Community perceptions of reasons for preference for consanguineous marriages in Pakistan

Awareness of consanguineous marriage burden and willingness towards premarital genetic testing in Sudan: a national cross-sectional study

Background

Despite the widespread practice of consanguinity in Sudan, there is a lack of exploration into the community's awareness of its health implications on offspring and their overall attitude towards consanguineous unions.

Aim

This study aimed to evaluate the community's awareness of the possible health adversities of consanguinity on children and assess the effect of knowledge level on the prevailing attitude towards this practice in Sudan.

Methods

From August to December 2018, data were collected from adults aged 18 years and above in five provinces of Sudan regardless of their marital status. The analysis involved both descriptive and multivariate statistical techniques.

Results

This study revealed a consanguinity rate of 30.2%. Despite a high awareness level (73.7%) regarding the effects of consanguineous marriage on the health of the offspring, a moderately negative attitude towards this practice (63.9%) was observed.

Conclusion

The discordance between the high consanguinity rate in the Sudanese population and the moderately negative attitude suggests a potential persistence of this practice in the future. Without the implementation of educational programs and the provision of genetic counselling services to consanguineous couples, the prevalence of consanguinity is likely to endure.

Assessing Students' Knowledge and Attitudes Regarding the Risks and Prevention of Consanguineous Marriage: A Cross-Sectional Online Survey

Background

Several studies indicate a correlation between consanguinity and genetic disorders, congenital malformations, harm to reproductive health, and increased child mortality.

Objective

To assess students' knowledge and attitudes about risks and prevention of consanguineous marriage.

Methods

Demographic details of the participants and data on knowledge and attitudes concerning the risks and prevention of consanguineous marriage were obtained using an online self-administered questionnaire. The factors associated with good knowledge and attitude toward consanguineous marriage were investigated by logistic regression analysis.

Results

A total of 667 participants enrolled in the study. The average knowledge score about consanguineous marriage risk and prevention was 78.6% with a 95% confidence interval (CI) [77.3, 79.8], and the average attitude was 79.7% with a 95% confidence interval (CI) [79, 80.6]. A better knowledge score was observed in older participants (OR 1.01; 95% CI 1.004-1.024), females (OR 1.69; 95% CI 1.48-1.94), participants with parental history of consanguinity (OR 1.33; 95% CI 1.17-1.52), participants with family history of consanguineous marriage (OR 5.18; 95% CI 2.19-7.10), and participants with family history of inherited disease (OR 1.52; 95% CI 1.25-1.86).

Conclusion

In general, the overall level of knowledge and attitudes toward consanguineous marriage risk and prevention was good among university students. To efficiently control and manage the adverse health impacts associated with consanguineous marriage, there is an urgent need to develop and implement evidence-based counseling and screening programs for consanguineous marriage that would significantly reduce the number of at-risk marriages.

Medical students' self-perceived knowledge and clinical comfort with genetics in Pakistan

Pakistan has a high rate of genetic disorders and neonatal mortality concurrent with noted lack of genetic counselors and geneticists. To meet the needs of the patient population, the responsibility of providing clinical genetic services falls on general and specialty physicians. However, their education regarding these essential services is not standardized in medical school curricula nor has it ever been evaluated. The purpose of this work is to describe the self-perceived knowledge, clinical comfort, and perspectives of Pakistani medical students toward their medical genetics' education. A web-based survey was distributed electronically to medical schools around the country. The survey comprised of four sections: (1) participant demographics, (2) self-perceived medical genetics knowledge, (3) level of comfort in applying genetic knowledge and skills, and (4) attitudes toward medical genetics education. Descriptive statistics and a one-way analysis of variance were used for data analysis. Medical students in years 3, 4, and 5 (n = 473) from 25 medical schools participated in this research representing medical education in four Pakistani provinces. Most medical students reported "minimal" to "basic" knowledge of genetic testing methodology (64.7%), cancer genetics (64.9%), prenatal genetic testing (63.02%), and treatment strategies for genetic disease (72.9%). A plurality of students (37%) reported they were uncomfortable with interpreting and communicating genetic test results to patients. Medical students also expressed dissatisfaction with their medical genetics (40%) and genetic counselors training (42%). The self-perceived knowledge and clinical comfort with genetics among Pakistani medical students was limited, especially regarding genetic testing. A significant portion (74.5%) expressed desire for additional genetics education during medical school to aid in their role as future physicians. It is important for physicians-in-training to have a solid understanding of genetic concepts, technologies, and genetic counseling to best support their patients. As endorsed by the participating medical students, this study supports inclusion of more robust genetics' education into Pakistan's medical school curricula.

Identifying the current status and future needs of clinical, educational, and laboratory genetics services in Pakistan: a web-based panel discussion

While the prevalence of genetic disorders has been well documented in the Muslim-majority, low-socioeconomic country of Pakistan, the provision of medical genetic services remains limited and cost-prohibitive to the masses in the country. With the objective of identifying gaps in the provision of medical genetics services as perceived by the healthcare providers and the general public, the Pakistani Society of Medical Genetics and Genomics (PSMG) organized a needs assessment webinar on December 6, 2020, titled, "A Vibrant Discussion on the Current Status and Future Needs of Medical Genetic Services in Pakistan." The objectives of the webinar were (1) to explore the current availability of medical genetics services, (2) to identify areas in clinical genetics delivery models needed to improve the state of medical genetics in the country, and (3) to garner the interest in such provisions from the expert and lay audience. The webinar consisted of a moderator-led, structured interview of an expert panel including the following topics: (1) postgraduate clinical genetics and genetic counseling training programs, (2) medical genetics clinics and formal genetic counseling services), (3) clinical genetic testing and (4) patient support and advocacy groups. The webinar was followed by a short, web-based survey completed by 35 of the 60 attendees. The results of this survey indicated overwhelming support for establishing formal genetic counseling educational opportunities (91.6%) and increasing the availability of genetic testing (100%). This report further summarizes the opinions and recommendations of the panelists and the audience survey results.

Different predictors of intimate partner and natal family violence against women

Background

Violence against women is often studied in the context of violence from intimate partners. However, women receive violence from a wider range of individuals—such as their natal kin—including their siblings, parents, uncles and cousins. Applying insights from evolutionary theory, we examine whether cousin marriage, which has been hypothesized to both reduce the risk of partner violence but increase the risk of natal family violence, associates differently with each type of violence. Second, we test whether common risk factors for partner violence, such as wealth, associate similarly with natal violence.

Methodology

We analyse over 16 000 Jordanian women from three cohorts of the Jordan Demographic Health Surveys. Predictor variables include type of cousin marriage (patrilateral or matrilateral), education, wealth, number of children, urban living and polygyny. Outcome variables include whether a woman’s husband or her natal family has ever been physically violent towards her.

Results

Being married to a patrilateral cousin but not a matrilateral cousin is associated with a reduced risk of reporting intimate partner violence (IPV). By contrast being married to a matrilateral cousin but not a patrilateral one is associated with a reduced risk of reporting natal family violence. As expected, wealth is negatively associated with reporting partner violence, but we find no association with reports of natal family violence. Finally, individuals with more children are more likely to report IPV.

Conclusions and implications

Findings indicate the importance of distinguishing between types of cousin marriage and highlight substantial differences in risk factors for intimate partner compared to natal family violence.

Lay Summary

Sociodemographic risk factors, such as wealth, may associate differently with intimate partner and natal family violence. Results suggest that whether cousin marriage is protective of violence may depend on the type of cousin and secondly, that violence can have fitness relevant outcomes.

Altruism as an Explanation for Human Consanguinity

BACKGROUND

Human inbreeding is a sociobiological puzzle. Despite widespread knowledge of its potential for genetic disorders, human consanguinity remains surprisingly common. The current reasons explaining its continued persistence in today's modern world have major shortcomings.

SUMMARY

We propose that the Neolithic Agrarian revolution modified the structure of populations. It increased competition for the limited resources in which a larger group had better chances of survival. As a result, small, drifting, socially open bands of hunter-gatherers were transformed into bigger, less mobile, and more powerful kinship groups (tribes). In this transformation, a central role was played by human trust - an aspect of human altruism which is a universal sociobiological principle of behavior. Altruism (and trust) is an essential premise of social contracts such as economic cooperation, marriage arrangement, and creation of alliances between people. In kinship groups, human trust is limited to kin, so tribes remain small, economically poor, and consanguineous due to lack of nonkin mates. The expanding of trust from kin to that of nonbiological relatives increases the size of human groups, fosters economic wealth, and decreases the rate of consanguinity. Key Messages: The lack of nonkin altruism leads to: (a) poverty (due to poor economic cooperation with nonkin), (b) maintaining small group size, and (c) inbreeding.

Consanguineous marriage and rare bleeding disorders

Introduction: Rare bleeding disorders (RBDs) are a heterogeneous group of bleeding disorders. Consanguineous marriage is the favorite partnership in many communities among a population of more than a billion. Consanguineous marriages allow the defective recessive genes in RBDs to remain in the family. Clinical approach to RBDs is not as straightforward as typical bleeding disorders, which are secondary to scarcity and variation of RBDs. However, in many developing countries, the limitations of diagnostic facilities, the supply of therapeutic coagulation concentrates, health budgets, and optimal health-care infrastructures may intensify the clinical practice of RBDs.Areas covered: The author addresses the role of consanguineous marriage in the incidence of RBDs and what preventive steps can be considered to minimize the incidence of RBDs. A literature review of PubMed and google Scholar was conducted in November of 2020 using the relevant keywords.Expert opinion: This review addresses the prevalence of consanguineous marriages in Middle Eastern countries and the various reasons behind the coexistence of consanguineous marriage with RBDs. Finally, prevention steps that may be considered by health-care systems to minimize the incidence of rare bleeding disorders have been discussed. Health-care systems should train partners with the intention of consanguineous marriage on the downside of consanguinity.

Diagnostic exome-based preconception carrier testing in consanguineous couples: results from the first 100 couples in clinical practice

Purpose

Consanguineous couples are at increased risk of being heterozygous for the same autosomal recessive (AR) disorder(s), with a 25% risk of affected offspring as a consequence. Until recently, comprehensive preconception carrier testing (PCT) for AR disorders was unavailable in routine diagnostics. Here we developed and implemented such a test in routine clinical care.

Methods

We performed exome sequencing (ES) for 100 consanguineous couples. For each couple, rare variants that could give rise to biallelic variants in offspring were selected. These variants were subsequently filtered against a gene panel consisting of ~2,000 genes associated with known AR disorders (OMIM-based). Remaining variants were classified according to American College of Medical Genetics and Genomics/Association for Molecular Pathology (ACMG/AMP) guidelines, after which only likely pathogenic and pathogenic (class IV/V) variants, present in both partners, were reported.

Results

In 28 of 100 tested consanguineous couples (28%), likely pathogenic and pathogenic variants not previously known in the couple or their family were reported conferring 25% risk of affected offspring.

Conclusion

ES-based PCT provides a powerful diagnostic tool to identify AR disease carrier status in consanguineous couples. Outcomes provided significant reproductive choices for a higher proportion of these couples than previous tests.

Genetic and reproductive consequences of consanguineous marriage in Bangladesh

Introduction

This study aimed to assess the prevalence, sociodemographic factors, reproductive consequences, and heritable disease burdens associated with consanguineous marriage (CM) in Bangladesh.

Methods

A total of 7,312 families, including 3,694 CM-families, were recruited from 102 locales of 58 districts of Bangladesh. Using a standard questionnaire, we collected medical history and background sociodemographic data of these families. Family history was assessed by pedigree analysis. Fertility, mortality, secondary sex ratio, selection intensity, lethal equivalents were measured using standard methods.

Results

The mean prevalence of CM in our studied population was 6.64%. Gross fertility was higher among CM families, as compared to the non-CM families (p < 0.05). The rate of under-5 child (U5) mortality was significantly higher among CM families (16.6%) in comparison with the non-CM families (5.8%) (p < 0.01). We observed a persuasive rise of abortion/miscarriage and U5 mortality rates with the increasing level of inbreeding. The value of lethal equivalents per gamete found elevated for autosomal inheritances as compared to sex-linked inheritance. CM was associated with the incidence of several single-gene and multifactorial diseases, and congenital malformations, including bronchial asthma, hearing defect, heart diseases, sickle cell anemia (p < 0.05). The general attitude and perception toward CM were rather indifferent, and very few people were concerned about its genetic burden.

Conclusion

This study highlights the harmful consequences of CM on reproductive behavior and the incidence of hereditary conditions. It essences the need for genetic counseling from premarital to postnatal levels in Bangladesh.

Exploring perceptions of consanguineous unions with women from an East London community: analysis of discussion groups

Consanguineous unions are relationships between blood relatives. This study explores the perceptions of consanguineous unions and risk of childhood disability and illness through the reported views and experiences of women in an ethnically diverse London community. This qualitative study utilised group discussions to elicit women's views and experiences. Field notes were recorded by independent note-takers in four group discussions. Field notes were coded manually and independently by two researchers who identified common themes for thematic analysis. Thirty-six women attended, of whom 20 identified as Asian Pakistani. Identified themes included variation in participants' views of consanguineous unions and associated health risks, the value of informed decisions and preferences for information distribution. Although participants had diverse opinions and experiences, they considered risk awareness to be vital for encouraging informed decisions in younger generations. This study highlights the importance of involving the community in efforts to increase awareness around consanguineous unions and genetic risk, emphasising the need for enabling educated choices and the value of co-developing educational efforts with the community.

Consanguinity and Autism

PURPOSE OF REVIEW

Consanguinity can increase the risk for autosomal recessive conditions, along with autism spectrum disorder (ASD). Rarely outside of the genetics community is this discussed. Understanding its impact on the development of ASD and increasing awareness for physicians is important.

RECENT FINDINGS

ASD is a polygenic multifactorial disorder associated with morbidity and burden of care. Studies have confirmed its heritability, suspecting to an autosomal recessive transmission. Consanguinity increases the risk for uncovering recessive disorder and its role as an independent contributor for the development of ASD should be examined. With consanguinity being a known risk factor for autosomal recessive conditions, clinicians should routinely screen for it when evaluating for ASD, as this is inconsistently done. If suspected, genetic testing should be also recommended. Understanding current risk as well as future risk and providing families with the education to make the most informed decisions is necessary.

Not Managing Expectations: A Grounded Theory of Intimate Partner Violence From the Perspective of Pakistani People

Intimate partner violence (IPV) is a major social and public health problem affecting people from different cultures and societies. Much research has been undertaken to understand the phenomenon, its determinants, and its consequences in numerous countries. However, there is a paucity of research on IPV in many areas of the world including Pakistan. The present study aimed to develop a theory of the meaning and process of IPV from the perspective of Pakistani men and women living in and outside Pakistan.

Epidemiology, risk factors, and opportunities for prevention of cardiovascular disease in individuals of South Asian ethnicity living in Europe

South Asian (SA) individuals represent a large, growing population in a number of European countries. These individuals, particularly first-generation SA immigrants, are at higher risk of developing type 2 diabetes, atherogenic dyslipidaemia, and coronary heart disease than most other racial/ethnic groups living in Europe. SAs also have an increased risk of stroke compared to European-born individuals. Despite a large body of conclusive evidence, SA-specific cardiovascular health promotion and preventive interventions are currently scarce in most European countries, as well as at the European Union level. In this narrative review, we aim to increase awareness among clinicians and healthcare authorities of the public health importance of cardiovascular disease among SAs living in Europe, as well as the need for tailored interventions targeting this group - particularly, in countries where SA immigration is a recent phenomenon. To this purpose, we review key studies on the epidemiology and risk factors of cardiovascular disease in SAs living in the United Kingdom, Italy, Spain, Denmark, Norway, Sweden, and other European countries. Building on these, we discuss potential opportunities for multi-level, targeted, tailored cardiovascular prevention strategies. Because lifestyle interventions often face important cultural barriers in SAs, particularly for first-generation immigrants; we also discuss features that may help maximise the effectiveness of those interventions. Finally, we evaluate knowledge gaps, currently available risk stratification tools such as QRISK-3, and future directions in this important field.

NEED OF GENETIC COUNSELING SERVICES AT DISTRICT D.I.KHAN

Genetic counseling is an advocating strategy based on family history and genetic testing results, in order to avoid inherited disorders and their transmission to next generation.1 For the first time Sarah Lawrence College at New York offered the first master’s level training course of genetic counseling in 1969. According to a recent estimate, seven thousand genetic counsellors in 28 different countries are offering their services in the field of medical genetics.4 Now-a-days, in the era of advance genomics, the genetic counseling services became more specialized as cancer genetics, cardiogenetics, neurogenetics, infertility genetics and other speciality areas. The clinical implementation of genetic counseling services in US, Canada, and European countries is well established. However, in Asia these only exist in India, Indonesia, Japan, Malaysia, Philippines, Singapore, South Korea, Taiwan and few Middle Eastern countries.4 As far as Pakistan is concerned, it is still in infancy in Pakistan, requiring great improvements to be done. Genetic counseling services are the dire need of those countries where consanguineous marriages are highly prevalent so as to reduce the burden of genetic disorders and improve the quality of life.2 Pakistan is one among those countries which has alarming rate of consanguineous marriages, especially first cousin unions.3 However, within Pakistan, Khyber-Pukhtunkhwa, including D.I.Khan division has comparatively high ratio of close familial marriages. Currently, D.I.Khan is inhabited by multi-ethnic population of local as well as those migrated from South Waziristan and other adjoining tribal areas. According to a non-documented evidence, it is observed that cancer, type-2 diabetes, thalassemia, cataract, and certain neurological disorders have high occurrence in these people. World Health Organization (WHO), in its report, has observed that genetic counseling services in developing countries are inadequate, and advised the governments to ensure, their availability as part of their healthcare systems.3,4 Keeping in view this scenario, D.I.Khan requires to establish a genetic counseling centre. It is proposed to set up genetic counseling centre with the mutual collaboration of Gomal University and Gomal Medical College, D.I.Khan that should advise the people regarding disease carrier testing, pharmacogenetics testing, pre-natal testing and pre-symptomatic testing. We also propose that each tertiary care hospital should engage a genetic counsellor to prevent the incidence of genetic disorders, select the best personalized medicine and pre-symptomatic management of disease.

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.

ESTIMATING THE HEALTH AND SOCIOECONOMIC EFFECTS OF COUSIN MARRIAGE IN SOUTH ASIA

The effects of marriage between biological relatives on the incidence of childhood genetic illness and mortality are of major policy significance, as rates of consanguinity exceed 50% in various countries. Empirical research on this question is complicated by the fact that consanguinity is often correlated with poverty and other unobserved characteristics of households, which may have independent effects on mortality. This study has developed an instrumental variables empirical strategy to re-examine this question, based on the concept that the availability of unmarried cousins of the opposite gender at the time of marriage creates quasi-random variation in the propensity to marry consanguineously. Using primary data collected in Bangladesh in 2006-07 and Pakistan in 2009-10, the study found that previous estimates of the impact of consanguinity on child health were biased and falsely precise. The study also empirically investigated the social and economic causes of consanguinity (including marital quality) and concludes that marrying a cousin can have positive economic effects for one's natal family, by allowing deferral of dowry payments until after marriage.

The gravity of an edge

We describe a methodology for characterizing the relative structural importance of an arbitrary network edge by exploiting the properties of a k-shortest path algorithm. We introduce the metric Edge Gravity, measuring how often an edge occurs in any possible network path, as well as k-Gravity, a lower bound based on paths enumerated while solving the k-shortest path problem. The methodology is demonstrated using Granovetter's original strength of weak ties network examples as well as the well-known Florentine families of the Italian Renaissance and the Krebs 2001 terrorist networks. The relationship to edge betweenness is established. It is shown that important edges, i.e. ones with a high Edge Gravity, are not necessarily adjacent to nodes of importance as identified by standard centrality metrics, and that key nodes, i.e. ones with high centrality, often have their importance bolstered by being adjacent to bridges to nowhere-e.g. ones with low Edge Gravity. It is also demonstrated that Edge Gravity distinguishes critically important bridges or local bridges from those of lesser structural importance.

Obesity genetics: insights from the Pakistani population

The Pakistani population is extensively diverse, indicating a genetic admixture of European and Central/West Asian migrants with indigenous South Asian gene pools. Pakistanis are organized in different ethnicities/castes based on cultural, linguistic and geographical origin. While Pakistan is facing a rapid nutritional transition, the rising prevalence of obesity is driving a growing burden of health complications and mortality. This represents a unique opportunity for the research community to study the interplay between obesogenic environmental changes and obesity predisposing genes in the time frame of one generation. This review recapitulates the ancestral origins of Pakistani population, the societal determinants of the rise in obesity and its governmental management. We describe the contribution of syndromic, monogenic non-syndromic and polygenic obesity genes identified in the Pakistani population. We then discuss the utility of gene identification approaches based on large consanguineous families and original gene × environment interaction study designs in discovering new obesity genes and causal pathways. Elucidation of the genetic basis of obesity in the Pakistani population may result in improved methods of obesity prevention and treatment globally.

On the origin of obesity: identifying the biological, environmental and cultural drivers of genetic risk among human populations

Genetic predisposition to obesity presents a paradox: how do genetic variants with a detrimental impact on human health persist through evolutionary time? Numerous hypotheses, such as the thrifty genotype hypothesis, attempt to explain this phenomenon yet fail to provide a justification for the modern obesity epidemic. In this critical review, we appraise existing theories explaining the evolutionary origins of obesity and explore novel biological and sociocultural agents of evolutionary change to help explain the modern-day distribution of obesity-predisposing variants. Genetic drift, acting as a form of 'blind justice,' may randomly affect allele frequencies across generations while gene pleiotropy and adaptations to diverse environments may explain the rise and subsequent selection of obesity risk alleles. As an adaptive response, epigenetic regulation of gene expression may impact the manifestation of genetic predisposition to obesity. Finally, exposure to malnutrition and disease epidemics in the wake of oppressive social systems, culturally mediated notions of attractiveness and desirability, and diverse mating systems may play a role in shaping the human genome. As an important first step towards the identification of important drivers of obesity gene evolution, this review may inform empirical research focused on testing evolutionary theories by way of population genetics and mathematical modelling.

Determinants of consanguinity and inbreeding coefficient in the multiethnic population of Mardan, Khyber Pakhtunkhwa, Pakistan

Background

Despite the high sociocultural preferences in contracting marriages among close relatives in Pakistan, marked regional differences exist in the prevalence of consanguinity. There is great interest to elucidate the sociodemographic variables underlying the heterogeneity in consanguinity prevalence in the various populations. The present study was conducted in the Mardan district of Pakistan, the second largest multiethnic Pashtun metropolis.

Objective

To find determinants of consanguineous unions.

Methods

In a cross-sectional study design, a convenience sample of 1,202 ever-married men from 3 tehsils of Mardan district was recruited in an unselected manner and data regarding their marital union types and sociodemographic variables were obtained by a structured interview. Descriptive statistics and multivariable logistic regression analyses were used.

Results

Consanguineous unions accounted for 44% of all marriages, and the inbreeding coefficient was calculated as 0.0258. Regression analyses revealed that 6 variables were significant predictors of consanguinity, namely, tehsil, age, year of marriage, caste (zaat/biradari) system, area of house, and marriage arrangement of the respondent, while 6 other variables, namely, rural/urban origin, literacy, occupation, monthly income, household type, and number of family members, were not found to be significant. Regression analyses showed that there were different combinations of variables predictive of consanguinity among the various tehsils.

Conclusions

The prevalence of consanguinity in the Mardan district was found to be lower than that in many other districts of Pakistan. National regional differences exist in consanguinity, and the combination of predictive factors varies greatly.

Pakistan Genetic Mutation Database (PGMD); A centralized Pakistani mutome data source

The development and advancement of next generation sequencing have not only sped up the process of identifying rare variants, but have also enabled scientists to explore all variants in a single individual. The Pakistani population has a high ratio of first degree consanguinity, which is why it is a rich source for various kinds of genetic disorders. Due to the heterogeneous composition of Pakistani population, the likelihood of genetic heterogeneity for each disorder is high. Therefore, the compilation and organization of such vast genetic data is necessary to facilitate access for analysis and interpretation to researchers and medical geneticists. The increased research on Pakistani ethnic families for disease gene identification has revealed many mutations, which has led us to develop a Pakistani mutome database entitled "Pakistan Genetic Mutation Database (PGMD)". In PGMD, the medico-genetic information about diseases are mainly compiled into Syndromic and Non-syndromic disorders. It is a public database, which can be freely accessed from http://www.pakmutation.com. At present, we have registered more than 1000 mutations, reported in about 130 different kinds of genetic disorders. Practically, PGMD will assist researchers, clinicians, and geneticists in genetic counseling and screening of population-specific mutations, which will also aid in personalized healthcare.

ASSESSMENT OF KNOWLEDGE, ATTITUDE AND PRACTICE TOWARDS CONSANGUINEOUS MARRIAGES AMONG A COHORT OF MULTIETHNIC HEALTH CARE PROVIDERS IN SAUDI ARABIA

This study aimed to assess knowledge, attitude and practice related to consanguinity among multiethnic health care providers in the Kingdom of Saudi Arabia. Using a cross-sectional study design, a validated, self-administered close-ended questionnaire was randomly distributed to health care providers in different health institutions in the country between 1st August 2012 and 31st July 2013. A total of 1235 health care providers completed the study questionnaire. Of the 892 married participants (72.23% of total), 11.43% were married to a first cousin, and were predominantly Arabs, younger than 40 years and male. Only 17.80% of the patients seen by the health care providers requested consanguinity related counselling. A knowledge barrier was expressed by 27.49% of the participants, and 85.67% indicated their willingness to have more training in basic genetic counselling. A language barrier was expressed as a limiting factor to counselling for consanguinity among non-Arabs. The health care providers had a major dearth of knowledge that was reflected in their attitude and practice towards consanguinity counselling. This finding indicates the need for more undergraduate and postgraduate medical and nursing education and training in the counselling of consanguineous couples. It is recommended that consanguinity counselling is included in the current premarital screening and counselling programmes in the Kingdom.

Consanguineous marriage in Oman: understanding the community awareness about congenital effects of and attitude towards consanguineous marriage

BACKGROUND

Although consanguinity is widely practiced in Oman, the attitude of community towards consanguinity and the awareness of its health consequences to offspring remain largely unexplored.

AIM

To analyse the levels and trends of consanguineous marriage and examine community awareness about congenital anomaly associated with consanguinity and attitude towards consanguinity in Oman.

SUBJECTS AND METHODS

The data come from a nationally representative survey on Omani adults of age 18 years and above, irrespective of their marital status. Data were analysed using both descriptive and multivariate statistical techniques.

RESULTS

The survey results indicate a very high rate (49%) of consanguineous marriage in Oman. There is a declining trend in consanguinity which may be attributed to decline in first cousin marriage. Omani adults have moderately high knowledge (69%) about health consequences of consanguineous marriage. There is a high positive attitude towards consanguineous marriage (75%) which appeared as a significant predictor of current practice of consanguineous marriage in Oman.

CONCLUSION

The positive attitude of the Omani community towards consanguinity outweighs the negative health consequences of consanguinity, and the practice is likely to remain high in the near future. Strong educational and motivational programmes are needed to bring further changes in attitude towards consanguinity and, thus, reduce the burden of congenital anomalies associated with consanguinity in Oman.

The Implications of Parental Consanguinity on the Care of Neonates

BACKGROUND

Approximately 6% of births worldwide, 7.9 million children, are born with a serious genetic congenital abnormality each year. A factor thought to increase the prevalence of birth defects is parental consanguinity, which is a social custom practiced in at least 20% of the world's population.

PURPOSE

The purpose of this article is to explore the relationship between consanguinity and congenital defects. This article also aims to enhance neonatal healthcare practitioners' comprehension of its implications for practice and research.

METHODS

A review of literature was compiled from a search of the online databases Cumulative Index of Nursing and Allied Health (CINAHL), PubMed, EBSCO MegaFILE, and Google Scholar.

RESULTS

Literature pertinent to this topic primarily consists of research studies that examine the inbreeding depression phenomenon through comparison of the prevalence of birth defects among the offspring of consanguineous and nonconsanguineous couples. Current studies indicate that the progeny of consanguineous couples are at an increased risk of congenital defects compared with those of nonconsanguineous couples.

IMPLICATIONS FOR PRACTICE

Consanguinity is one risk factor among many that can lead to a major birth defect. Relationships between consanguineous populations and neonatal healthcare practitioners such as registered nurses, advanced practice nurses, and physicians could significantly alter neonatal health outcomes. Specific recommendations such as genetic counseling and therapeutic communication are discussed.

IMPLICATIONS FOR RESEARCH

Further studies need to investigate the connection between consanguinity and birth defects while controlling for nongenetic variables. Moreover, a focus on consanguineous communities in the United States would prove beneficial.

THE CAUSAL RELATIONSHIP BETWEEN CONSANGUINEOUS MARRIAGES AND INFANT MORTALITY IN TURKEY

Turkey has high levels of infant mortality and consanguineous marriages. It has had a high level of infant mortality for its economic level for many years. Over recent decades, although adult mortality rates have not been very different from those of other countries with similar socioeconomic structures, its life expectancy at birth has remained low due to its high infant mortality rate. This has been called the Turkish Puzzle. According to the Turkey Family Structure and Population Issues Survey, 27% of women had a consanguineous marriage in 1968. Subsequent Turkish Demographic and Health Surveys (TDHSs) found the rate of consanguineous marriages to be stagnated at 22-24%, with a resistance to reduction. According to the TDHS-2008, 24% of women had a consanguineous marriage. Numerous studies in various countries of the world have indicated that consanguineous marriages, particularly of first-degree, have the effect of increasing infant mortality. The main aim of this study was to assess the causal impact of consanguineous, particularly first-degree consanguineous, marriages on infant mortality, controlling for individual, cultural, bio-demographic and environmental factors. Data were merged from four Turkish DHS data sets (1993, 1998, 2003 and 2008). Multivariate analysis revealed that first-degree consanguineous marriages have increased infant mortality by 45% in Turkey: 57% in urban areas and 39% in rural areas. The results indicate that there is a causal relationship between consanguineous marriages and infant mortality. This finding should be taken into account when planning policies to reduce infant mortality in Turkey, and in other countries with high rates of consanguineous marriage and infant mortality.

THE PREVALENCE OF CONSANGUINEOUS MARRIAGES AND AFFECTING FACTORS IN TURKEY: A NATIONAL SURVEY

This study was carried out by the Turkish Republic Ministry of Health to determine the prevalence of consanguineous marriage and its correlates with socio-demographic and obstetric risk factors in women in Turkey. The cross-sectional, national-level study was carried out from October to December 2013. The study population was composed of women between the ages of 15 and 65 years living in Turkey. The sample size was calculated as 9290 houses within Turkey's 81 provinces so as to improve the Turkish rural-urban expectations by means of systematic stack sampling according to the Turkish Statistical Institute's address-based vital statistics system. The target sample size was 6364, but only eligible 4913 women, who had been married, were included in the study. The consanguineous marriage frequency in the sample was found to be 18.5%, and of these 57.8% were first cousin marriages. Women living in an extended family and whose education level and first marriage ages were low, and whose perceived economic status was poor, had higher frequencies of consanguineous marriage (p<0.001). Consanguineous marriage frequencies were higher (p<0.001) for women who had spontaneous abortions and stillbirths or who had given birth to infants with a congenital abnormality. In this context, it is important to develop national policies and strategies to prevent consanguineous marriages in Turkey.

Attitude of Saudi Arabian adults towards consanguineous marriage

Background: Research on the attitudes of Saudi adults towards consanguinity is scarce. The study aimed to explore the attitudes towards consanguinity and its associations with socio-demographic characteristics in a sample of Saudi adults. Methods: A cross-sectional study was conducted using a self-administered questionnaire. A total of 386 outpatient waiting-area attendees at King Abdul-Aziz Medical City-Riyadh were included. Participants were asked about their socio-demographic characteristics, attitude towards consanguinity and the reasons behind this. Results: The positive attitude towards consanguinity among the study respondents was 48.1% with 95% confidence interval (42.91–53.33%). Social and traditional culture (59.9%) were found to be the predominant reasons for favoring consanguinity in Saudi Arabia. Evidence against a positive attitude towards consanguinity was noted in respondents who received medical information about consanguinity versus those who had not received medical information (42.3% vs. 57%, p-value = 0.008). According to the multivariate logistic model, the odds of a positive attitude towards consanguinity were 2 times higher for males (adjusted odds ratio [aOR]: 2.2; 95% CI: 1.147, 4.290) and 4.1 times higher in respondents in consanguineous marriages (aOR: 4.1; 95% CI: 2.350, 7.156). The odds of a positive attitude towards consanguinity were 50% less in respondents who received health information on consanguinity compared to those who had not received health information about consanguinity (aOR: 0.50; 95% CI: 0.253, 0.863). Conclusion: One in every two Saudi adults favors consanguinity however, Saudi men and women differ in their attitudes towards consanguinity. Receiving health information on consanguinity was associated with a negative attitude towards this practice.

Genetic Counseling and Screening of Consanguineous Couples and Their Offspring: Recommendations of the National Society of Genetic Counselors

The objective of this document is to provide recommendations for genetic counseling and screening for consanguineous couples (related as second cousins or closer) and their offspring with the goals of1. providing preconception reproductive options2. improving pregnancy outcome and identifying reproductive choices3. reducing morbidity and mortality in the 1st years of life, and4. respecting psychosocial and multicultural issues.The recommendations are the opinions of a multicenter working group (the Consanguinity Working Group (CWG)) with expertise in genetic counseling, medical genetics, biochemical genetics, genetic epidemiology, pediatrics, perinatology, and public health genetics, which was convened by the National Society of Genetic Counselors (NSGC). The consensus of the CWG and NSGC reviewers is that beyond a thorough medical family history with follow-up of significant findings, no additional preconception screening is recommended for consanguineous couples. Consanguineous couples should be offered similar genetic screening as suggested for any couple of their ethnic group. During pregnancy, consanguineous couples should be offered maternal-fetal serum marker screening and high-resolution fetal ultrasonography. Newborns should be screened for impaired hearing and detection of treatable inborn errors of metabolism. These recommendations should not be construed as dictating an exclusive course of management, nor does use of such recommendations guarantee a particular outcome. The professional judgment of a health care provider, familiar with the facts and circumstances of a specific case, will always supersede these recommendations.

Intimate Partner Violence in Pakistan: A Systematic Review

Intimate partner violence (IPV) is a major social and public health problem affecting people in various cultures and societies. Though the issue of IPV in Pakistan has been researched since the 1990 s, no attempt has been made systematically to review the available evidence on IPV in Pakistan. This article presents findings of a systematic review of available empirical literature related to IPV in Pakistan. Using various key words, MEDLINE, CINAHL, and PsycINFO were searched to identify relevant studies. This resulted in the identification of 55 potential studies for inclusion. After application of exclusion criteria 23 studies were identified, 20 of which used quantitative research designs, two used qualitative designs and one adopted a mixed method case study approach. All studies reported men as the perpetrators of IPV and women as its victims. Findings are presented and discussed for IPV for its forms, predictors, effects and victims' responses. Pakistani peoples' perceived reasons for and their attitudes towards IPV are also presented and discussed.

UK Pakistani views on the adverse health risks associated with consanguineous marriages

This is a qualitative study exploring the perceptions of members from the Pakistani/Kashmiri community living in Luton, UK, on the adverse health risks associated with consanguineous marriages. Rates of stillbirths and infant mortality are higher than the national average in Luton and the existing evidence base suggests that these higher rates may be associated with consanguinity (especially first cousin marriages) in highly consanguineous populations, such as the Pakistani/Kashmiri ethnic group. This qualitative study included 9 focus groups and 10 one to one in-depth interviews (n = 58) with members from the Pakistani/Kashmiri community in Luton during 2012. Audio-recorded transcripts were analysed using framework analysis. Emerging themes included a limited knowledge, opposition to evidence and need for a more culturally sensitive health services approach. Findings from the focus group and interview discussions indicated that participants had a limited and varied understanding of genetic risk and indicated a lack of discussion within the community regarding genetic risk. They also opposed evidence that may link consanguineous marriages with infant mortality, stillbirth or genetic disorders that led to disability. The participants stressed the need for culturally sensitive and locally constructed services for information on genetic risk and services. These findings may be used to address higher rates of infant mortality and adverse health impacts associated with higher rates of consanguinity in Luton and elsewhere, through a partnership approach, improve upon current services and develop culturally appropriate services.

Arranging marriage; negotiating risk: genetics and society in Qatar

This paper considers how the globalized discourse of genetic risk in cousin marriage is shaped, informed and taken up in local moral worlds within the context of Qatar. This paper investigates the way Qataris are negotiating the discourse on genetics and risk. It is based on data from ongoing ethnographic research in Qatar and contributes to anthropological knowledge about this understudied country. Participants were ambivalent about genetic risks and often pointed to other theories of causation in relation to illness and disability. The discourse on genetic risk associated with marrying in the family was familiar, but for some participants the benefits of close marriage outweighed potential risks. Furthermore, the introduction of mandatory pre-marital screening gave participants confidence that risks were monitored and minimized.

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.

Health problems, complex life, and consanguinity among ethnic minority Muslim women in Nepal

BACKGROUND

Marriage between blood relatives is common among Muslim ethnic minority population in Nepal. Albeit, the adverse effects of such a consanguineous marriage on health are controversial.

OBJECTIVE

To determine the prevalence, characteristics and health outcomes related to consanguineous marriage.

DESIGN

A cross-sectional survey was carried out using a cluster sampling technique to select the respondents. A total of 400 women aged 15-49 years were interviewed from September 2011 to February 2012. A structured questionnaire was administered through face-to-face meetings. Adjusted odds ratios (AOR) were estimated by a stepwise likelihood ratio method with binary logistic regression.

RESULTS

The overall prevalence of consanguinity was 36.7%. The median age at marriage and age at first childbirth was 15 and 18 years, respectively. The association of being in a consanguineous marriage among women whose husband's education level were secondary or higher was 3.35 (95% CI 1.56, 7.12) times greater than among those whose husbands were unable to read and write. Woman who have consanguineous marriage were less likely to have (AOR 0.46, 95% CI 0.26, 0.82) used contraceptive than those who have non-consanguineous marriage. Women who have consanguineous marriage were more (AOR 1.80; 95% CI 0.90, 3.61) likely to have birth defect in their children than those who have non-consanguineous marriage. The association of having a history of death after live birth among women who experienced emotional violence was 2.60 (95% CI 1.36, 5.00) and physical violence 2.15 (95% CI 1.16, 3.93) times greater than among those who did not experience violence.

CONCLUSIONS

Several factors like husband's education and dowry practices are associated with consanguineous marriage. Further, these factors including consanguineous marriage and marital violence are also accountable for negative health consequences. Thus, multicomponent interventions are needed in order to improve the health condition of Nepalese Muslim community in rural area.

Health Awareness and Consequences of Consanguineous Marriages

Objectives: This community-based study was done to assess the awareness of people regarding the ill effects of consanguinity and to observe its association with various sociodemographic variables and complications among children. Methods: Houses were chosen by systematic random sampling method and any married person in each household was interviewed. Results: Only 35 (18.7%) out of 187 participants were aware of health hazards associated with consanguineous marriages. The prevalence of consanguineous marriages was found to be 23 (12.3%). History of consanguineous marriage was seen significantly more among illiterates ( P = .05) and respondents with parental history of consanguinity ( P < .001). The mean age at marriage was found to be significantly lower among women married consanguineously ( P = .05). Congenital anomalies ( P = .02) and low birth weight ( P = .05) was seen significantly more among children with parental history of consanguinity. Conclusion: Large-scale awareness campaigns are needed to address the ill effects of this seemingly innocuous cultural practice.

A model-based 'varimax' sampling strategy for a heterogeneous population

BACKGROUND AND AIMS

Sampling strategies are planned to enhance the homogeneity of a sample, hence to minimize confounding errors. A sampling strategy was developed to minimize the variation within population groups. Karachi, the largest urban agglomeration in Pakistan, was used as a model population.

SUBJECTS AND METHODS

Blood groups ABO and Rh factor were determined for 3000 unrelated individuals selected through simple random sampling. Among them five population groups, namely Balochi, Muhajir, Pathan, Punjabi and Sindhi, based on paternal ethnicity were identified. An index was designed to measure the proportion of admixture at parental and grandparental levels. Population models based on index score were proposed. For validation, 175 individuals selected through stratified random sampling were genotyped for the three STR loci CSF1PO, TPOX and TH01.

RESULTS

ANOVA showed significant differences across the population groups for blood groups and STR loci distribution. Gene diversity was higher across the sub-population model than in the agglomerated population. At parental level gene diversities are significantly higher across No admixture models than Admixture models. At grandparental level the difference was not significant.

CONCLUSION

A sub-population model with no admixture at parental level was justified for sampling the heterogeneous population of Karachi.

CIVIL UNREST AND THE CURRENT PROFILE OF CONSANGUINEOUS MARRIAGE IN KHYBER PAKHTUNKHWA PROVINCE, PAKISTAN

Information on the current prevalence and types of consanguineous marriages in Malakand District, Khyber Pakhtunkhwa Province (KPK), Pakistan, was collected from 1192 rural couples. Some 66.4% of marriages were between couples related as second cousins or closer (F≥0.0156), equivalent to a mean coefficient of inbreeding (α) of 0.0338. The data suggest that the prevalence of consanguineous unions in Malakand has been increasing during the last decade, in response to the high levels of violence across KPK.

Risk factors predisposing to congenital heart defects

Introduction:

Congenital heart disease (CHD) is associated with multiple risk factors, consanguinity may be one such significant factor. The role of consanguinity in the etiology of CHD is supported by inbreeding studies, which demonstrate an autosomal recessive pattern of inheritance of some congenital heart defects. This study was done to find out the risk factors for CHD.

Methods:

A case-control study was done on pediatric patients at a tertiary care hospital, Aga Khan University Hospital, located in Karachi, Pakistan. A total of 500 patients, 250 cases and 250 controls were included in the study.

Results:

Amongst the 250 cases (i.e. those diagnosed with CHD), 122 patients (48.8%) were born of consanguineous marriages while in the controls (i.e. non-CHD) only 72 patients (28.9%) showed a consanguinity amongst parents. On multivariate analysis, consanguinity emerged as an independent risk factor for CHD; adjusted odds ratio 2.59 (95% C. I. 1.73 - 3.87). Other risk factors included low birth weight, maternal co-morbidities, family history of CHD and first born child. On the other hand, medications used by the mother during the index pregnancy, maternal age and gender of the child did not significantly increase the risk of developing CHD.

Conclusions:

Analyses of our results show that parental consanguinity, family history of CHD, maternal co-morbidities, first born child and low birth weight are independent risk factors for CHD.