Management of neural tube defects in a Sub-Saharan African country: The situation in Yaounde, Cameroon

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Abstract

Background

Neural tube defect is a serious disabling but preventable congenital malformation with an incidence of 1.99 per 1000 births in Yaounde [A.K. Njamnshi, V. d e P. Djientcheu, A. Lekoubou, M. Guemse, M.T. Obama, R. Mbu, S. Takongmo, I. Kago. Neural tube defects are rare among black Americans but not in Sub-Saharan black Africans: The case of Yaounde – Cameroon. Journal of the Neurological Sciences 2008; 270: 13–17]. The management requires highly qualified personnel and a significant social cost. The aim of this study was to evaluate the management of neural tube defect in a resource-limited developing Sub-Saharan nation like Cameroon.

Methods

We reviewed all patients with neural tube defects admitted in the neonatology unit of the Mother and Child Center (Chantal Biya Foundation Yaounde) between January 1st 2000 and December 31st 2006.

Results

Sixty-nine (69) patients were enrolled. There was a male predominance (69.57%) in the sample. Myelomeningomecele represented 68.11% of cases, followed by encephalocele (27.54%) and meningocele (4.35%). Antenatal ultrasound examinations were done in 27 cases (32.8%). The prenatal diagnosis was made only in 8 cases. No medical abortion was performed in any of these cases. Medical abortion is illegal in Cameroon (except in certain specific situations) as well as other Sub-Saharan African countries. Hydrocephalus was diagnosed in 40.02% of cases. As most of the patients (62.32%) could not afford modern treatment, only 26.09% of them were operated at birth. The rest sought traditional and other forms of treatment, due to poverty or cultural beliefs. Eight patients (11.59%) died before surgery. Surgery consisted of local closure alone (40%) or local closure associated to CSF shunting (60%). The complications were wound dehiscence (13.69%), shunt infection (1.37%), meningitis (1.37%) and iatrogenic pulmonary oedema (1.37%).

Conclusion

Neural tube defects are the most frequent and disabling malformations in neonates in the Sub-Saharan African paediatric environment. Prenatal management and outcome at birth are limited by poverty and cultural beliefs. Prevention is possible and may be better than palliative care in developing countries.

Introduction

Neural tube defects have been considered for a long time as a rare malformation in Africa [1]. However, recent studies have revealed incidence rates of 1.99 and 7 for 1000 births respectively in Yaounde and the middle belt Nigeria [2], [3]. Spina bifida, anencephaly and encephalocele are the most frequent and severe forms. The place of encephalocele among neural tube defects is still debated [4]. The management of these conditions involves different specialities including paediatrics, neurosurgery, orthopaedics, urology and physical medicine [5].

However, this corrective management is difficult to achieve in resource-limited developing countries. Furthermore, there is no policy to prevent these defects in Sub-Saharan Africa and other developing countries [2], [3], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]. More and more hospital series are being reported in Sub-Saharan Africa with many underlying difficulties in management [6], [8], [10], [12], [13], [16]. The aim of this study was to describe neural tube defects in the Neonatology Unit of the Mother and Child Center (Chantal Biya Foundation Yaounde) and to assess its management in a resource-limited context like our capital city where no structured social system of mutual medical risk-sharing exists.

This was a retrospective study of all patients admitted in the Neonatology Unit of the Mother and Child Center of Yaounde (Chantal Biya Foundation) from January 1st 2000 to December 31st 2006 with a neural tube defect. The Mother and Child Center (Chantal Biya Foundation) is the Paediatric Hospital associated to the Central Hospital of Yaounde which has the only neurosurgical service of Yaounde.

The patients were identified from the service register and the files were then obtained from the archives. For the purpose of comparison, the prevalence rates were obtained from the paediatric registers of the other university teaching hospitals of Yaounde: General Hospital of Yaounde, University Hospital Center of Yaounde and the Gynaecological-Obstetric and Paediatric Hospital of Yaounde. The estimated population of Yaounde is about 2,000,000 inhabitants with a general crude birth rate of 47 births for 1000 inhabitants [17]. The socio-economic status of patients' parents was assessed by the observation of social workers and nurses based on the ease of the families to buy drugs and food, prepare the patient bed and the number and quality of the patient visitors. They were then classified as of low, middle or high socio-economic status. The diagnosis of neural tube defect and associated hydrocephalus was done clinically. Trans-frontanellar ultrasound was done in neonates suspected of having hydrocephalus. During the study period, surgical management of the patients was done by the two neurosurgeons of the Central Hospital of Yaounde.

Section snippets

Prevalence

A total of 69 patients with neural tube defects were admitted in the Neonatology Unit of the Mother and Child Center of Yaounde within the period of the study. This represents a prevalence rate of 0.9% compared to the total number of patients admitted in the paediatric service during this period. During the same period, the admissions register of the 2 other teaching hospitals of Yaounde revealed prevalence rates of 0.52% and 0.39% for the Gynaecological-Obstetric and Paediatric Hospital of

Discussion

Neural tube defects are frequent and disabling congenital malformations in Sub-Saharan paediatric hospitals (Table 2, Table 3). They used to be considered as rare pathologies among blacks in general [1], [18], [19] but recent studies have demonstrated a higher incidence in sub-Saharan black Africans [2], [3], [14], compared to black Americans [18], [19], [20]. The prevalence varies from one service to another[6], [8], [10], [12], [13], [16] according to the degree of specialisation of the

Conclusion

The prevalence of neural tube defects in our paediatric environment, the pattern of lesions, the factors affecting the management and the outcome are comparable with those of Sub-Saharan African countries where data are available. Poverty, cultural beliefs and the insufficiencies of social organizations are limiting factors for management (only 26.09% of patients could afford modern treatment). Effective and efficient prevention policies (peri-conceptional folic acid supplementation) may

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