ArticlesAssociation of low maternal education with neural tube defects in Colorado, 1989–1998
Introduction
Neural tube defects (NTDs) are among the most common congenital birth defects in the United States, placing a substantial economic burden on the US health care system1 and an emotional burden on the families affected. Significant advances have been made over the past 10 years in identifying aetiologic factors. Folic acid supplementation before conception and during the first four weeks of pregnancy has the potential to decrease the incidence of neural tube defects by at least half.2, 3 However, wide variations in incidence based on geography, time of year, race, and ethnicity suggest a complex interaction of multiple environmental and genetic factors.4 Maternal factors that have been associated with an increased risk of NTD-affected pregnancies include poor diet,1, 2 diabetes,4 pesticide exposures,5 poverty6, 7 fever in the first trimester,8 stress,9 use of folic acid antagonists,10 and obesity.11
Ethnicity also appears to play a role in the incidence of NTDs, but the causative mechanism has not been defined.12 NTDs occur with a much higher incidence in Mexico than in the United States.4 Several studies have shown that people of Mexican heritage residing in the United States are at greater risk of having a child with a NTD than are non-Hispanic white people.12, 13, 14 In addition, one study has suggested that Latin women born in Mexico are at significantly greater risk of giving birth to a child with an NTD than are Latin women born in the United States, or non-Latin white women.13 However, in some populations, maternal country of birth in Mexico does not appear to be a risk factor.14 Low maternal education has also been associated with an increased likelihood of having a child with an NTD,6, 13, 14 although its relationship with maternal country of birth and ethnicity has not been clearly defined. Given the rapidly increasing Latin population in the United States, it is important to further delineate factors associated with the increased incidence of NTDs seen in some Hispanic populations.
We utilized birth registry and birth defect data in Colorado from 1989 to 1998 in a case control study to evaluate maternal factors associated with infants born with NTDs. Specifically, we wished to examine the association of maternal education, ethnicity, and country of birth with NTDs, in a state with a significant proportion of Hispanic women, many of whom are first generation immigrants from Mexico.
Section snippets
Methods
We conducted a population-based, case-control study on women who gave birth to children with neural tube defects in Colorado from 1989 to 1998. We used data from Colorado vital records (birth certificates), which document every live birth in the state, and from the Colorado Responds to Children with Special Needs (CRCSN) neural tube defect (NTD) registry, a separate database that records all live children born with NTDs. The Colorado Department of Public Health and Environment (CDPHE) maintains
Results
Between 1989 and 1998, 251 infants with neural tube defects were born in Colorado; 224 were born to mothers who themselves were born in the United States or Mexico and had complete information on the birth certificate for the risk factors of interest. Of these 224 infants, 30 had anencephaly, 150 spina bifida, and 40 encephalocele/meningomyelocele (Table 1). The number of NTDs per year ranged from a minimum of 14 in 1993 to a maximum of 32 cases in 1998. Two infants had more than one of these
Discussion
These population-based data demonstrate the complex interplay of maternal country of birth, ethnicity, and educational level with NTDs. A large population-based study in California demonstrated an increased odds ratio for NTDs in children of Mexican-born women, but not in US-born Hispanic women. The increased risk persisted even after controlling for education.13 In contrast, a population-based study done in Texas showed an increased incidence of neural tube defects among Hispanic babies but no
Acknowledgements
We wish to acknowledge Dennis Lezotte, PhD, and Ned Calonge, MD, MPH of the University of Colorado Dept of Preventive Medicine and Biometrics for help with study design and data analysis; and Russel Rickard of Colorado Responds to Children with Special Needs, at the Colorado Department of Public Health and Environment, for assistance with the Colorado neural tube defects database.
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Cited by (57)
Lower rates of neural tube defects in Israel following folic acid supplementation policy
2020, Preventive MedicineCitation Excerpt :This has also been shown in a large case-control study of over half a million infants in Colorado, USA, in which women with less than 10 years of education had nearly twice the odds of giving birth to a child with a NTD. ( Farley et al., 2002) Age is an unlikely confounding factor in the association between education and NTD risk, since no significant association has been established between maternal or paternal age and NTDs in pregnancy in neither the international literature (Frey and Hauser, 2003; Detrait et al., 2005) nor in reports from Israel. ( Israeli Ministry of Health Report, 2005) It is likely that women with lower levels of education also have lower health literacy, and are therefore less aware of and likely to comply with FA supplementation recommendations.
Myelomeningocele and Other Spinal Dysraphisms
2020, Braddom's Physical Medicine and RehabilitationMaternal, paternal, and neonatal risk factors for neural tube defects: A systematic review and meta-analysis
2019, International Journal of Developmental NeuroscienceCitation Excerpt :The meta-analysis evaluated 12 potential risk factors [8 maternal, 1 paternal, and 3 neonatal]. The selection process is presented in Fig. 1, and the characteristics of each included study are presented in Tables 1–3 (Ingstrup et al., 2016; Ye et al., 2011; Correa et al., 2000; Fedrick, 1974; Yazdy et al., 2012; Zhang et al., 2018; Lu et al., 2015; Talebian et al., 2015; Carmichael et al., 2014; Deb et al., 2014; Li et al., 2013; Anderka et al., 2012; Garne et al., 2012; De Marco et al., 2011; Lu et al., 2011; Yin et al., 2011; Grewal et al., 2009; Carmichael et al., 2007; Suarez et al., 2007; Czeizel et al., 2006; Macintosh et al., 2006; Blanco-Munoz et al., 2006; Li et al., 2006; Anderson et al., 2005; Mandiracioglu et al., 2004; Ray et al., 2004; Morris et al., 2003; Suarez et al., 2003; Farley et al., 2002; Elliott et al., 2001; Todoroff and Shaw, 2000; Carmichael and Shaw, 2000; Wasserman et al., 1998; Dolk et al., 1998; Croen et al., 1997; Canfield et al., 1996; Janssen et al., 1996; Kurinczuk and Clarke, 1993; Yang et al., 2007; Kazaura et al., 2004; McIntosh et al., 1995; Norman et al., 2012; Gu et al., 2007; Nili and Jahangiri, 2006; Khoury et al., 1988). The Newcastle-Ottawa Scale [NOS] was used to evaluate the studies.
Myelomeningocele and Other Spinal Dysraphisms
2018, Braddom's Rehabilitation Care: A Clinical HandbookImpact of maternal education level on risk of low Apgar score
2016, Public HealthCitation Excerpt :In Brazil, a previous study14 that evaluated 210,000 singleton and non-singleton births in São Paulo identified that education level was associated with the risk of a low Apgar score (OR 0.433 for women with ≥12 years of education, reference group 1–3 years). The effects of maternal education on 1-min Apgar score, neural tube defects and low birth weight have also been investigated,16,31,32 and infants with less-educated parents have been reported to be at higher risk. The comparison of ORs without overlapping CIs allows for some interesting observations (Table 2 and Fig. 2).
Birth Defects in the Newborn Population: Race and Ethnicity
2015, Pediatrics and NeonatologyCitation Excerpt :National estimates of the prevalence of birth defects represent an important foundation in our understanding of the public health burden posed by these conditions. Although some previous studies have looked at racial differences in the occurrence of selected birth defect diagnoses,8–10,24–29 there are certain strengths and novelty in our study that makes it different from any other prior study. Firstly, our data was derived from the largest national database of hospitalization information with a sample size of 1.2 million live births, marking the largest study of birth defect birth prevalence in the United States.