Margaret L. Watkins

Trends in serum folate after food fortification

From 1994 to 1998, median serum folate values in clinical specimens increased from 12.6 to 18.7 microg/L. The percentage of low values decreased. Food fortification with folic acid is a likely explanation.

Maternal obesity, gestational diabetes, and central nervous system birth defects.

Background: Maternal obesity and diabetes are both associated with increased risk of congenital central nervous system (CNS) malformations in the offspring and may share a common underlying mechanism. Our objective was to evaluate whether gestational diabetes influenced the association of prepregnancy maternal obesity and risks for CNS birth defects. Methods: This Texas population-based case-control study evaluated births occurring January 1997 through June 2001. Data came from structured telephone interviews. Cases (n = 477) were mothers of offspring with anencephaly (n = 120), spina bifida (n = 184), holoprosencephaly (n = 49), or isolated hydrocephaly (n = 124). Controls (n = 497) were mothers of live infants without abnormalities randomly selected from the same hospitals as cases. Response rates were approximately 60% for both cases and controls. We evaluated maternal obesity (body mass index ≥30.0 kg/m2) and risks for CNS birth defects, as well as whether gestational diabetes influenced the risks. Results: After adjusting for maternal ethnicity, age, education, smoking, alcohol use, and periconceptional vitamin use, obese women had substantially increased risks of delivering offspring with anencephaly (odds ratio = 2.3; 95% confidence interval = 1.2–4.3), spina bifida (2.8; 1.7–4.5), or isolated hydrocephaly (2.7; 1.5–5.0), but not holoprosencephaly (1.4; 0.5–3.8). Odds ratios were higher for the joint effects of maternal obesity and gestational diabetes, with evidence for interaction on a multiplicative scale. Conclusions: Maternal obesity and gestational diabetes may increase the risk of CNS birth defects through shared causal mechanisms.

Maternal multivitamin use and orofacial clefts in offspring.

BACKGROUND Cleft lip with or without cleft palate (CLP) and cleft palate alone (CP) affect approximately 1 in 1000 infants and 1 in 2,500 infants, respectively. Studies of the relation between orofacial clefts and multivitamins or folic acid have been inconsistent. METHODS We used data from a population-based case-control study involving 309 nonsyndromic cleft-affected births (222 with CLP, 87 with CP) and 3,029 control births from 1968 to 1980 to evaluate the relation between regular multivitamin use and the birth prevalence of orofacial clefts. RESULTS We found a 48% risk reduction for CLP (odds ratio = 0.52, 95% confidence interval = 0.34-0.80) among mothers who used multivitamins during the periconceptional period or who started multivitamin use during the first postconceptional month, after controlling for several covariates. The risk reduction for CP was less than those for CLP (odds ratio = 0.81, 95% confidence interval = 0.44-1.52); however, a small number of CP cases limited interpretation. No risk reductions for CLP or CP were found for women who began multivitamin use in the second or third month after conception. CONCLUSIONS The magnitude of the risk reduction in our study is comparable to those of other recent studies; our study does not support the contention that only large dosages of folic acid are needed to prevent orofacial clefts. More studies are needed to test the effects of multivitamins and varying dosages of folic acid on the recurrence and/or occurrence of orofacial clefts to provide information needed to determine possible prevention strategies. Published 2001 Wiley-Liss, Inc.

Reasons related to non-vaccination and under-vaccination of children in low and middle income countries: Findings from a systematic review of the published literature, 1999–2009

OBJECTIVE Despite increases in routine vaccination coverage during the past three decades, the percent of children completing the recommended vaccination schedule remains below expected targets in many low and middle income countries. In 2008, the World Health Organization Strategic Advisory Group of Experts on Immunization requested more information on the reasons that children were under-vaccinated (receiving at least one but not all recommended vaccinations) or not vaccinated in order to develop effective strategies and interventions to reach these children. METHODS A systematic review of the peer-reviewed literature published from 1999 to 2009 was conducted to aggregate information on reasons and factors related to the under-vaccination and non-vaccination of children. A standardized form was used to abstract information from relevant articles identified from eight different medical, behavioural and social science literature databases. FINDINGS Among 202 relevant articles, we abstracted 838 reasons associated with under-vaccination; 379 (45%) were related to immunization systems, 220 (26%) to family characteristics, 181 (22%) to parental attitudes and knowledge, and 58 (7%) to limitations in immunization-related communication and information. Of the 19 reasons abstracted from 11 identified articles describing the non-vaccinated child, 6 (32%) were related to immunization systems, 8 (42%) to parental attitudes and knowledge, 4 (21%) to family characteristics, and 1 (5%) to communication and information. CONCLUSIONS Multiple reasons for under-vaccination and non-vaccination were identified, indicating that a multi-faceted approach is needed to reach under-vaccinated and unvaccinated children. Immunization system issues can be addressed through improving outreach services, vaccine supply, and health worker training; however, under-vaccination and non-vaccination linked to parental attitudes and knowledge are more difficult to address and likely require local interventions.

Is maternal obesity a risk factor for anencephaly and spina bifida

&NA; To determine whether the risk of having an infant with anencephaly or spina bifida is greater among obese women than among average‐weight women, we compared 307 Atlanta‐area women who gave birth to a liveborn or stillborn infant with anencephaly or spina bifida (case group) with 2,755 Atlantaarea women who gave birth to an infant without birth defects (control group). The infants of control women were randomly selected from birth certificates and frequency‐matched to the case group by race, birth hospital, and birth period from 1968 through 1980. After adjusting for maternal age, education, smoking status, alcohol use, chronic illness, and vitamin use, we found that, compared with average‐weight women, obese women (pregravid body mass index greater than 29) had almost twice the risk of having an infant with spina bifida or anencephaly (odds ratio = 1.9; 95% confidence limits = 1.1, 3.4). A womans risk increased with her body mass index: adjusted odds ratios ranged from 0.6 (95% confidence limits = 0.3, 2.1) for very underweight women to 1.9 for obese women.

Maternal Prepregnancy Weight and Congenital Heart Defects in the Offspring.

To determine the relation between having an infant with a major heart defect and a mother’s prepregnancy weight, we compared 1,049 Atlanta-area women who gave birth to liveborn or stillborn infants, each with a major heart defect, with 3,029 Atlanta-area women who gave birth to infants without birth defects. The infants of control women were randomly selected from birth certificates and were frequency-matched to the case group by race, birth hospital, and birth period from 1968 through 1980. After excluding diabetic mothers and adjusting for potential confounders, compared with average-weight women (body mass index 19.9–22.7), we found that underweight women (body mass index <16.5) were less likely to have a child with a major isolated heart defect [odds ratio (OR) = 0.64; 95% confidence interval (CI) = 0.43–0.97], whereas the OR was elevated among overweight or obese women (body mass index >26) (OR = 1.36; 95% CI = 0.95–1.93). Using average-weight women who did not take periconceptional multivitamins as the reference group, periconceptional multivitamin use was associated with a reduced OR for isolated heart defects among average-weight women (OR = 0.61, 95% CI = 0.36–0.99) and underweight women but not among overweight or obese women (OR = 1.69, 95% CI = 0.69–3.84).

Efficacy of folic acid prophylaxis for the prevention of neural tube defects

Thirty years ago, researchers suggested that maternal intake of certain vitamins during pregnancy affected the incidence of serious birth defects. Since then, two randomized controlled trials and several observational studies have proven that if women take folic acid during the periconceptional period, they can lower their risk of having children with neural tube defects (NTDs), serious birth defects of the spine and brain. In 1992, the U.S. Public Health Service recommended that all women capable of becoming pregnant take 0.4 mg of folic acid daily. Translating this recommendation into practice, however, presents a major public health challenge. In 1996, the U.S. Food and Drug Administration ruled that “enriched” cereal grain products must be fortified with folic acid, the first time food has been fortified for the prevention of birth defects. However, because the level chosen for folic acid fortification will not provide all women the optimal protection against the occurrence of NTDs, efforts to increase reproductive-age womens consumption of folic acid-containing vitamins and folate-rich foods are underway. The mechanism underlying folic acids efficacy in preventing NTDs is unknown. It may work by correcting a deficiency or by overcoming an inherited disorder of folate metabolism. The role of genetics and agents such as vitamin B12, methionine, and homocysteine in NTD prevention, and the relationship of these factors with folic acid, are under investigation. Although the mechanism for folic acids protective effect is unknown, it is clear that a significant proportion of NTDs can be prevented and that prevention efforts should not await the elucidation of specific mechanisms. MRDD Research Reviews 1998;4:282–290.

Impact of Integration of Hygiene Kit Distribution With Routine Immunizations on Infant Vaccine Coverage and Water Treatment and Handwashing Practices of Kenyan Mothers

Integration of immunizations with hygiene interventions may improve use of both interventions. We interviewed 1361 intervention and 1139 comparison caregivers about hygiene practices and vaccination history, distributed water treatment and hygiene kits to caregivers during infant vaccination sessions in intervention clinics for 12 months, and conducted a followup survey of 2361 intervention and 1033 comparison caregivers. We observed significant increases in reported household water treatment (30% vs 44%, P < .0001) and correct handwashing technique (25% vs 51%, P < .0001) in intervention households and no changes in comparison households. Immunization coverage improved in both intervention and comparison infants (57% vs 66%, P = .04; 37% vs 53%, P < .0001, respectively). Hygiene kit distribution during routine immunizations positively impacted household water treatment and hygiene without a negative impact on vaccination coverage. Further study is needed to assess hygiene incentives, implement alternative water quality indicators, and evaluate the impact of this intervention in other settings.

Integration of Routine Vaccination and Hygiene Interventions: A Comparison of 2 Strategies in Kenya

BACKGROUND Hygiene interventions reduce child mortality from diarrhea. Vaccination visits provide a platform for delivery of other health services but may overburden nurses. We compared 2 strategies to integrate hygiene interventions with vaccinations in Kenyas Homa Bay district, 1 using community workers to support nurses and 1 using nurses. METHODS Homa Bay was divided into 2 geographical areas, each with 9 clinics. Each area was randomly assigned to either the nurse or community-assisted strategy. At infant vaccination visits hygiene kits were distributed by the nurse or community member. Surveys pre- and post-intervention, measured hygiene indicators and vaccination coverage. Interviews and focus groups assessed acceptability. RESULTS Between April 2009 and March 2010, 39 158 hygiene kits were distributed. Both nurse and community-assisted strategies were well-accepted. Hygiene indicators improved similarly in nurse and community sites. However, residual chlorine in water changed in neither group. Vaccination coverage increased in urban areas. In rural areas coverage either remained unchanged or increased with 1 exception (13% third dose poliovirus vaccine decrease). CONCLUSIONS Distribution of hygiene products and education during vaccination visits was found to be feasible using both delivery strategies. Additional studies should consider assessing the use of community members to support integrated service delivery.

Community and Health Worker Perceptions and Preferences Regarding Integration of Other Health Services With Routine Vaccinations: Four Case Studies

BACKGROUND Integration of routine vaccination and other maternal and child health services is becoming more common and the services being integrated more diverse. Yet knowledge gaps remain regarding community members and health workers acceptance, priorities, and concerns related to integration. METHODS Qualitative health worker interviews and community focus groups were conducted in 4 African countries (Kenya, Mali, Ethiopia, and Cameroon). RESULTS Integration was generally well accepted by both community members and health workers. Most integrated services were perceived positively by the communities, although perceptions around socially sensitive services (eg, family planning and human immunodeficiency virus) differed by country. Integration benefits reported by both community members and health workers across countries included opportunity to receive multiple services at one visit, time and transportation cost savings, increased service utilization, maximized health worker efficiency, and reduced reporting requirements. Concerns related to integration included being labor intensive, inadequate staff to implement, inadequately trained staff, in addition to a number of more broad health system issues (eg, stockouts, wait times). CONCLUSIONS Communities generally supported integration, and integrated services may have the potential to increase service utilization and possibly even reduce the stigma of certain services. Some concerns expressed related to health system issues rather than integration, per se, and should be addressed as part of a wider approach to improve health services. Improved planning and patient flow and increasing the number and training of health staff may help to mitigate logistical challenges of integrating services.