Consanguineous marriage and differentials in age at marriage, contraceptive use and fertility in Pakistan

Consanguinity, inbreeding coefficient, fertility and birth-outcome in population of Okara district, Pakistan

Objectives

This study was aimed to illustrate the determents of consanguinity and inbreeding coefficient-F (ICF) in the population of Okara district of Pakistan and to elucidate the impact of consanguinity on fertility and birth outcome.

Methods

Through a cross-sectional sampling design, 1,521 married women were recruited from Okara district during 2016-2017. Data on demographic variables, marital union types, subject's fertility, and reproductive outcome, were gathered in face-to-face interviews. Descriptive statistics and multivariable logistic regression were employed.

Results

The prevalence of consanguineous unions (CU) was calculated to be 61% yielding ICF=0.0356. Multivariable regression analyses revealed that six variables including younger age at marriage, joint family structure, caste-system of spouse, exchange marriage, matrimonial distance, and parental consanguinity, were significant predictors of consanguinity. The women having CU had significantly higher mean fertility, mean live-births and mean live-born sons compared with subjects having non-consanguineous unions (NCU). However, there were no significant differences in the average mortalities, i.e., prenatal, postnatal and <5 years, between the mothers with CU and NCU.

Conclusion

The prevalence of consanguineous unions (CU) in Okara district is quite high like other inbred populations of Pakistan. The striking findings of this study are the higher mean fertility and mean live-births in women with CU. The likely reasons underlying this phenomenon have been discussed.

Consanguinity rates among Syrian refugees in Lebanon: a study on genetic awareness

Consanguineous marriage is a deeply rooted tradition in the Arab world. Such marriages are linked to higher rates of recessive genetic diseases. During the Syrian conflict, which started in 2011, around one million Syrian individuals became refugees in Lebanon. This study assessed the consanguinity rates among Syrian refugees living in Lebanon up to three successive consanguineous generations, and examined refugees' awareness of the possible consequences of consanguineous marriage and their attitudes towards consanguinity. Their knowledge of, and access to, premarital screening was also assessed. The study was conducted between January and May 2018. Several study sites representing refugees' distribution within the country were chosen. The study sample included 1008 interviewees from different families. Of those interviewed, 51.9% were in a consanguineous marriage. Interestingly, 23.9% were the product of consanguineous marriages themselves, and 17.9% were consanguineous for three successive generations. The interviewees generally knew about premarital screening, but the majority (61.9%) had not had the screening. The high rates of consanguinity in these Syrian refugees call for immediate action, including raising genetic awareness and providing appropriate genetic counselling. Despite the respondents' familiarity with premarital screening, there was a low rate of uptake of the test, underscoring the importance of providing better education to these refugees.

A review of the reproductive consequences of consanguinity

BACKGROUND

Consanguinity is the close union, sexual relationship or marriage between persons who have common biological ancestors usually up to about 2nd cousins. Contrary to general opinion consanguinity is quite common and is practiced worldwide. It is an important topic as while rates of consanguineous unions in certain society have decreased over time, rates have remained stable or increased in other societies with rates as high as 80.6% in some communities. Our aim was to conduct a review looking at general aspects of consanguinity and any published reproductive outcomes in literature. We also looked at possible future directions that could be relevant in the management of the consanguineous couple to help improve reproductive outcomes.

METHOD

We conducted a PUBMED, CINAHL, Web of Knowledge and Google Scholar search looking at articles on consanguinity. Consanguinity articles related to pregnancy and reproduction were searched using additional filters looking at our specific areas of interest. All relevant publications up to March 2015 were reviewed. Additional search for relevant articles pertaining to pre implantation genetic diagnosis for future directions in the management of the consanguineous couple was done. Most publications were found in books, on line articles and journals. Most were retrospective, population or cohort studies.

RESULT

Consanguinity is practiced by up to 10% of the world's population with rates ranging from 80.6% in certain provinces in the Middle East to less than 1% in western societies. It predates Islam and has been practiced since Old Testament times. The most commonly cited reason for consanguinity is sociocultural and socioeconomic although it is also more common in certain religions. In areas where rates of Consanguinity are reducing urban migration and increasing education rates are thought to be contributory. Congenital malformations have long been established to be higher in consanguineous couples above the background rate (4.5% Vs 1%).Due to "Founder effect" or a common ancestor, Consanguinity is most commonly associated with Inborn errors of metabolism most of which are autosomal recessive. Consanguinity increases the incidence of multifactorial disorders such as diabetes, cardiovascular disorders, obesity and certain types of cancers. These may in turn affect reproductive outcomes. It may also affect fertility rates. Pregnancy outcomes like increased pregnancy wastages and preterm labor have been reported with consanguinity. Other studies produced conflicting evidence on its effect regarding outcomes like hypertensive disorders of pregnancy and Intrauterine growth restriction.

CONCLUSION

Consanguinity continues to be practiced worldwide and in some countries rates are increasing. The main reason for the practice appears to be sociocultural and socioeconomic although religious beliefs is a contributory factor. The most significant effects on reproductive outcomes are mostly due to autosomal recessive inherited conditions and inborn errors of metabolism. It also significantly increases the inheritance of certain multifactorial disorders like diabetes which may indirectly affect reproductive outcomes. In the future with the completion of the study of the whole human Genome and current advances in Pre implantation Genetic diagnosis and screening it may be possible to mitigate some of the adverse reproductive outcomes associated with consanguinity.

Fertility Patterns Among Turkish Women in Turkey and Abroad: The Effects of International Mobility, Migrant Generation, and Family Background

In this paper, we examine the fertility behavior of Turkish women in Europe from a context-of-origin perspective. Women with different migration biographies (first-generation, 1.5-generation, second-generation migrants, and return migrants) are compared with "stayer" women from the same regions of origin in Turkey. This approach provides us with new insights into the study of the effects of international migrations. First-, second-, and third-birth transitions are analyzed using data from the 2000 Families Study, which was conducted in 2010 and 2011 in Turkey and in western Europe. The classical hypotheses of disruption, interrelated events, adaptation, socialization, and selectivity/composition are developed with reference to the context-of-origin perspective. To account for socialization and family-related composition effects, we also look at family characteristics. Our findings provide no support for the disruption hypothesis, but suggest that the first-generation migrant women have higher first-birth risks than the stayers. However, this gap can be fully explained by differences in marriage duration. Differences in composition-namely in educational attainment-account for our finding that the second migrant generation has lower first-birth transition rates than the women in Turkey. Except for the number of siblings, the family influence, including the processes of intergenerational transmission, is minor and hardly accounts for the migrant-stayer differences in birth transitions. Most remarkably, the analyses show that the second- and third-birth risks of almost all of the migrant groups are higher than those of the women in Turkey, when individual and family factors are held constant; which suggests that there is a fertility crossover between the origin and the destination contexts.

Consanguinity and its socio-biological parameters in Rahim Yar Khan District, Southern Punjab, Pakistan

BACKGROUND

Rahim Yar Khan (RYK) District is a multi-ethnic assemblage of both ancient and migrated communities in Southern Punjab, Pakistan. There is a paucity of knowledge on the bio-demographic structure of this endogamous population.

METHODS

We have carried out a cross-sectional epidemiological study in RYK District and recruited 2174 random Muslim married females. Detailed account of marital union types, level of consanguinity, and subject's fertility, was taken.

RESULTS

The analyses of these data revealed that consanguineous unions (CU) were 58.46 %, rendering an inbreeding coefficient (IC-F) = 0.0355. The CU were observed to be significantly higher in subjects originating from rural areas, speaking Saraiki language, illiterate or having a religious/Madarsa education only, and belonging to nuclear family type. The rate of consanguinity was also higher in subjects whose husbands were engaged in unskilled manual or skilled manual jobs, and had consanguinity in the parental generation. Multivariate logistic regression analyses revealed that variables like Saraiki language, illiteracy, reciprocal marriages, and parental consanguinity, were the significant predictors of CU in the subject. Among the first cousin unions (which constituted 52 % of all marriages), parallel-cousin and patrilineal unions were in the majority (54 and 57 %, respectively), and father's brother's daughter type had the highest representation (31 %). The analyses further demonstrated that fertility and mean live-births were significantly higher in women who had CU compared to the non-consanguineous (NCU) group (p < 0.006); and significantly higher number of sons per women were born to the mothers who had CU compared with the NCU sample (p = 0.0002). However, there were no differences in the CU and NCU samples with respect to pre- or post-natal mortalities and child morbidities.

CONCLUSIONS

The scientific findings in RYK District are distinct from the observations in other Pakistani populations and clue to a unique nature of this population. This study presents a comprehensive account of consanguinity and IC-F in RYK District and would be helpful in getting an insight into the structure of this population.

Contraceptive use before first pregnancy by women in India (2005-2006): determinants and differentials

Background

There exist ample of research literature investigating the various facet of contraceptive use behaviors in India but the use of contraception by married Indian women, prior to having their first pregnancy has been neglected so far. This study attempts to identify the socio demographic determinants and differentials of contraceptive use or non use by a woman in India, before she proceeds to have her first child. The analysis was done using data from the third National Family Health Survey (2005–2006), India.

Methods

This study utilized information from 54,918 women who ever have been married and whose current age at the time of NFHS-3 survey was 15–34 years. To identify the crucial socio-demographic determinants governing this pioneering behavior, logistic regression technique has been used. Hosmer Lemeshow test and ROC curve analysis was also performed in order to check the fitting of logistic regression model to the data under consideration.

Results

Of all the considered explanatory variables religion, caste, education, current age, age at marriage, media exposure and zonal classifications were found to be significantly affecting the study behavior. Place of residence i.e. urban - rural locality came to be insignificant in multivariable logistic regression.

Conclusions

In the light of sufficient evidences confirming the presence of early marriages and child bearing practices in India, conjunct efforts are required to address the socio demographic differentials in contraceptive use by the young married women prior to their first pregnancy. Encouraging women to opt for higher education, ensuring marriages only after legal minimum age at marriage and promoting the family planning programs via print and electronic media may address the existing socio economic barriers. Also, the family planning programs should be oriented to take care of the geographical variations in the study behavior.

Genetics and psychotic disorders: A fresh look at consanguinity

Consanguineous unions refer to marriages between related individuals who share a common ancestor. These unions are still commonplace in certain regions of the world such as the southern coast of the Mediterranean, throughout the Middle East and South-East Asia. According to available data, couples of second cousins or closer and their offspring currently represent 10.4% of the world's population, thus resulting in increased frequencies of autosomal recessive disorders. Furthermore, consanguinity may be implicated in the increased frequency of multifactorial pathologies such as mental disorders. The few existing epidemiological studies in consanguineous and/or geographically isolated populations confirm that there is a significant association between consanguinity and mental disorders and a higher risk of schizophrenia or bipolar disorders among offspring from consanguineous couples. There exists a strong and complex genetic component in the predisposition to psychotic disorders that has been confirmed in numerous studies. However, the genetic basis of these disorders remains poorly understood. GWAS studies (Genome Wide Association Studies) over the past 10 years have identified a few weak associations, thus refuting the "common diseases-common variants" hypothesis. A model implicating numerous rare variants has been supported by the recent discovery of CNVs (Copy Number Variants) and their statistically significant association with psychiatric disorders such as schizophrenia, bipolar disorders and autism. The study of consanguineous families may contribute to identifying rare variants in homogenous populations who have conserved certain alleles. Major developments in molecular biology techniques would facilitate these studies as well as contributing to identifying major genes. These results emphasize the need for genetic counseling in high-risk communities and the importance of implementing preventive actions and raising awareness concerning the risk of consanguineous unions.

CONSANGUINITY AND INBREEDING COEFFICIENT IN TRIBAL PASHTUNS INHABITING THE TURBULENT AND WAR-AFFECTED TERRITORY OF BAJAUR AGENCY, NORTH-WEST PAKISTAN

The north-western populations of Pakistan in the Federally Administered Tribal Areas (FATA) adjoining the Pakistan–Afghanistan border are an amalgamation of native and migrated Pashtun tribes. These tribal populations are in transition due to war conditions and geo-political turmoil on both sides of the border since the Soviet invasion in 1979. Bio-demographic and epidemiological data for these tribes are scarce. A prospective cross-sectional sample of 967 males was selected from a representative Pashtun population of Bajaur Agency, and information obtained on bio-demographic variables and marital union types. Analysis of these data revealed that consanguinity was 22.34% and the inbreeding coefficient F was calculated to be 0.0134. The inbreeding coefficient was observed to be higher in subjects who were illiterate, had unskilled jobs and who belonged to younger age categories, extended families and the Tarkalani tribe. Further analyses with respect to temporal variables like subject's age, year of marriage and age at marriage revealed that after a transition in marital union types in the early 80s, there has been a declining trend in the rate of consanguineous unions. Further, consanguineous unions in the parental generation were only 5%, but parental marriage types were predictors of subjects' marital union types. The data further establish that, contrary to a general notion about a high consanguinity rate in Pakistan, consanguineous unions are not common in Bajaur Agency and first cousin marriage is not the preferred type. Furthermore, this research shows that there is a great regional variation in the pattern of consanguinity in Pakistan that needs to be documented in order to draw a more comprehensive picture of the inbreeding coefficient in the country.

Girl child marriage and its effect on fertility in Pakistan: findings from Pakistan Demographic and Health Survey, 2006-2007

Child marriage (before 18 years) is prevalent in Pakistan, which disproportionately affects young girls in rural, low income and low education households. Our study aims to determine the association between early marriage and high fertility and poor fertility health indicators among young women in Pakistan beyond those attributed to social vulnerabilities. Nationally representative data from Pakistan Demographic and Health Survey, 2006-2007, a cross-sectional observational survey, were limited to ever-married women aged 20-24 years (n = 1,560; 15% of 10,023) to identify differences in poor fertility outcomes [high fertility (three or more childbirths); rapid repeat childbirth (<24 months between births); unwanted pregnancy (any ever); pregnancy termination (any stillbirth, miscarriage or abortion ever)] by early (<18) versus adult (≥18) age at marriage. Associations between child marriage and fertility outcomes were assessed by calculating adjusted odds ratios (AORs) using logistic regression models after controlling for demographics, social equity indicators (education, wealth index, rural residence), contraception use, marriage duration and culture-specific factors (husband's desire for more children, son preference). Overall, 50% of ever-married women aged 20-24 years in Pakistan were married before the age of 18 years. Girl child marriage was significantly (p < 0.001) associated with low social equity indicators (poverty, rural residence, and no formal education). Adjusted logistic regression models showed that girl child marriage was significantly associated with high fertility (AOR 6.62; 95% CI 3.53-12.43), rapid repeat childbirth (AOR 2.88; 95% CI 1.83-4.54), unwanted pregnancy (AOR 2.90; 95% CI 1.75-4.79), and pregnancy termination (AOR 1.75; 95% CI 1.10-2.78). Girl child marriage affects half of all ever-married women aged 20-24 years in Pakistan, and increases their risk for high fertility and poor fertility health indicators, highlighting the need of increasing the age of marriage among women in Pakistan. Efforts to eliminate girl child marriage by strict law enforcement, promoting civil, sexual and reproductive health rights for women can help eliminate girl child marriage in Pakistan.

A positive association between consanguinity and fertility in communities of Paraíba, Northeast Brazil

BACKGROUND

Consanguinity of human populations can but does not have to be associated with increased fertility. A recent study involving communities of Northeast Brazil revealed increased levels of endogamy.

SUBJECTS AND METHODS

Data from 20 451 interviewed couples and their 74 289 children were analysed.

AIM

The present study aimed to compare fertility between consanguineous and unrelated couples of these communities.

RESULTS

Consanguineous and unrelated couples of the 39 communities had an average of 4.3 (SD = 0.9) and 3.5 (SD = 0.8) children (p < 0.0001), respectively. Average offspring number of consanguineous couples varied from 3.9 (SD = 1.1) to 5.6 (SD = 3.4) for couples related at the level of third cousins and double first cousin/uncle-niece, respectively (p < 0.005). The correlation coefficient between Human Development Index and fertility was -0.38 (p = 0.0179) and -0.23 (p = 0.17) for unrelated and related couples, respectively.

CONCLUSION

Results indicated an overall positive association between consanguinity and fertility. Fertility tended to be increased, for closely related couples, compared to those related more distantly.

The practice of consanguineous marriage in Oman: prevalence, trends and determinants

The practice of consanguineous marriage has been the culturally preferred form of marriage in most Arab and the Middle Eastern countries, including Oman, but due to a paucity of population-based data in the past there is a dearth of information about its form and dynamics in Oman. Recent national-level surveys allow this gap to be filled. This paper examines the prevalence, trends and determinants of consanguineous marriages in Oman using data from the 2000 Oman National Health Survey. The results indicate a very high prevalence of consanguineous marriage in Oman, as more than half (52%) of marriages are consanguineous. First cousin unions are the most common type of consanguineous unions, constituting 39% of all marriages and 75% of all consanguineous marriages. The study observed various patterns of consanguinity, some of them common with other Arab nations, and some unique in nature. Women's age at marriage, employment, place of childhood residence and geographical region appear to be significant determinants of consanguineous marriages. Consanguineous marriage shows a strong association with marital stability, early age at marriage and early-age childbearing. There has been no appreciable change in the prevalence of consanguineous unions in Oman over the last four decades despite massive socioeconomic development and modernization. However, recent marriage cohorts show slight declining trends. The results suggest that consanguinity is likely to remain stable in the future or decline at a slow rate. Specific health education and genetic counselling should be followed in line with WHO recommendations to minimize the negative health consequences of consanguinity for child health.

Assessing a thematic condom advertising campaign on condom use in urban Pakistan

This study aims to assess communication processes involving a thematic condom advertising campaign in Pakistan in 2009. To evaluate the social marketing campaign for Touch condoms, the authors conducted a nationally representative survey of 1,606 men married to women aged 15-49 years. About 15% of urban married men were aware of Touch advertising. After controlling for a range of other variables including daily television viewership, confirmed awareness of Touch advertising was associated with a higher level of belief in the effectiveness of condoms, reduced embarrassment in negotiating condom use, reduced embarrassment in purchasing condoms, increased discussion of family planning, and increased use of condoms and other contraceptive methods. The findings have implications for the further development and dissemination of contraceptive advertising in Pakistan, as well as the broader construction of scientific knowledge on how advertising can influence contraceptive and other critical health behaviors in other contexts.

Consanguineous Marriage and Human Evolution

Mate choice among early human groups and in many historical populations was subject to both demographic and social constraints, ensuring that most unions were between couples who had coinherited substantial proportions of their genomes from common ancestors. Even in populations in which close consanguineous marriage was proscribed, community endogamy would have been sufficient to ensure high levels of homozygosity. Consanguineous marriage remains the choice of an estimated 10.4% of the global population, although there has been an overall decline in its popularity, especially in developed countries. Recent studies have indicated that the shift from consanguineous marriage to panmixia has been accompanied by a reduction in homozygosity. The concomitant predicted decrease in incidence of both recessive single-gene disorders and more common adult-onset diseases will have a significant impact on the health of future generations.

Reproductive pattern in consanguineous and non-consanguineous marriages in La Cabrera, Spain

BACKGROUND

Among determinants of the structure of human populations, consanguineous marriages can be useful in determining to what extent they influence the genetic structure of the population. This knowledge may be gained by comparing the reproductive performance of related and non-related couples. The population studied, La Cabrera, is a mountainous region in the Leon province (north-western Spain). It includes four neighbouring municipalities with similar geographic, climatic and ecological features with 37 parishes occupying an area of 784.2 km(2), of which only 1.5% is arable. The number of inhabitants remained stable from 1887 (9526 inhabitants) to 1960 (8984), when due to emigration it began to decrease. The average inbreeding coefficient (alpha) for the period 1880-1989 (up to third degree) was 4.82 x 10(-3).

AIM

The objective of this analysis was to evaluate the possible factors determining the differences between consanguineous and non-consanguineous families residing in La Cabrera during the period 1880-1959.

SUBJECTS AND METHODS

To study the structure and dynamics of each couple, families were reconstituted for the period 1880-1959 using demographic data corresponding to births, deaths and marriages obtained from parish registers. This procedure provided information on each couple's reproductive history through information concerning the mates' deaths as well as their offspring's births and deaths. Principal component analysis revealed the existence of three factors that together explained 57% of the reproductive pattern variability of La Cabrera.

RESULTS

The first component (eigenvalue: 3.56) correlated positively with the number of live births and with the duration of the reproductive period. Component II (eigenvalue: 1.54) had a positive correlation with variables describing the beginning of the marital union, and with those indicating its ending. Finally, component III (eigenvalue: 1.13) reflected a negative association with the two variables that described neonatal and post-neonatal mortality. The above demographic variables represented the reproductive process in La Cabrera adequately. Fertility was the variable that offered the best explanation of the reproductive pattern (32%), followed by the marital structure (13%) and the infant mortality (12%).

CONCLUSION

In the La Cabrera population, consanguinity appears as a socio-cultural process that affects the reproductive dynamic. Consanguinity modifies the marital structure and alters the reproductive pattern, prolonging the reproductive period, which results in a greater number of offspring. Lower infertility rates and the possible compensatory effect for infant mortality may reflect biological factors making the wife's reproductive period more efficient.

Decrease in consanguinity among parents of children born in Norway to women of Pakistani origin: a registry-based study

AIMS

To describe the prevalence of consanguinity among Norwegian Pakistani parents in the period from 1995 to 2005.

METHODS

All first births to women of Pakistani origin in 1995-2005 (n = 1962) were identified by linking the Medical Birth Registry of Norway with information on country of origin and country of birth from Statistics Norway. Prevalence ratios (PRs) and prevalence differences were calculated by multiple binomial regression analyses with adjustment for maternal age and education. Women born in Pakistan who gave birth in Norway in 1995-97 formed the reference group.

RESULTS

The proportion of women who were consanguineously related to their co-parent decreased from 45.5% in 1995-97 to 27.3% in 2002-2005 among those who were born in Pakistan, and from 48.3% to 18.8% among women of Pakistani origin who were born in Norway. The proportion of women who were related to their co-parent as first cousin decreased from 37.7% to 24.7% among women born in Pakistan, and from 43.3% to 16.7% among women of Pakistani origin who were born in Norway. The proportion of births to women with an unrelated co-parent increased by 25% for women born in Pakistan (PR = 1.25, 95% confidence interval (CI) = 1.12-1.39), and by 53% for women of Pakistani origin born in Norway (PR = 1.53, 95% CI = 1.35-1.74).

CONCLUSIONS

In contrast to previous reports from the UK, our analysis suggests that there is a decrease in the proportion of consanguineously related parents of children born to women of Pakistani origin in Norway.

Impact of inbreeding on fertility in a pre-industrial population

Little is known about the effects of inbreeding on reproduction in modern human societies. It appears indeed that biological effects are hidden by socioeconomic factors, which are the major determinants of fertility. It has been established, in particular, that socially induced reproductive compensation tends to homogenize the number of offspring per family in a given population. Besides, in the field of evolutionary biology, a number of empirical and theoretical studies have shown that the effects of inbreeding are condition dependent. In particular, theoretical developments on the evolution of senescence predict that the deleterious effects of inbreeding should increase with age. We rely on these developments to examine the effects of inbreeding on fertility in a cohort of Canadian women born in the late 19th century. The analysis does not allow for the detection of any effect of inbreeding on the overall number of offspring of women. However, results indicate that high levels of close father inbreeding are associated with a reduction of the productivity of parents during the second half of their reproductive period, as compared with the first half. We suggest that inbreeding depression affects reproduction in modern societies through an interaction with age.

Polygamy and the use of contraceptives

OBJECTIVES

To compare contraceptive use among women in monogamous and polygamous marriages in Nigeria.

METHODS

Structured questionnaires administered to married women enquired about their marriage type, sociodemographic characteristics, and contraceptive use.

RESULTS

Of the 532 respondents, 33.6% were in polygamous marriages. There was a statistically significant association between monogamy and nonutilization of contraception (P=0.03); however, women in polygamous marriages were more likely not to use contraception when they were older than 35 years, had 4 or more living children, had no male child, had 3 or more female children, or lived in rural areas. There was also a statistically significant association between nonutilization of contraception and number of male children of co-wives (P=0.003), number of female children of co-wives (P=0.05), and use of contraception by co-wives (P=0.002).

CONCLUSION

Polygamy influences contraceptive use and the role of co-wives in this regard merits further study.

Consanguineous marriages in the province of Antalya, Turkey

To assess the trends in the frequency and the medical effects of consanguinity in the south coast of Turkish population using local and national data in the last 11 years. This cross-sectional study was carried out in Manavgat province, which is a major tourism center on the Mediterranean coast of Turkey. The authors studied consanguineous marriages in rural and urban population in the Mediterranean coast, Manavgat province, Turkey, via a 1500 random survey sample of married couples. There has been a significant increase in the incidence of consanguineous marriages in rural areas (40.7%) since 1989 in the southern population of Turkey. The results showed that the most frequent type of marriage was between the first cousins. It is found that there is no statistically significant difference between the consanguineous and non-consanguineous marriages in the different age groups. The results were discussed on the basis of educational status, reasons for having consanguineous marriages and the general medical effects as well as with the relation of congenital malformations. The custom of consanguineous unions in the Mediterranean population of Turkey is still extremely high, and preventive measures should be done to decrease its frequency and associated complications.

Risk factors for non-fatal myocardial infarction in young South Asian adults

OBJECTIVE

To determine the risk factors for premature myocardial infarction among young South Asians.

DESIGN AND SETTING

Case-control study in a hospital admitting unselected patients with non-fatal acute myocardial infarction.

METHODS AND SUBJECTS

Risk factor assessment was done in 193 subjects aged 15-45 years with a first acute myocardial infarct, and in 193 age, sex, and neighbourhood matched population based controls.

RESULTS

The mean (SD) age of the subjects was 39 (4.9) years and 326 (84.5%) were male. Current smoking (odds ratio (OR) 3.82, 95% confidence interval (CI) 1.47 to 9.94), use of ghee (hydrogenated vegetable oil) in cooking (OR 3.91, 95% CI 1.52 to 10.03), raised fasting blood glucose (OR 3.32, 95% CI 1.21 to 8.62), raised serum cholesterol (OR 1.67, 95% CI 1.14 to 2.45 for each 1.0 mmol/l increase), low income (OR 5.05, 95% CI 1.71 to 14.96), paternal history of cardiovascular disease (OR 4.84, 95% CI 1.42 to 16.53), and parental consanguinity (OR 3.80, 95% CI 1.13 to 1.75) were all independent risk factors for acute myocardial infarction in young adults. Formal education versus no education had an independently protective effect on acute myocardial infarction (OR 0.04, 95% CI 0.01 to 0.35).

CONCLUSIONS

Tobacco use, ghee intake, raised fasting glucose, high cholesterol, paternal history of cardiovascular disease, low income, and low level of education are associated with premature acute myocardial infarction in South Asians. The association of parental consanguinity with acute myocardial infarction is reported for the first time and deserves further study.

Risk factors for neonatal mortality in low-income population subgroups in Karachi, Pakistan

This paper assesses the risk factors for neonatal mortality (0-28 days of life) for full-term singleton live births. The study sample comprised 1,011 ever-married women who were residents of four multi-ethnic, multi-religious low-income areas of Karachi, Pakistan during 1995. The analysis sample was restricted to 4,488 live births to 912 women. Results showed that 4.8% (n = 217) of all births ended in death in the neonatal period, and 76% (n = 164) of these neonatal deaths occurred in the first week of life. While neonatal mortality rates had declined appreciably over time, a large proportion of neonatal deaths were clustered in a small group of women. The univariate analysis showed a statistically significant association between a number of maternal-level parameters (e.g., mother's age at birth, level of formal education, employment status, religious affiliation, and consanguinity) and child-level parameters (e.g., birth order, birth interval, survival status of the preceding child, sex of the neonate, year of death). At the multivariate level, consanguinity, birth order and year of death were found to be statistically significant risk factors for neonatal mortality analyses despite adjustment for death clustering. The study highlights the importance of inbreeding as a determinant of early offspring death, and points to the need for better understanding of why deaths are clustered in certain families. Given the widespread practice of close cousin marriages in Pakistan across all socio-economic groups, there is a need to validate the findings in less economically disadvantaged population subgroups within the country.

Ethnic subgroup differences in hypertension in Pakistan

OBJECTIVE

Cardiovascular risks are globally elevated in South Asians, but this masks important ethnic subgroup differences in risk factors, such as hypertension, which have not been fully explored. We conducted this study to explore the variations in hypertension within ethnic subgroups among South Asians.

DESIGN

Cross-sectional survey [National Health Survey of Pakistan (NHSP) (1990-1994)].

SETTING

Population based.

PARTICIPANTS

A total of 9442 individuals aged 15 years or over.

METHODS

Data on sociodemographic and clinical variables were collected. Distinct ethnic subgroups - Muhajir, Punjabi, Sindhi, Pashtun and Baluchi - were defined by mother tongue.

MAIN OUTCOME MEASURE

Hypertension defined as systolic blood pressure >or= 140 mmHg or diastolic blood pressure >or= 90 mmHg, or currently receiving antihypertensive therapy.

RESULTS

The age-standardized prevalence of hypertension was highest among Baluchis (25.3% in men and 41.4% in women), then Pashtuns (23.7% in men and 28.4% in women), Muhajirs (24.1% in men and 24.6% in women), and lowest among Punjabis (17.3% in men and 16.4% in women) and Sindhis (19.0% in men and 9.9% in women) (P = 0.001). While hypertension was more prevalent in urban (22.7%) versus rural dwellers (18.1%) [odds ratio (OR) 1.34; 95% confidence interval (CI), 1.20, 1.49], this difference was no longer significant after adjusting for body mass and waist circumference (OR 1.03; 95% CI, 0.91, 1.16). However, ethnic differences persisted after adjusting for major sociodemographic, dietary and clinical risk factors (unadjusted OR for Baluchi versus Sindhi, 2.92; 95% CI, 2.20-3.89; adjusted OR, 2.71; 95% CI, 1.97-3.75).

CONCLUSIONS

A threefold difference in prevalence of hypertension exists between people of South Asian descent, which, unlike the urban/rural difference, cannot be accounted for by measured risk factors. Further study would provide valuable etiological and therapeutic clues.

Contribution of BRCA1 and BRCA2 mutations to breast and ovarian cancer in Pakistan

The population of Pakistan has been reported to have the highest rate of breast cancer of any Asian population (excluding Jews in Israel) and one of the highest rates of ovarian cancer worldwide. To explore the contribution that genetic factors make to these high rates, we have conducted a case-control study of 341 case subjects with breast cancer, 120 case subjects with ovarian cancer, and 200 female control subjects from two major cities of Pakistan (Karachi and Lahore). The prevalence of BRCA1 or BRCA2 mutations among case subjects with breast cancer was 6.7% (95% confidence interval [CI] 4.1%-9.4%), and that among case subjects with ovarian cancer was 15.8% (95% CI 9.2%-22.4%). Mutations of the BRCA1 gene accounted for 84% of the mutations among case subjects with ovarian cancer and 65% of mutations among case subjects with breast cancer. The majority of detected mutations are unique to Pakistan. Five BRCA1 mutations (2080insA, 3889delAG, 4184del4, 4284delAG, and IVS14-1A-->G) and one BRCA2 mutation (3337C-->T) were found in multiple case subjects and represent candidate founder mutations. The penetrance of deleterious mutations in BRCA1 and BRCA2 is comparable to that of Western populations. The cumulative risk of cancer to age 85 years in female first-degree relatives of BRCA1-mutation-positive case subjects was 48% and was 37% for first-degree relatives of the BRCA2-mutation-positive case subjects. A higher proportion of case subjects with breast cancer than of control subjects were the progeny of first-cousin marriages (odds ratio [OR] 2.1; 95% CI 1.4-3.3; P=.001). The effects of consanguinity were significant for case subjects with early-onset breast cancer (age <40 years) (OR=2.7; 95% CI 1.5-4.9; P=.0008) and case subjects with ovarian cancer (OR=2.4; 95% CI 1.4-4.2; P=.002). These results suggest that recessively inherited genes may contribute to breast and ovarian cancer risk in Pakistan.

God should give daughters to rich families only: attitudes towards childbearing among low-income women in Punjab, Pakistan

We evaluated perceptions and experiences of bearing sons and daughters among 42 women in Punjab, Pakistan, with special emphasis on son preference, changes in women's status within the marital family and resulting health effects. Data were collected through repeated, in-depth interviews in Urdu or Punjabi in an urban area in Lahore and a village 40 km. outside of Lahore. For triangulation purposes, four focus group discussions were performed with additional women, as well as in-depth interviews with eight mothers-in-law, three traditional practitioners and three medical practitioners. In general, these women felt that they had limited control over their lives, and this was exemplified by early marriages, high expectations on newly wed women to conceive and poor access to contraceptives. Women frequently expressed a strong preference for sons, mostly for economic reasons, reflecting women's subordinate position in society and the low economic value placed on women's work. Mothers of sons mainly discussed health problems during pregnancy and health effects of repeated childbearing. Mothers of daughters and women without children spoke of harassment in the family as well as in society. The results should be of importance in the public health planning in Pakistan as well as for those engaged in women's health issues internationally.