Neural Tube Defect: Burden, Determinants, Dietary practice and Effect of Picture Based Nutrition Education toward women’s Adherence to Preconception Iron-Folic Acid Supplementation in Eastern Ethiopia

Introduction: Globally, neural tube defects (NTDs) are the top five causes of infant mortality, morbidity, and disability. NTDs are invisible to policy-makers yet have a significant emotional, economical psychological, impact on families and society while also contributing to the loss of human potential and associated with substantial mortality, morbidity, disability problems. Due to the sheer number of its population, Ethiopia is one of the four sub-Saharan African countries with the largest number of NTDs cases. However, the burden and determinants of NTDs are not sufficiently studied and the data is largely remains unknown. In addition, there is no data has been found the linkage between maternal dietary practice and developing NTDs. Furthermore, there is a lack of evidence about the practice of preconception folate supplementation to reduce the risk of NTDs among women planning to get pregnant in the existing health care system. Despite the fact that numerous evidence-based studies have been conducted to investigate the effects of preconception folic acid supplementation on reducing the risk of NTDs. However, no or a few studies has been conducted in Ethiopia to examine the effect of preconception picture based health education on the adherence of iron folic acid supplementation to reduce the risk of NTDs among women planning to become pregnant. Objectives: To assess the burden, determinants, dietary practice and to examine the effect of pictured based nutrition education knowledge and adherence to preconception iron-folic acid supplementation among women planning to be pregnant in Eastern Ethiopia. This study also aimed to explore the practice of preconception folate supplementation among women planning to get pregnant in the Ethiopian health care system. Methods: The study is used both quantitative and qualitative components. The quantitative study included retrospective cohort study, matched case control, comparative and parallel randomized controlled trail. A structured checklist questionnaire with open and close-ended questions were used for data collection. Data were collected by interviewing mothers/caretakers and reviewing retrospective medical records. The study subjects were recruited in purposively selected hospitals from Eastern Ethiopia based on caseloads. Data retrieving form was used to collect the data from neonates and terminated with neural tube defects medical records of the period 2017-2019. Data collectors were trained midwives nurses, health extension workers and other health professionals working at the selected study hospitals. For matched case control and 14 comparative cross sectional study, cases were ascertained using a prospective study approach, whereas controls were randomly selected from the same selected health facilities. For the case control and comparative cross sectional study, 276 pregnant women (138 cases who delivered or terminated the pregnancy due to NTDs and 138 women who gave birth apparently healthy neonate) were studied. For parallel RCT, 244 women (122 interventional and 122 control groups) who have a plan to pregnancy were included. The incidence (burden) of each case is calculated by dividing the number of cases per year by the total number of births in each hospital. A linear trend of NTDs over time and Extended Mantel-Haenszel chi-square was performed. The dietary practice was assessed using modified food frequency questionnaire (FFQ). The dietary practice of women was determined by using meal frequency, dietary diversity score (DDS), food variety score (FVS), and animal food source (ASF). Statistical procedures, such as frequency, percentage, chi-square, bivariate, and multivariate were used to analyze the data and determine the frequency of NTDs, associated factors and Odds ratio. The qualitative study was aimed to explore the practice, challenges, and opportunities for preconception folate supplementation to reduce the risk of NTDs. In this study 45 participants included pregnant women who followed ANC, women who had a plan to be pregnant, health care providers who work at family planning service, gynecology ward and experts of maternal and child health care services (MCH). A purposive sampling method was used to select the study participants from health facilities. Content validation of the instruments was done by two experts after which the instruments were pretested and ambiguous questions were removed or revised. An in-depth interview was conducted. Field notes and audio recordings were transcribed verbatim, translated, and analyzed by inductive thematic analysis using Atlas ti.7.1. Result: For retrospective cohort study a total of 48,567 newborn were participated and 522 newborns with NTDs were identified. The linear trends of NTDs over the three years of 2017- 2019 were OR of 1 (base year), 4.3, and 8.3, respectively, [Extended Mantel-Haenszel chi-square for linear trend = 200.53 (P<0.0001)]. Thus the burden of NTDs showed that a statistically significant increased trend over the three years. For the case control study, Illiterate (AOR=0.34, 95% CI: 0.12-0.92, P=0.034), rural residents (AOR=3.4, 95% CI: 1.18-9.78, P=0.023), having a history of elective termination (AOR=2.95, 95% CI: 1.15-7.55, P=0.023), those who suffered severe anemia in pre or early pregnancy (AOR=3.4, 95% CI: 1.17-9.87, P=0.024), having history 15 of fever in pre or early pregnancy (AOR=2.75; 95% CI: 1.05-7.15, P=0.038), and mothers who had an exposure to various agrochemicals (AOR=3.39, 95% CI: 1.11-10.3, P=0.032) were significantly associated with occurrence of NTDs. For comparative cross sectional study, the prevalence of good dietary practice in the study population was 29% (95% CI = 23.6%–34.3%). Illiterate women were 84% less likely to adhere to good dietary practice than women with higher education (AOR=0.16, 95% CI, 0.03-0.8), and respondents in the comparison group are more likely to have a good dietary practice than compared to these case groups (AOR=2.1, 95% CI 1.07–4.1). For parallel RCT study, the intervention group (42.6%) had adherence to iron-folic acid supplements compared to the control group (3.3%); this difference was significant (P<0.0001). History of NTDs affecting pregnancy, history of spontaneous abortion, and knowledge was independently associated with adherence to iron-folic acid supplement (P<0.05). In the qualitative study, there was no provision of preconception folic acid supplementation for those who planned to be pregnant. The challenges for this disruption in the continuum of care include the absence of clear policy, program, and guidelines, lack of knowledge among caregivers and women, unfavorable attitude and belief, the high workload of providers, and poor adherence. Conclusion: NTDs is a significant public health burden in the study area, with the most common forms being anencephaly and Spinal bifida. Illiterate, rural residents, having a history of elective termination, those who suffered severe anemia in pre or early pregnancy, having history of fever in pre or early pregnancy, and mothers who had an exposure to various agrochemicals were significantly associated with occurrence of NTDs, history of NTDs affecting pregnancy, history of spontaneous abortion, and knowledge was independently associated. The findings suggest that primary preventative strategies should be strengthened by actively promoting preconception care services, such as preconception iron folic acid supplement, as well as food fortification and good dietary practices. This study highlighted the need for policy, program, guidelines, and a structure for preconception care services in the country