Magnitude and determinants of neural tube defect in Africa: a systematic review and meta-analysis

BMC Pregnancy and Childbirth, Volume 21, No. 1, Year 2021

Interpretation

Background: Neural tube defects (NTDs) are a group of disorders that arise from the failure of the neural tube close between 21 and 28 days after conception. About 90% of neural tube defects and 95% of death due to these defects occurs in low-income countries. Since these NTDs cause considerable morbidity and mortality, this study aimed to determine the prevalence and associated factors of NTDs in Africa. Methods: The protocol of this study was registered in the International Prospective Register of Systematic Reviews (PROSPERO number: CRD42020149356). All major databases such as PubMed/MEDLINE, EMBASE, CINAHL, Web of Science, African Journals Online (AJOL), and Google Scholar search engine were systematically searched. A random-effect model was used to estimate the pooled prevalence of NTDs in Africa, and Cochran’s Q-statistics and I2 tests were used to assess heterogeneity between included studies. Publication bias was assessed using Begg ’s tests, and the association between determinant factors and NTDs was estimated using a random-effect model. Results: Of the total 2679 articles, 37 articles fulfilled the inclusion criteria and were included in this systematic review and meta-analysis. The pooled prevalence of NTDs in Africa was 50.71 per 10,000 births (95% CI: 48.03, 53.44). Folic acid supplementation (AOR: 0.40; 95% CI: 0.19–0.85), maternal exposure to pesticide (AOR: 3.29; 95% CI: 1.04–10.39), mothers with a previous history of stillbirth (AOR: 3.35, 95% CI: 1.99–5.65) and maternal exposure to x-ray radiation (AOR 2.34; 95% CI: 1.27–4.31) were found to be determinants of NTDs. Conclusions: The pooled prevalence of NTDs in Africa was found to be high. Maternal exposure to pesticides and x-ray radiation were significantly associated with NTDs. Folic acid supplementation before and within the first month of pregnancy was found to be a protective factor for NTDs. The protocol of this study was registered in the International Prospective Register of Systematic Reviews (PROSPERO), the University of York Centre for Reviews and Dissemination (ID number: CRD42020149356) [14]. This review and meta-analysis were conducted according to the guideline of Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) (additional file 1) [15]. A systematic review and meta-analysis were conducted using published and unpublished articles on the prevalence and associated factors of NTDs in Africa. The databases used to search for studies were PubMed, EMBASE, Google Scholar, CINAHL, POPLINE, and African Journals Online (AJOL), and grey literature was searched on Google and Research Gate. The following vital terms neural AND tube AND defect AND “determinant factors” OR “associated factors” OR “protective factors” OR “risk factors” AND “Africa countries” were used separately or in combination with the Boolean operator’s terms “AND” and “OR.” The search was also done by combining the above search terms with the names of all countries included in Africa and the sub-region of Africa (additional file 2). The reference lists of the retrieved studies were also scanned to access additional articles and screened against our eligibility criteria. Any study in Africa that reported magnitude and determinant factors for NTDs and fulfilled the following criteria were recruited into the analysis: All studies conducted in African countries. Epidemiological studies had reported prevalence and risk factors of NTDs as an outcome. All observational studies (cross-sectional, case-control, and cohort) reporting the prevalence and determinants of NTDs were eligible for this systematic review and meta-analysis. Articles published in English were considered. Both published and unpublished articles were considered. No restriction of the period applied to this review. Important articles identified from the databases mentioned above and websites were imported into an Endnote X8, and duplicates were removed. Screening retrieved articles titles, abstracts, and full-text quality was conducted independently by two review authors (DA & KS) based on the eligibility criteria. The disagreement between the two reviewers was resolved by reaching a consensus through discussion. The study risk of bias was assessed using the Joana bridge institute (JBI) critical appraisal tool [16]. Two authors (DA & KS) evaluated the quality of the full text considered to be included in the meta-analysis. The tool consists of ten items for case-control and eight for cross-sectional studies (additional files 3 and 4). Each item for each study was judged as Yes (1) and No (0). When the information provided was not adequate to make a judgment for a specific item, we agreed to grade that item with a ‘No’ (0). Each study was graded depending on the number of items judged ‘Yes’ (1) as low risk (≥ 7), medium risk (5 to 6) or high risk (≤ 4) for cross-sectional studies and low risk (≥8), medium risk (7 to 6) and high risk (< 5) for case-control studies (additional files 3 and 4). The selected papers were thoroughly reviewed, and the required information for the systematic review was extracted and summarized using an extraction table in Microsoft Office Excel software (additional files 5 and 6). The data extraction tool consists of the name of the author (s), country and sub-region, study design, setting, year of publication, sample size, and number of NTDs (additional file 5). Data were extracted in two-by-two tables for determinants of NTDs, pooled odds ratio with their corresponding 95% confidence interval (CI) was calculated based on the original studies report (additional file 6). The extracted data were imported into STATA/SE version 14 software for all statistical analysis. The heterogeneity among all included studies was assessed by using the I2 statistics and Cochran Q test. In this meta-analysis, the tests indicate significant heterogeneity among included studies (I2 = 100, P-value <.001). For this reason, we used a random-effects model as a method of analysis. The publication bias was assessed using begg ‘s test statistics. Pooled prevalence and odds ratios along their corresponding 95% CI were presented using a forest plot. Subgroup analyses for the prevalence of NTDs were performed by sub-regions of Africa. To determine factors associated with NTDs, data were entered into Review Manager Version 5, and pooled odds ratios (ORs) with 95% confidence interval (CI) were used. Neural tube defects all newborns having one of the following defects are considered as having NTD. Spina bifida (meningocele and myelomeningocele), anencephaly, and encephalocele. Prevalence of NTDs = number of a newborn with NTDs/total number of newborns *100

AI Digest

Study Justification:

This study aimed to determine the prevalence and associated factors of neural tube defects (NTDs) in Africa. NTDs are a group of disorders that result from the failure of the neural tube to close properly during early fetal development. These defects cause significant morbidity and mortality, with a majority of cases occurring in low-income countries. Understanding the magnitude and determinants of NTDs in Africa is crucial for developing effective prevention and intervention strategies.

Study Highlights:

– The study included a systematic review and meta-analysis of 37 articles that met the inclusion criteria.
– The pooled prevalence of NTDs in Africa was found to be 50.71 per 10,000 births.
– Folic acid supplementation was identified as a protective factor against NTDs.
– Maternal exposure to pesticides and x-ray radiation were found to be associated with an increased risk of NTDs.
– Maternal history of stillbirth was also identified as a determinant of NTDs.

Recommendations for Lay Readers:

1. Increase awareness about the importance of folic acid supplementation before and during early pregnancy to reduce the risk of NTDs.
2. Implement measures to minimize maternal exposure to pesticides and x-ray radiation during pregnancy.
3. Provide support and counseling for mothers who have experienced a previous stillbirth to reduce the risk of NTDs.
4. Strengthen healthcare systems to ensure access to prenatal care and screening for NTDs.

Recommendations for Policy Makers:

1. Develop and implement public health campaigns to promote folic acid supplementation among women of childbearing age.
2. Enforce regulations and policies to reduce maternal exposure to pesticides and x-ray radiation in occupational and environmental settings.
3. Invest in research and development of alternative methods for pest control that are safe for pregnant women.
4. Improve access to quality prenatal care services, including screening and counseling for NTDs.
5. Allocate resources for training healthcare providers on the prevention, diagnosis, and management of NTDs.

Key Role Players:

1. Ministry of Health: Responsible for developing and implementing policies and programs related to maternal and child health, including NTD prevention.
2. Healthcare Providers: Play a crucial role in educating and counseling women about folic acid supplementation and minimizing exposure to harmful substances during pregnancy.
3. Non-Governmental Organizations (NGOs): Can support awareness campaigns, provide resources, and advocate for policies to address NTDs.
4. Research Institutions: Conduct further studies to explore additional determinants and interventions for NTDs in Africa.

Cost Items for Planning Recommendations:

1. Public Health Campaigns: Budget for designing and implementing awareness campaigns on folic acid supplementation and NTD prevention.
2. Training Programs: Allocate funds for training healthcare providers on NTD prevention and management.
3. Research Funding: Invest in research grants to support studies on NTDs, including epidemiological research and development of alternative pest control methods.
4. Healthcare Infrastructure: Allocate resources for improving access to prenatal care services, including screening and counseling for NTDs.
5. Monitoring and Evaluation: Set aside funds for monitoring and evaluating the effectiveness of interventions and programs aimed at reducing NTDs.
Please note that the cost items provided are general categories and not actual cost estimates. The specific budget items would depend on the context and priorities of each country or organization.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it is based on a systematic review and meta-analysis of 37 articles. The study protocol was registered, and the study followed the PRISMA guidelines. The prevalence of NTDs in Africa was estimated using a random-effect model, and determinants of NTDs were identified. However, to improve the evidence, it would be beneficial to provide more information on the quality assessment of the included studies, such as the risk of bias assessment using the JBI critical appraisal tool. Additionally, it would be helpful to include information on the study limitations and potential sources of bias.

Abstract

The protocol of this study was registered in the International Prospective Register of Systematic Reviews (PROSPERO), the University of York Centre for Reviews and Dissemination (ID number: CRD42020149356) [14]. This review and meta-analysis were conducted according to the guideline of Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) (additional file 1) [15]. A systematic review and meta-analysis were conducted using published and unpublished articles on the prevalence and associated factors of NTDs in Africa. The databases used to search for studies were PubMed, EMBASE, Google Scholar, CINAHL, POPLINE, and African Journals Online (AJOL), and grey literature was searched on Google and Research Gate. The following vital terms neural AND tube AND defect AND “determinant factors” OR “associated factors” OR “protective factors” OR “risk factors” AND “Africa countries” were used separately or in combination with the Boolean operator’s terms “AND” and “OR.” The search was also done by combining the above search terms with the names of all countries included in Africa and the sub-region of Africa (additional file 2). The reference lists of the retrieved studies were also scanned to access additional articles and screened against our eligibility criteria. Any study in Africa that reported magnitude and determinant factors for NTDs and fulfilled the following criteria were recruited into the analysis: All studies conducted in African countries. Epidemiological studies had reported prevalence and risk factors of NTDs as an outcome. All observational studies (cross-sectional, case-control, and cohort) reporting the prevalence and determinants of NTDs were eligible for this systematic review and meta-analysis. Articles published in English were considered. Both published and unpublished articles were considered. No restriction of the period applied to this review. Important articles identified from the databases mentioned above and websites were imported into an Endnote X8, and duplicates were removed. Screening retrieved articles titles, abstracts, and full-text quality was conducted independently by two review authors (DA & KS) based on the eligibility criteria. The disagreement between the two reviewers was resolved by reaching a consensus through discussion. The study risk of bias was assessed using the Joana bridge institute (JBI) critical appraisal tool [16]. Two authors (DA & KS) evaluated the quality of the full text considered to be included in the meta-analysis. The tool consists of ten items for case-control and eight for cross-sectional studies (additional files 3 and 4). Each item for each study was judged as Yes (1) and No (0). When the information provided was not adequate to make a judgment for a specific item, we agreed to grade that item with a ‘No’ (0). Each study was graded depending on the number of items judged ‘Yes’ (1) as low risk (≥ 7), medium risk (5 to 6) or high risk (≤ 4) for cross-sectional studies and low risk (≥8), medium risk (7 to 6) and high risk (< 5) for case-control studies (additional files 3 and 4). The selected papers were thoroughly reviewed, and the required information for the systematic review was extracted and summarized using an extraction table in Microsoft Office Excel software (additional files 5 and 6). The data extraction tool consists of the name of the author (s), country and sub-region, study design, setting, year of publication, sample size, and number of NTDs (additional file 5). Data were extracted in two-by-two tables for determinants of NTDs, pooled odds ratio with their corresponding 95% confidence interval (CI) was calculated based on the original studies report (additional file 6). The extracted data were imported into STATA/SE version 14 software for all statistical analysis. The heterogeneity among all included studies was assessed by using the I2 statistics and Cochran Q test. In this meta-analysis, the tests indicate significant heterogeneity among included studies (I2 = 100, P-value <.001). For this reason, we used a random-effects model as a method of analysis. The publication bias was assessed using begg ‘s test statistics. Pooled prevalence and odds ratios along their corresponding 95% CI were presented using a forest plot. Subgroup analyses for the prevalence of NTDs were performed by sub-regions of Africa. To determine factors associated with NTDs, data were entered into Review Manager Version 5, and pooled odds ratios (ORs) with 95% confidence interval (CI) were used. Neural tube defects all newborns having one of the following defects are considered as having NTD. Spina bifida (meningocele and myelomeningocele), anencephaly, and encephalocele. Prevalence of NTDs = number of a newborn with NTDs/total number of newborns *100

Materials

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can allow pregnant women in remote or underserved areas to access prenatal care and consultations with healthcare providers through video calls or phone calls.

2. Mobile health (mHealth) applications: Developing mobile applications that provide educational resources, reminders for prenatal appointments and medication intake, and access to teleconsultations can help improve maternal health outcomes.

3. Community health workers: Training and deploying community health workers who can provide basic prenatal care, education, and support to pregnant women in their communities can help improve access to maternal health services.

4. Transport services: Establishing transportation services specifically for pregnant women in remote areas can help them reach healthcare facilities for prenatal care and delivery.

5. Maternal health clinics: Setting up dedicated maternal health clinics in underserved areas can provide comprehensive prenatal care, including screenings, vaccinations, and counseling services.

6. Public awareness campaigns: Conducting public awareness campaigns to educate communities about the importance of prenatal care, nutrition, and early detection of risk factors can help increase demand for maternal health services.

7. Mobile clinics: Deploying mobile clinics equipped with necessary medical equipment and staffed by healthcare professionals can bring prenatal care services directly to communities that lack access to healthcare facilities.

8. Task-shifting: Training and empowering non-specialist healthcare providers, such as nurses and midwives, to provide certain aspects of prenatal care can help alleviate the shortage of skilled healthcare professionals in underserved areas.

9. Financial incentives: Implementing financial incentives, such as cash transfers or subsidies, for pregnant women to seek prenatal care and deliver in healthcare facilities can help overcome financial barriers to accessing maternal health services.

10. Partnerships with community organizations: Collaborating with local community organizations and NGOs can help leverage existing resources and networks to improve access to maternal health services and support.

It’s important to note that the specific context and needs of each community should be considered when implementing these innovations to ensure their effectiveness and sustainability.

AI Innovations Description

The recommendation to improve access to maternal health based on the findings of the study “Magnitude and determinants of neural tube defect in Africa: a systematic review and meta-analysis” is to prioritize and promote folic acid supplementation for women before and within the first month of pregnancy. This is because the study found that folic acid supplementation was a protective factor for neural tube defects (NTDs) in Africa.

Additionally, the study identified maternal exposure to pesticides and x-ray radiation as significant risk factors for NTDs. Therefore, it is recommended to raise awareness among pregnant women about the potential dangers of pesticide exposure and the importance of avoiding unnecessary exposure to x-ray radiation during pregnancy.

By implementing these recommendations, healthcare providers and policymakers can contribute to reducing the prevalence of NTDs in Africa and improving maternal and child health outcomes.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Increase awareness and education: Implement comprehensive public health campaigns to raise awareness about the importance of maternal health and the prevention of neural tube defects. This can include educating women and their families about the benefits of folic acid supplementation, the risks associated with pesticide exposure and x-ray radiation, and the importance of regular prenatal care.

2. Improve access to folic acid supplementation: Ensure that folic acid supplements are readily available and affordable for women of reproductive age. This can be done through government programs, partnerships with pharmaceutical companies, and community-based initiatives.

3. Strengthen antenatal care services: Enhance the quality and accessibility of antenatal care services, including routine screening for neural tube defects and other maternal health conditions. This can involve training healthcare providers, improving infrastructure, and implementing guidelines for comprehensive antenatal care.

4. Enhance maternal health surveillance: Establish a robust system for monitoring and reporting maternal health indicators, including the prevalence of neural tube defects. This can help identify trends, target interventions, and evaluate the impact of implemented strategies.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Determine the specific population group that will be the focus of the simulation, such as pregnant women in a particular region or country.

2. Collect baseline data: Gather relevant data on the current prevalence of neural tube defects, access to folic acid supplementation, utilization of antenatal care services, and other relevant indicators.

3. Develop a simulation model: Create a mathematical or statistical model that incorporates the various factors influencing access to maternal health, such as awareness, availability of resources, and healthcare utilization. This model should be based on the best available evidence and expert input.

4. Input intervention scenarios: Define different scenarios that represent the potential impact of the recommended interventions. This can include variations in the coverage and effectiveness of folic acid supplementation, changes in awareness levels, and improvements in antenatal care services.

5. Run simulations: Use the simulation model to estimate the impact of each intervention scenario on the prevalence of neural tube defects and other relevant outcomes. This can involve running multiple iterations of the model to account for uncertainty and variability.

6. Analyze results: Evaluate the simulation results to determine the potential effectiveness of each intervention scenario in improving access to maternal health. This can include comparing the outcomes of different scenarios and identifying the most promising strategies.

7. Refine and validate the model: Continuously update and refine the simulation model based on new data and feedback from experts. Validate the model by comparing its predictions with real-world data and conducting sensitivity analyses.

8. Communicate findings: Present the simulation results in a clear and accessible manner to stakeholders, policymakers, and healthcare providers. Highlight the potential benefits of the recommended interventions and advocate for their implementation.

By following this methodology, policymakers and healthcare professionals can gain insights into the potential impact of different interventions on improving access to maternal health and make informed decisions to prioritize and implement effective strategies.

Author

Dima Health

Statistics:

Citations: 6

Identifiers:

DOI: 10.1186/s12884-021-03848-9

Research Areas:

Cancer, Environmental, Genetics and Genomics, Health System and Policy, Maternal and Child Health, Sexual and Reproductive Health, Social Determinants

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study

Study Approach:

Mixed-methods, Quantitative, Systematic Review