicados en el ensayo aleatorizado MOMS.

Determinants of folic acid supplement use outside national recommendations for pregnant women: results from the Growing Up in New Zealand cohort study

OBJECTIVE

To evaluate the sociodemographic and lifestyle factors associated with insufficient and excessive use of folic acid supplements (FAS) among pregnant women.

DESIGN

A pregnancy cohort to which multinomial logistic regression models were applied to identify factors associated with duration and dose of FAS use.

SETTING

The Growing Up in New Zealand child study, which enrolled pregnant women whose children were born in 2009-2010.

SUBJECTS

Pregnant women (n 6822) enrolled into a nationally generalizable cohort.

RESULTS

Ninety-two per cent of pregnant women were not taking FAS according to the national recommendation (4 weeks before until 12 weeks after conception), with 69 % taking insufficient FAS and 57 % extending FAS use past 13 weeks' gestation. The factors associated with extended use differed from those associated with insufficient use. Consistent with published literature, the relative risks of insufficient use were increased for younger women, those with less education, of non-European ethnicities, unemployed, who smoked cigarettes, whose pregnancy was unplanned or who had older children, or were living in more deprived households. In contrast, the relative risks of extended use were increased for women of higher socio-economic status or for whom this was their first pregnancy and decreased for women of Pacific v. European ethnicity.

CONCLUSIONS

In New Zealand, current use of FAS during pregnancy potentially exposes pregnant women and their unborn children to too little or too much folic acid. Further policy development is necessary to reduce current socio-economic inequities in the use of FAS.

Maternal gene-micronutrient interactions related to one-carbon metabolism and the risk of myelomeningocele among offspring

BACKGROUND

Few studies have evaluated interactions between maternal genetic variation in 5,10-methylenetetrahydrofolate reductase (MTHFR) and micronutrient intake on the risk of myelomeningocele (MM) in offspring. Therefore, we sought to determine if the role of maternal MTHFR C677T and A1298C on MM risk is altered by maternal intake of micronutrients related to one-carbon metabolism.

METHODS

The study consisted of 220 MM case-parent trios recruited from 1996 to 2006. A dietary questionnaire was used to obtain information on maternal dietary intake on eight micronutrients including folate and cobalamin. TaqMan assays were used to generate MTHFR C677T and A1298C genotypes. Log-linear models were used to evaluate the joint effects of maternal genotype and micronutrient intake dichotomized as at or above versus below the United States Recommended Dietary Allowance (US RDA) on MM.

RESULTS

There was little evidence to suggest maternal MTHFR genotypes interacted with micronutrient intake to influence the risk of MM. For instance, the effect of MTHFR 677T was similar for mothers with cobalamin intake below US RDA (relative risk [RR] = 0.97) versus at or above US RDA cobalamin intake (RR = 0.81, interaction p = 0.87). However, some differences were noted. For example, the effect of MTHFR 1298C appeared to be different between those mothers below US RDA folate intake (RR = 0.98) versus those at or above US RDA folate intake (RR = 0.68), but the interaction was not statistically significant (interaction p = 0.27).

CONCLUSION

There did not appear to be strong effects of maternal micronutrient intake on the role of maternal genetic polymorphisms in MTHFR C677T and A1298C on MM risk. Birth Defects Research 109:99-105, 2017. © 2016 Wiley Periodicals, Inc.

Folic Acid Exposure Rescues Spina Bifida Aperta Phenotypes in Human Induced Pluripotent Stem Cell Model

Neural tube defects (NTDs) are severe congenital abnormalities, caused by failed closure of neural tube during early embryonic development. Periconceptional folic acid (FA) supplementation greatly reduces the risk of NTDs. However, the molecular mechanisms behind NTDs and the preventive role of FA remain unclear. Here, we use human induced pluripotent stem cells (iPSCs) derived from fetuses with spina bifida aperta (SBA) to study the pathophysiology of NTDs and explore the effects of FA exposure. We report that FA exposure in SBA model is necessary for the proper formation and maturation of neural tube structures and robust differentiation of mesodermal derivatives. Additionally, we show that the folate antagonist methotrexate dramatically affects the formation of neural tube structures and FA partially reverts this aberrant phenotype. In conclusion, we present a novel model for human NTDs and provide evidence that it is a powerful tool to investigate the molecular mechanisms underlying NTDs, test drugs for therapeutic approaches.

Estimates of global and regional prevalence of neural tube defects for 2015: a systematic analysis

Neural tube defects (NTDs) are associated with substantial mortality, morbidity, disability, and psychological and economic costs. Many are preventable with folic acid, and access to appropriate services for those affected can improve survival and quality of life. We used a compartmental model to estimate global and regional birth prevalence of NTDs (live births, stillbirths, and elective terminations of pregnancy) and subsequent under-5 mortality. Data were identified through web-based reviews of birth defect registry databases and systematic literature reviews. Meta-analyses were undertaken where appropriate. For 2015, our model estimated 260,100 (uncertainty interval (UI): 213,800-322,000) NTD-affected birth outcomes worldwide (prevalence 18.6 (15.3-23.0)/10,000 live births). Approximately 50% of cases were elective terminations of pregnancy for fetal anomalies (UI: 59,300 (47,900-74,500)) or stillbirths (57,800 (UI: 35,000-88,600)). Of NTD-affected live births, 117,900 (∼75%) (UI: 105,500-186,600) resulted in under-5 deaths. Our systematic review showed a paucity of high-quality data in the regions of the world with the highest burden. Despite knowledge about prevention, NTDs remain highly prevalent worldwide. Lack of surveillance and incomplete ascertainment of affected pregnancies make NTDs invisible to policy makers. Improved surveillance of all adverse outcomes is needed to improve the robustness of total NTD prevalence estimation, evaluate effectiveness of prevention through folic acid fortification, and improve outcomes through care and rehabilitation.

Considerations for Secondary Prevention of Nutritional Deficiencies in High-Risk Groups in High-Income Countries

Surveys in high-income countries show that inadequacies and deficiencies can be common for some nutrients, particularly in vulnerable subgroups of the population. Inadequate intakes, high requirements for rapid growth and development, or age- or disease-related impairments in nutrient intake, digestion, absorption, or increased nutrient losses can lead to micronutrient deficiencies. The consequent subclinical conditions are difficult to recognize if not screened for and often go unnoticed. Nutrient deficiencies can be persistent despite primary nutrition interventions that are aimed at improving dietary intakes. Secondary prevention that targets groups at high risk of inadequacy or deficiency, such as in the primary care setting, can be a useful complementary approach to address persistent nutritional gaps. However, this strategy is often underestimated and overlooked as potentially cost-effective means to prevent future health care costs and to improve the health and quality of life of individuals. In this paper, the authors discuss key appraisal criteria to consider when evaluating the benefits and disadvantages of a secondary prevention of nutrient deficiencies through screening.