**11. Preventing birth defects: which approach?**

The prevention of birth defects in Africa should be modified from the traditional approach that is adopted in other regions of the world. This is because of the

comprehensive evaluation and diagnosis. This makes final decision on management

In this circumstance management of congenital anomalies cannot comprehensive and will be provided in a scattered manner. Often times when an anomaly is diagnosed treatment is limited to pregnancy termination where the laws allow. In one hospital 65% of pregnant women request for pregnancy termination when an anomaly is found in their fetus. In those with distressing polyhydramnius intermittent aspiration of the amniotic fluid is done to relieve the distress. Women who present with obstructed labor and a dead congenitally malformed fetus with hydrocephalus, delivery can be effected by craniotomy. For those that present with ruptured uterus, laparotomy is done and further management will depend on the extent of the rent and the clinical state of the fetus. Few countries [e.g. Egypt and South Africa] have centers that offer prenatal screening, diagnosis, treatment and follow up services, however such centers are not within the reach of the poor who

The cases below illustrate how pregnant women with undiagnosed fetuses with congenital anomaly will labor at home and developed ruptured uterus and present for treatment. All these cases presented with ruptured uterus following various

extremely difficult for the physician in Africa. Such is the environment

*Congenital Anomalies in Newborn Infants - Clinical and Etiopathological Perspectives*

perinatologists practice in Africa.

**10. Illustrative cases**

interventions at home.

**206**

carry most of the burden of congenital anomaly.

peculiarities of the African environment. As much as possible all preventive strategies should be simple, low cost and innovative. All stakeholders must be involved, governments, communities, professional societies dealing with the issue, and nongovernmental organizations. First stage should involve educating policy makers with emphasis on the burden of the problem on families and society at large. Educating policy makers on the need to understand how congenital anomalies contribute to both maternal and perinatal mortality. Areas that will require government intervention especially in community education, training of personnel and provision of equipment. Involving traditional and religious leaders who are gate keepers, educating them on the causes and prevention of birth defects. Involving the media in community enlightenment through discussion programs, talk shows and jingles.

industrialized countries [38]. Africa is the continent worse off compared to other regions as only one of 47 countries in Africa immunize against rubella. Currently there is an effort to develop a vaccine against Zika. For immunization program to succeed political will is required and thus policy makers should be encouraged by all

*Fetal Congenital Anomalies in Africa: Diagnostic and Management Challenges*

**Folic acid and other micronutrients supplementation:** Folate supplementation has been effective in preventing neural tube defect. Although available in various food substances in common use but one sure way of getting adequate levels in women before conception is through supplementation. Folate is chief and can be afforded by women in Africa. Different countries have used different approaches to ensure that women of reproductive age get adequate levels prior to conception. The United States Public Health Service recommended that women capable of becoming pregnant should consume 400 μg of folic acid daily [39], and in 1996 the Food and Drug Administration mandated the fortification of all enriched grain products, like flour and pastas, with 140 μg per 100 g of grain. The efficacy of folic acid in preventing neural tube defects has been proven in a community-based intervention study in China. In this study 400 μg of folic acid pills alone given before conception was found to be effective in reducing neural tube defects by 85% in an area of high prevalence and by 41% in an area of low incidence [40]. South American countries have implemented various successful folic acid supplementation programs [Chile and Cuba], supported by various organizations including the Pan American Health Organization, the March of Dimes and the CDC. There are plans being implemented to monitor the effect of the policy on the prevalence of neural tube defects, taking advantage of a preexisting and ongoing register of congenital malformations [41]. Africa can take queue to implement a similar program and follow up to determine its effectiveness in preventing neural tube defects in the African environment. **Family planning:** Africa has one of the highest fertility rates in the world and this is creating concerns as it is overstretching resources in the continent. High fertility rates go hand in hand with prevalence of various pregnancy complications including birth prevalence of congenital malformation. To address this, Africa has to make effort to reduce its population growth. Uncontrolled population growth is a precursor to poverty, disease and malnutrition all of which contribute to the prevalence of congenital malformation. Family planning reduces the prevalence of congenital malformations by reducing birth rates and fertility. It has been estimated that in many countries with high fertility reducing the number of children per family to 2–3 could reduce the prevalence of genetic disorders by 40–50%. Further, combined with encouragement to complete reproduction before the age of 35 years, family planning can contribute to a 50% reduction of Down syndrome [42].

**Avoidance of teratogens:** Exposure to teratogens has multiple angles. In Africa use of traditional remedies is common in many communities. The chemical constituents of such remedies are not known and could contain teratogenic substances. Another factor is behavior of pharmaceutical companies selling drugs to consumers without following the regulatory procedures. People can also buy drugs over the counter without recourse to physician's prescription and use it anyhow with the potential of harm. Again counterfeit drugs are everywhere and people buy them because they are cheaper but their potential for harm is much greater compared to the original. Compounding these factors are lax environmental quality regulations and unhealthy working conditions which expose pregnant women to environmental pollutants [43]. Community education on what teratogens are, teratogens in the vicinity of communities and how they can cause harm can go along way in reducing

**Other measures:** Premarital counseling and testing can go along way in reduc-

ing genetic/hereditary disorders. A case in point is sickle cell disease in which

to make commitment in this regard.

*DOI: http://dx.doi.org/10.5772/intechopen.91994*

exposure.

**209**

Even as we want evolve our own model of prevention based on our peculiar social, environmental and economic circumstances, we must learn lessons from the experiences of other countries such as Cuba, China, India and Brazil. We must extract some of elements in the model they used and input them in to our own model. As we develop our preventive strategies we need to have the following at the background for us to succeed:


This is background to discussing the strategies for the prevention of congenital anomalies in Africa.

First strategy is education which is the backbone of development and progress in all spheres of life. It is known that the higher the level of literacy of a community the better are its economic indices, social status and health seeking behavior of its members. Education may be crucial in understanding the causes, treatment options and methods of prevention of congenital anomalies. It will also go along way in eliminating traditional and cultural practices that put communities at risk for congenital anomalies.

#### **12. Specific measures**

**Immunization** is an important strategy that has proven it efficacy in preventing other diseases. Congenital Rubella syndrome has virtually been eliminated in the United States and this is achieved through universal vaccination as a component of childhood immunization. In contrast the burden of congenital rubella in developing countries has been estimated to be about 100,000 per year [37], but only 28% of all developing countries have rubella immunization in place, as compared to 92% of

#### *Fetal Congenital Anomalies in Africa: Diagnostic and Management Challenges DOI: http://dx.doi.org/10.5772/intechopen.91994*

industrialized countries [38]. Africa is the continent worse off compared to other regions as only one of 47 countries in Africa immunize against rubella. Currently there is an effort to develop a vaccine against Zika. For immunization program to succeed political will is required and thus policy makers should be encouraged by all to make commitment in this regard.

**Folic acid and other micronutrients supplementation:** Folate supplementation has been effective in preventing neural tube defect. Although available in various food substances in common use but one sure way of getting adequate levels in women before conception is through supplementation. Folate is chief and can be afforded by women in Africa. Different countries have used different approaches to ensure that women of reproductive age get adequate levels prior to conception. The United States Public Health Service recommended that women capable of becoming pregnant should consume 400 μg of folic acid daily [39], and in 1996 the Food and Drug Administration mandated the fortification of all enriched grain products, like flour and pastas, with 140 μg per 100 g of grain. The efficacy of folic acid in preventing neural tube defects has been proven in a community-based intervention study in China. In this study 400 μg of folic acid pills alone given before conception was found to be effective in reducing neural tube defects by 85% in an area of high prevalence and by 41% in an area of low incidence [40]. South American countries have implemented various successful folic acid supplementation programs [Chile and Cuba], supported by various organizations including the Pan American Health Organization, the March of Dimes and the CDC. There are plans being implemented to monitor the effect of the policy on the prevalence of neural tube defects, taking advantage of a preexisting and ongoing register of congenital malformations [41]. Africa can take queue to implement a similar program and follow up to determine its effectiveness in preventing neural tube defects in the African environment.

**Family planning:** Africa has one of the highest fertility rates in the world and this is creating concerns as it is overstretching resources in the continent. High fertility rates go hand in hand with prevalence of various pregnancy complications including birth prevalence of congenital malformation. To address this, Africa has to make effort to reduce its population growth. Uncontrolled population growth is a precursor to poverty, disease and malnutrition all of which contribute to the prevalence of congenital malformation. Family planning reduces the prevalence of congenital malformations by reducing birth rates and fertility. It has been estimated that in many countries with high fertility reducing the number of children per family to 2–3 could reduce the prevalence of genetic disorders by 40–50%. Further, combined with encouragement to complete reproduction before the age of 35 years, family planning can contribute to a 50% reduction of Down syndrome [42].

**Avoidance of teratogens:** Exposure to teratogens has multiple angles. In Africa use of traditional remedies is common in many communities. The chemical constituents of such remedies are not known and could contain teratogenic substances. Another factor is behavior of pharmaceutical companies selling drugs to consumers without following the regulatory procedures. People can also buy drugs over the counter without recourse to physician's prescription and use it anyhow with the potential of harm. Again counterfeit drugs are everywhere and people buy them because they are cheaper but their potential for harm is much greater compared to the original. Compounding these factors are lax environmental quality regulations and unhealthy working conditions which expose pregnant women to environmental pollutants [43]. Community education on what teratogens are, teratogens in the vicinity of communities and how they can cause harm can go along way in reducing exposure.

**Other measures:** Premarital counseling and testing can go along way in reducing genetic/hereditary disorders. A case in point is sickle cell disease in which

peculiarities of the African environment. As much as possible all preventive strategies should be simple, low cost and innovative. All stakeholders must be involved, governments, communities, professional societies dealing with the issue, and nongovernmental organizations. First stage should involve educating policy makers with emphasis on the burden of the problem on families and society at large. Educating policy makers on the need to understand how congenital anomalies contribute to both maternal and perinatal mortality. Areas that will require government intervention especially in community education, training of personnel and provision of equipment. Involving traditional and religious leaders who are gate keepers, educating them on the causes and prevention of birth defects. Involving the media in community enlightenment through discussion programs, talk shows and jingles. Even as we want evolve our own model of prevention based on our peculiar social, environmental and economic circumstances, we must learn lessons from the experiences of other countries such as Cuba, China, India and Brazil. We must extract some of elements in the model they used and input them in to our own model. As we develop our preventive strategies we need to have the following at the

*Congenital Anomalies in Newborn Infants - Clinical and Etiopathological Perspectives*

2.Uncontrolled birth rates and poor uptake of family planning services

5.Loose control of drugs and substances which are known to be teratogenic

8.Emphasis should be on primary prevention as we prepare to introduce

This is background to discussing the strategies for the prevention of congenital

First strategy is education which is the backbone of development and progress in all spheres of life. It is known that the higher the level of literacy of a community the better are its economic indices, social status and health seeking behavior of its members. Education may be crucial in understanding the causes, treatment options and methods of prevention of congenital anomalies. It will also go along way in eliminating traditional and cultural practices that put communities at risk for congenital anomalies.

**Immunization** is an important strategy that has proven it efficacy in preventing other diseases. Congenital Rubella syndrome has virtually been eliminated in the United States and this is achieved through universal vaccination as a component of childhood immunization. In contrast the burden of congenital rubella in developing countries has been estimated to be about 100,000 per year [37], but only 28% of all developing countries have rubella immunization in place, as compared to 92% of

background for us to succeed:

1.Endemic poverty and illiteracy

3.Malnutrition and micronutrient deficiencies

6.Customs and traditions which are harmful to health

7.Our goal is to eliminate causative factors of congenital defect

4.Poor uptake of immunization services

secondary and tertiary prevention.

anomalies in Africa.

**12. Specific measures**

**208**

premarital counseling and testing can reduce its prevalence. Avoiding consanguineous marriage has the potential of reducing propagation of hereditary diseases within population groups with hereditary diseases.

**Secondary/tertiary prevention:** This aims to reduce the number of children delivered with congenital malformation, whereas tertiary prevention is aimed at cure and amelioration of problems once a child with a congenital birth defect is born. Postnatal neonatal examination and screening of newborn children is a strategy in tertiary prevention, because once an anomaly is detected ameliorative measures can be instituted.

**Ultrasound screening of congenital anomalies with an option of pregnancy termination:** This has the potential of reducing the birth prevalence of congenital malformation but the issue of termination of pregnancy is the difficult part, as in many countries in Africa pregnancy termination can only be done when the life of the woman is at risk. Congenital malformations are not in themselves life threatening to the woman and therefore pregnancy cannot be terminated on account of congenital malformation in countries with restrictive abortion laws.

**A new concept [Targeted screening]:** The ideal thing is to screen all pregnant women for structural anomalies and test them for hereditary disorders and infections but the ideal is not always possible because the health care system in Africa is constrained by limited resource allocation. In view of this a transitional concept can be adopted pending acceptance of the whole population to prenatal screening and improve resource allocation to health care.

Targeted screening can be offered to the following category of pregnant women; Women with; Previous history of babies with congenital anomalies, history of congenital anomaly in the family, index pregnancy with polyhydramnious, age more than 35 years, multiple gestation, consanguineous marriage, diabetes and those with sickle cell disease/Thalassemia.
