SAINT MONICA UNIVERSITY HIGHER INSTITUTE, BUEA, CAMEROON

CONGENITAL MALFORMATION: KNOWLEDGE, AWARENESS AND RISK

FACTORS AMONG WOMEN AT THE REGIONAL HOSPITAL BUEA.

A Research Project Submitted to the School of Health and Human Services of

Saint Monica Higher Institute in Partial Fulfillment of the Requirements
For the Award of the Bachelor of Nursing Science.

BY

IGE BLESSING IYANUOLUWA

(SHHS22NR003)

Committee Members:
W Ndaleh PhD (Chair)
Mr. Tasong George Njuzi (Member)
CONGENITAL MALFORMATION: KNOWLEDGE, ATTITUDE AND RISK FACTORS
AMONG WOMEN AT THE REGIONAL HOSPITAL BUEA

July, 2022
IGE BLESSING IYANUOLUWA
ALL RIGTHS RESERVED
CONGENITAL MALFORMATION: KNOWLEDGE, ATTITUDE AND RISK FACTORS
AMONG WOMEN AT THE REGIONAL HOSPITAL BUEA

A Research Project Submitted to the School of Health and Human Services of

Saint Monica Higher Institute in Partial Fulfillment of the Requirements
For the Award of the Nursing Science

BY

IGE BLESSING IYANUOLUWA

(SHHS22NR003)

Project Approval Committee Members

Signature:……………………….. Date:……………………………

Dr. W Ndaleh (Chair)

Signature: ……………………………. Date:………………………..…...

Mr. Tasong George Njuzi (Member)

Signature:………………………. Date:…………………………….

Prof. Ndeso A. Sylvester (Dean)

 ACKNOWLEDGEMENTS

I will like to express my heartfelt gratitude to my supervisor Mr. Tasong George Njuzi, whose

professional, time and physical support were vital in the completion of this work. Special thanks

go to all staff of Saint Monica university Higher Institution of Buea, for their professionalism

and critics which have played a great deal to my present achievement. Especially my Head of

department Mrs. Agbor Catherine.

My Acknowledge is incomplete without mentioning my beloved parents Mr&Mrs. Ige olusola,

whom gives me all the fully support I needed in my academic carrier. I am glad to use this

medium to express my appreciations to Oladeji Olumide and my siblings for their support and

encouragement inspired me to work harder, especially my sisters Ige Tolulope Adenike and Ige

Ruth Aanuoluwa and my friends Adeniyi Adetutu peace and Ajayi Lateefat Oluwabukunmi, who

assisted me with prayers and financial support throughout period of my studies. To all my friends

and well-wisher, I appreciate your presence in my life.

Above all to almighty God the who guide and protect me throughout the period of my study.
 ABSTRACT

The purpose of this study is to evaluate the knowledge and attitude on the risk factors of

congenital malformations among pregnant women in RHB. This write up will study the

knowledge on the different causes of congenital malformations and the different cultural beliefs

on congenital malformations and the attitude about such beliefs and also on the risk factors

associated with congenital malformations. This study will elaborate on the different risk factors

and how it can be avoided based on relevant information about congenital malformation. A

descriptive research design will be utilized in this study and A Convenient sample of the

pregnant women registered for anti-natal care in Regional Hospital, Buea. (50) pregnant women

will be given questionnaire for this study for one month and it will be for those who were willing

to participate in the study.

 DEDICATION

I dedicate this research work to my parent (Mr. & Mrs. Ige Akintola Olusola).
 CHAPTER ONE

GENNNERAL INTRODUCTION

Introduction

Congenital malformations (CM) are structural, functional, and metabolic defects that develop

during the organogenesis period and present at birth or detected later in life (Nhoncanse GC,et.al

2014). According to Beck (2012) throughout most of human history, congenital anomalies were

perceived as omens, portents or punishment of supernatural origin in many early cultures. For

example, if a Woman gives birth and the Anus is closed the land will suffer famine. These

malformations are present in 3% of all newborns and responsible for nearly 7% of neonatal

deaths worldwide (Ahmed W, Dey D, Farid R.2017). Congenital malformations can be caused

by genetic, chromosomal, environmental, multifactorial effects, and micronutrient deficiencies or

unknown etiological agents (Li Z, Ren A, Zhang L, Guo Z, Li Z.2006). Achondroplasia and

other forms of dwarfism are portrayed as divinities in the act of ancient Egypt and Greece as well

as Pre-Hispanic cultures of central and South America (Dasen, 2013). Other explanation includes

witchcraft, astrological configurations or emotional experience of the pregnant mother.

Background of the Study

In the 18th century, superstitions still dominated public conception of malformations but this

topic was beginning to attract serious attention from the physicians and scientist. Toward the end

of the century, epigenesist finally achieved acceptance by the leading scientists opening the

doors to the investigation of normal and abnormal development. According to the Global Burden

of Disease (GBD) (2010) report, congenital anomalies accounted for 510,400 deaths worldwide
in 2010, 1% of all deaths (6% of neonatal and postnatal infant deaths) 2.5% of deaths 1-4 years.

Congenital anomalies ranked 14th among the causes of death (Boyle et al., 2018); an estimate of

7.9million children are born with a serious birth defect; many infants die worldwide within 4

weeks of birth and some die during delivery due to complications associated with birth defects.

Prevalence rate is more severe in middle- and low-income countries wherein 94% of serious

birth defects and 95% of deaths of these children occur (Bello et al., 2013).

Congenital anomalies have also been found to be among the top 20 leading cause of burden of

disease globally and a significant contributor to infant mortality with 11.3% of neonatal death

caused by congenital anomalies which may result in long term disabilities (Saus et al., 2017).

In Africa and Middle East, the prevalence ranged between 20 and 30/1000 live births in Uganda,

Saudi Atrabia, Pakistan and Kenya. In Egypt the prevalence was 65.3/1000 live births (Ali et al.,

2019) and in South Africa it was 1.49%.  Another study carried out in Nigeria teaching hospital

showed that, out of 1057 new born, 67 had congenital anomalies giving a percentage of 6.3%

(Akinlabi E. Ajao and Ikeola A. Adeoye 2019). Congenital malformations are common in

Cameroon. According to a research carried out in Yaounde, the prevalence was 9 per 1000

births. The most common types of malformations were (per 1.000 births) polydactyly 2.1;

clubfeet 1.1, Neural tube defects 1.4; Hydrocephalus 1.1; oro-facial clefts 0.9; and abdominal

parietal defects 0.7 (Charlotte, T.et al 2015). Also another research carried out in General

Hospital Douala, 6048 neonates were examine 99 of whom had a malformation giving a

prevalence of 1.64% and among them musculoskeletal defects were the most common (36.4%)

followed by digestive tract defect (22.2%) neural tube defect (11.1%) and polymalformation

among the malformed babies 33% died within the first 48 hours (Robinson EnowMbu, et al.,
2016) Children who survive suffer from long term disabilities and pose a negative impact on

economic and social status on the family.

Statement of the Problem

According to global burden of disease (2010) report, congenital malformations contribute to a

very high percentage of death and it calls for serious concern. The prevalence of this health

condition predisposes the children suffering from it to a lot of health challenges that makes their

stages of development to be complicated and makes them dependent on their family members for

care. The amount of care needed and the money needed to correct some of these malformations

are much and the specialists for these procedures are scarce and not easily available in our

hospitals in Cameroon which leads to the use of foreign experts to provide care. Most of these

conditions occurs due to the defects that occurs during pregnancy and they can also be prevented

if appropriate care is taken during the embryonic stage of development. Hence, the researcher

seeks to research on the knowledge, awareness and the risk factors of congenital malformation

among the women of the Regional Hospital, Buea.

General Research Objective

To assess the knowledge, awareness and risk factors of congenital malformation among the

pregnant women at the Regional Hospital, Buea.

Specific Research Objectives

 To assess pregnant women level of knowledge on congenital abnormalities

 To identify the risk factors of congenital abnormalities

  To assess on the prevention of congenital abnormalities

General Research Question

What is the level of knowledge, awareness and the risk factors of congenital abnormalities

among pregnant women of the Regional Hospital, Buea

Specific research questions

 What is the level of knowledge of pregnant women on congenital abnormalities?

 What are the risk factors of congenital abnormalities?

 What are ways of preventing congenital malformation?

Scope of the Study

This study will be focused on the knowledge, awareness and the risk factors of congenital

malformations in pregnant women in Regional Hospital, Buea.

Significant of the Study

The study will be useful in assessing the knowledge of pregnant women on congenital

abnormalities. It will enlighten women on the dangers that congenital malformation poses to the

unborn child and how it affects their future and the economic status of the family and the

community. It will enlighten the women on the risk factors that predisposes the unborn child to

future complication and how to prevent it.

Operational Definition of Terms

Congenital malformation: Congenital malformations (CM) are structural, functional, and

metabolic defects that develop during the organogenesis period and present at birth or detected

later in life (Nhoncanse GC,et.al 2014).

Knowledge: facts, information, and skills acquired through experience or education; the

theoretical or practical understanding of a subject.

Assessment: refers to the wide variety of methods or tools use to evaluate, measure and

document a particular subject.

Awareness: concern about and well informed interest in a particular situation or development.

Risk factors: it is something that increases the chances of someone developing a disease.

Birth defects: an often inherited medical condition that occurs at or before birth.

Summary of the Chapter

This chapter shows the brief introduction on the concept of congenital malformations and also it

talks about the different belief of the past about congenital malformation and also shows the new

scientific knowledge about congenital malformation. It also talks about the level of awareness of

pregnant women on the risk factors of congenital malformations.

 CHAPTER TWO

LITERATURE REVIEW

CONCEPTUAL FRAMEWORK

Concept of Knowledge on congenital malformation

The term "knowledge" can refer to a theoretical or practical understanding of a subject. It can be

implicit (as with practical skill or expertise) or explicit (as with the theoretical understanding of a

subject); formal or informal; systematic or particular (oxford dictionary, 2010). The philosopher

Plato argued that there was a distinction between knowledge and true belief in the Theaetetus,

leading many to attribute to him a definition of knowledge as "justified true belief" (Paul

Boghossian, 2007; Steup Matthias, Neta Ram, 2020)

Knowledge is the primary subject of the field of epistemology, which studies what we know,

how we come to know it, and what it means to know something (Steup Matthias, Neta Ram,

2020) Defining knowledge is an important aspect of epistemology, because it does not suffice to

have a belief; one must also have good reasons for that belief, because otherwise there would be

no reason to prefer one belief over another.

Concept of awareness on Congenital Malformation

Awareness is the state of being conscious of something. More specifically, it is the ability to

directly know and perceive, to feel, or to be cognizant of events. Another definition describes it
as a state wherein a subject is aware of some information when that information is directly

available to bring to bear in the direction of a wide range of behavioral actions (Chalmers David,

1997). The concept is often synonymous to consciousness and is also understood as being

consciousness itself (Hussain Amir, et al.,2009)

The states of awareness are also associated with the states of experience so that the structure

represented in awareness is mirrored in the structure of experience (Chalmers David, 1997).

Awareness is a relative concept. It may be focused on an internal state, such as a visceral feeling,

or on external events by way of sensory perception (Hussain Amir, et al.,2009). It is analogous to

sensing something, a process distinguished from observing and perceiving (which involves a

basic process of acquainting with the items we perceive) (Locke Don, 2002). Awareness or "to

sense" can be described as something that occurs when the brain is activated in certain ways,

such as when the color red is what is seen once the retina is stimulated by light waves (Locke

Don, 2002). This conceptualization is posited amid the difficulty in developing an analytic

definition of awareness or sensory awareness (Locke Don, 2002).

Awareness is also associated with consciousness in the sense that this concept denotes a

fundamental experience such as a feeling or intuition that accompanies the experience of

phenomena (Kokoszka Andrzej,2007). Specifically, this is referred to as awareness of experience.

As for consciousness, it has been postulated to undergo continuously changing levels (P.A.

Guertin, 2019).

Concept of Congenital Malformation

Congenital anomalies can be defined as structural or functional anomalies that occur during

intrauterine life, is a condition present at birth regardless of its cause (nichd,2017). Also called

birth defects, congenital disorders, or congenital malformations, these conditions develop

prenatally and may be identified before or at birth, or later in life. Congenital anomalies are one

of the main causes of the global burden of disease, and low- and middle-income countries are

disproportionately affected. Birth defects may result in disabilities that may be physical,

intellectual, or developmental (nichd,2017). The disabilities can range from mild to severe.

Additionally, some congenital birth defects disrupt pregnancies leading to stillbirths and

miscarriages, which is particularly devastating to parents who plan to start a family (Gregory,

MacDorman, & Martin, 2014; Stillbirth Collaborative Research Network Writing Group, 2011).

Every year around 8 million children are born with severe birth defects worldwide, which

constitutes roughly 6% of births (Christianson, Howson, & Modell, 2006). Birth defects are

divided into two main types: structural disorders in which problems are seen with the shape of a

body part and functional disorders in which problems exist with how a body part works.

Functional disorders include metabolic and degenerative disorders. Some birth defects include

both structural and functional disorders(nichd,2017).

Primarily Structural

Several terms are used to describe congenital abnormalities. (Some of these are also used to

describe non congenital conditions, and more than one term may apply in an individual

condition.)

Terminology
 A congenital physical anomaly is an abnormality of the structure of a body part. It may

or may not be perceived as a problem condition. Many, if not most, people have one or

more minor physical anomalies if examined carefully. Examples of minor anomalies can

include curvature of the fifth finger (clinodactyly), a third nipple, tiny indentations of the

skin near the ears (preauricular pits), shortness of the fourth metacarpal or metatarsal

bones, or dimples over the lower spine (sacral dimples). Some minor anomalies may be

clues to more significant internal abnormalities.

 Birth defect is a widely used term for a congenital malformation, i.e. a congenital,

physical anomaly that is recognizable at birth, and which is significant enough to be

considered a problem. According to the Centers for Disease Control and Prevention

(CDC), most birth defects are believed to be caused by a complex mix of factors

including genetics, environment, and behaviors (CDC,2015), though many birth defects

have no known cause. An example of a birth defect is cleft palate, which occurs during

the fourth through seventh weeks of gestation (CDC,2016). Body tissue and special cells

from each side of the head grow toward the center of the face. They join to make the face

(CDC,2016). A cleft means a split or separation; the "roof" of the mouth is called the

palate (American Academy of Otolaryngology,2016).

 A congenital malformation is a physical anomaly that is deleterious, i.e. a structural

defect perceived as a problem. A typical combination of malformations affecting more

than one body part is referred to as a malformation syndrome.

 Some conditions are due to abnormal tissue development:

o A malformation is associated with a disorder of tissue development.

Malformations often occur in the first trimester.

 o A dysplasia is a disorder at the organ level that is due to problems with tissue

development.

 Conditions also can arise after tissue is formed:

o A deformation is a condition arising from mechanical stress to normal tissue.

Deformations often occur in the second or third trimester, and can be due to

oligohydramnios.

o A disruption involves breakdown of normal tissues (Graham John

Whichello,2007).

 When multiple effects occur in a specified order, they are known as a sequence. When

the order is not known, it is a syndrome.

Primarily Metabolic

A congenital metabolic disease is also referred to as an inborn error of metabolism. Inborn errors

of metabolism are rare genetic disorders in which the body cannot properly turn food into

energy. The disorders are usually caused by defects in specific proteins(enzymes) that help break

down parts of food. A food product that is not broken down into energy can build up in the body

and cause a wide range of symptoms. Several inborn errors of metabolism cause developmental

delays or other medical problems if they are not controlled. There are many different types of

inborn errors of metabolism like; fructose intolerance, galactosemia, maple sugar urine disease,

phenylketouria.

Risk factors of congenital malformation

1. Alcohol Exposure
The mother's consumption of alcohol during pregnancy can cause a continuum of various

permanent birth defects: craniofacial abnormalities (Jones K, Smith D, 1975) brain damage

(Clarren S, Alvord E, Sumi S, Streissguth A, Smith D,1978), intellectual disability (Abel EL,

Sokol RJ, 1986), heart disease, kidney abnormality, skeletal anomalies, ocular abnormalities

(Strömland K, Pinazo-Durán M, 2002)

The prevalence of children affected is estimated at least 1% in U.S (May PA., Gossage JP.,2001)

as well in Canada.

However, recent animal research has shown a correlation between paternal alcohol exposure and

decreased offspring birth weight. Behavioral and cognitive disorders, including difficulties with

learning and memory, hyperactivity, and lowered stress tolerance have been linked to paternal

alcohol ingestion. The compromised stress management skills of animals whose male parent was

exposed to alcohol are similar to the exaggerated responses to stress that children with fetal

alcohol syndrome display because of maternal alcohol use. These birth defects and behavioral

disorders were found in cases of both long- and short-term paternal alcohol ingestion (Trasler

Jacquetta M., Doerksen Tonia,1999; Abel E. L.,2004). In the same animal study, paternal alcohol

exposure was correlated with a significant difference in organ size and the increased risk of the

offspring displaying ventricular septal defects at birth (Abel E. L.,2004).

2. Toxic Substances

Substances whose toxicity can cause congenital disorders are called teratogens, and include

certain pharmaceutical and recreational drugs in pregnancy, as well as many environmental

toxins in pregnancy (Alliance Genetic,2010)

A review published in 2010 identified six main teratogenic mechanisms associated with

medication use: folate antagonism, neural crest cell disruption, endocrine disruption, oxidative

stress, vascular disruption, and specific receptor- or enzyme-mediated teratogenesis (van Gelder

MM et.al.,2010)

An estimated 10% of all birth defects are caused by prenatal exposure to a teratogenic agent

(Ronan O'Rahilly, Fabiola Müller,2001). These exposures include medication or drug exposures,

maternal infections and diseases, and environmental and occupational exposures. Paternal

smoking has also been linked to an increased risk of birth defects and childhood cancer for the

offspring, where the paternal germline undergoes oxidative damage due to cigarette use (Zhu J.

L et.al.,2005; Ji B.T. et. al.,1997). Teratogen-caused birth defects are potentially preventable.

Nearly 50% of pregnant women have been exposed to at least one medication during gestation

(Bracken MB, Holford TR, Holford,1981). During pregnancy, a woman can also be exposed to

teratogens from contaminated clothing or toxins within the seminal fluid of a partner (Anderson

Diana, et al., 2014; Chia S-E, Shi L. M.,2002). An additional study found that of 200 individuals

referred for genetic counseling for a teratogenic exposure, 52% were exposed to more than one

potential teratogen (King CR,1986).

3. Medications and Supplements

Probably, the most well-known teratogenic drug is thalidomide. It was developed near the end of

the 1950s by Chemie Grünenthal as a sleep-inducing aid and antiemetic. Because of its ability to

prevent nausea, it was prescribed for pregnant women in almost 50 countries worldwide between

1956 and 1962 (Novotná Miroslav, Peterka Božena.2010). Until William McBride published the

study leading to its withdrawal from the market in 1961, about 8,000 to 10,000 severely
malformed children were born. The most typical disorders induced by thalidomide were

reductional deformities of the long bones of the extremities. Phocomelia, otherwise a rare

deformity, therefore helped to recognise the teratogenic effect of the new drug. Among other

malformations caused by thalidomide were those of ears, eyes, brain, kidney, heart, and digestive

and respiratory tracts; 40% of the prenatally affected children died soon after birth (Novotná

Miroslav, Peterka Božena.2010). As thalidomide is used today as a treatment for multiple

myeloma and leprosy, several births of affected children were described in spite of the strictly

required use of contraception among female patients treated by it.

Vitamin A is the sole vitamin that is embryotoxic even in a therapeutic dose, for example in

multivitamins, because its metabolite, retinoic acid, plays an important role as a signal molecule

in the development of several tissues and organs. Its natural precursor, β-carotene, is considered

safe, whereas the consumption of animal liver can lead to malformation, as the liver stores

lipophilic vitamins, including retinol (Novotná Miroslav, Peterka Božena.2010). Isotretinoin (13-

cis-retinoic-acid; brand name Roaccutane), vitamin A analog, which is often used to treat severe

acne, is such a strong teratogen that just a single dose taken by a pregnant woman (even

transdermally) may result in serious birth defects. Because of this effect, most countries have

systems in place to ensure that it is not given to pregnant women and that the patient is aware of

how important it is to prevent pregnancy during and at least one month after treatment. Medical

guidelines also suggest that pregnant women should limit vitamin A intake to about 700 μg/day,

as it has teratogenic potential when consumed in excess (Hunt JR, 1996; Hartmann S, Brørs O,

Bock J, et al.,2005). Vitamin A and similar substances can induce spontaneous abortions,

premature births, defects of eyes (microphthalmia), ears, thymus, face deformities, and
neurological (hydrocephalus, microcephalia) and cardiovascular defects, as well as intellectual

disability (Novotná Miroslav, Peterka Božena.2010).

Tetracycline, an antibiotic, should never be prescribed to women of reproductive age or to

children, because of its negative impact on bone mineralization and teeth mineralization. The

"tetracycline teeth" have brown or grey colour as a result of a defective development of both the

dentine and the enamel of teeth (Novotná Miroslav, Peterka Božena.2010).

4. Toxic Substances

Drinking water is often a medium through which harmful toxins travel. Heavy metals, elements,

nitrates, nitrites, and fluoride can be carried through water and cause congenital disorders.

Nitrate, which is found mostly in drinking water from ground sources, is a powerful teratogen. A

case-control study in rural Australia that was conducted following frequent reports of prenatal

mortality and congenital malformations found that those who drank the nitrate-containing

groundwater, as opposed to rain water, ran the risk of giving birth to children with central

nervous system disorders, muscoskeletal defects, and cardiac defects (Croen Lisa, Todoroff

Karen. Shaw Gary,2001).

Chlorinated and aromatic solvents such as benzene and trichloroethylene sometimes enter the

water supply due to oversights in waste disposal. A case-control study on the area found that by

1986, leukemia was occurring in the children of Woburn, Massachusetts, at a rate that was four

times the expected rate of incidence. Further investigation revealed a connection between the

high occurrence of leukemia and an error in water distribution that delivered water to the town

with significant contamination with manufacturing waste containing trichloroethylene (Costas

K., Knorr R.S., Condon S.K.,2002). As an endocrine disruptor, DDT was shown to induce

miscarriages, interfere with the development of the female reproductive system, cause the

congenital hypothyroidism, and suspectably childhood obesity (Novotná Miroslav, Peterka

Božena.2010).

Fluoride, when transmitted through water at high levels, can also act as a teratogen. Two reports

on fluoride exposure from China, which were controlled to account for the education level of

parents, found that children born to parents who were exposed to 4.12 ppm fluoride grew to have

IQs that were, on average, seven points lower than their counterparts whose parents consumed

water that contained 0.91 ppm fluoride. In studies conducted on rats, higher fluoride in drinking

water led to increased acetylcholinesterase levels, which can alter prenatal brain development.

The most significant effects were noted at a level of 5 ppm (Cite journal,2000).

5. Smoking

Paternal smoking prior to conception has been linked with the increased risk of congenital

abnormalities in offspring (De Santis Marco, et al.,2008).

Smoking causes DNA mutations in the germline of the father, which can be inherited by the

offspring. Cigarette smoke acts as a chemical mutagen on germ cell DNA. The germ cells suffer

oxidative damage, and the effects can be seen in altered mRNA production, infertility issues, and

side effects in the embryonic and fetal stages of development. This oxidative damage may result

in epigenetic or genetic modifications of the father's germline. Fetal lymphocytes have been

damaged as a result of a father's smoking habits prior to conception (Ji B.T. et. al.,1997;

Anderson Diana, et al., 2014).

Correlations between paternal smoking and the increased risk of offspring developing childhood

cancers (including acute leukemia, brain tumors, and lymphoma) before age five have been

established. Little is currently known about how paternal smoking damages the fetus, and what

window of time in which the father smokes is most harmful to offspring (Ji B.T. et. al.,1997).

6. Infections

A vertically transmitted infection is an infection caused by bacteria, viruses, or in rare cases,

parasites transmitted directly from the mother to an embryo, fetus, or baby during pregnancy or

childbirth.

Congenital disorders were initially believed to be the result of only hereditary factors. However,

in the early 1940s, Australian pediatric ophthalmologist Norman Gregg began recognizing a

pattern in which the infants arriving at his surgery were developing congenital cataracts at a

higher rate than those who developed it from hereditary factors. On October 15, 1941, Gregg

delivered a paper that explained his findings-68 out of the 78 children with congenital cataracts

had been exposed in utero to rubella due to an outbreak in Australian army camps. These

findings confirmed, to Gregg, that, in fact, environmental causes for congenital disorders could

exist.

Rubella is known to cause abnormalities of the eye, internal ear, heart, and sometimes the teeth.

More specifically, fetal exposure to rubella during weeks five to ten of development (the sixth

week particularly) can cause cataracts and microphthalmia in the eyes. If the mother is infected

with rubella during the ninth week, a crucial week for internal ear development, destruction of

the organ of Corti can occur, causing deafness. In the heart, the ductus arteriosus can remain
after birth, leading to hypertension. Rubella can also lead to atrial and ventricular septal defects

in the heart. If exposed to rubella in the second trimester, the fetus can develop central nervous

system malformations. However, because infections of rubella may remain undetected,

misdiagnosed, or unrecognized in the mother, and/or some abnormalities are not evident until

later in the child's life, precise incidence of birth defects due to rubella are not entirely known.

The timing of the mother's infection during fetal development determines the risk and type of

birth defect. As the embryo develops, the risk of abnormalities decreases. If exposed to the

rubella virus during the first four weeks, the risk of malformations is 47%. Exposure during

weeks five through eight creates a 22% chance, while weeks 9–12, a 7% chance exists, followed

by 6% if the exposure is during the 13th-16th weeks. Exposure during the first eight weeks of

development can also lead to premature birth and fetal death. These numbers are calculated from

immediate inspection of the infant after birth. Therefore, mental defects are not accounted for in

the percentages because they are not evident until later in the child's life. If they were to be

included, these numbers would be much higher (Sadler T.W.,1985)

Other infectious agents include cytomegalovirus, the herpes simplex virus, hyperthermia,

toxoplasmosis, and syphilis. Maternal exposure to cytomegalovirus can cause microcephaly,

cerebral calcifications, blindness, chorioretinitis (which can cause blindness),

hepatosplenomegaly, and meningoencephalitis in fetuses (Sadler T.W.,1985). Microcephaly is a

disorder in which the fetus has an atypically small head (Mayo Clinic,2014), cerebral

calcifications means certain areas of the brain have atypical calcium deposits

(MedicineNet,2014) and meningoencephalitis is the enlargement of the brain. All three disorders

cause abnormal brain function or mental retardation. Hepatosplenomegaly is the enlargement of

the liver and spleen which causes digestive problems (RSS,2011). It can also cause some
kernicterus and petechiae. Kernicterus causes yellow pigmentation of the skin, brain damage,

and deafness (Medical Encyclopedia,2014). Petechaie is when the capillaries bleed resulting in

red/purple spots on the skin (Mayo Clinic,2014). However, cytomegalovirus is often fatal in the

embryo. The Zika virus can also be transmitted from the pregnant mother to her baby and cause

microcephaly.

The herpes simplex virus can cause microcephaly, microphthalmus (abnormally small eyeballs)

(Texas School for the Blind and Visually Impaired, 2014), retinal dysplasia, hepatosplenomegaly,

and mental retardation. Both microphthalmus and retinal dysplasia can cause blindness.

However, the most common symptom in infants is an inflammatory response that develops

during the first three weeks of life. Hyperthermia causes anencephaly, which is when part of the

brain and skull are absent in the infant (Centers for Disease Control and Prevention,2014).

Mother exposure to toxoplasmosis can cause cerebral calcification, hydrocephalus (causes

mental disabilities) (Mayo Clinic,2014) and mental retardation in infants. Other birth

abnormalities have been reported as well, such as chorioretinitis, microphthalmus, and ocular

defects. Syphilis causes congenital deafness, mental retardation, and diffuse fibrosis in organs,

such as the liver and lungs, if the embryo is exposed.

7. Lack of Nutrients

For example, a lack of folic acid, a B vitamin, in the diet of a mother can cause cellular neural

tube deformities that result in spina bifida. Congenital disorders such as a neural tube deformity

can be prevented by 72% if the mother consumes 4 mg of folic acid before the conception and

after 12 weeks of pregnancy. Folic acid, or vitamin B 9, aids the development of the fetal nervous

system (Raats Monique, 1998).

Studies with mice have found that food deprivation of the male mouse prior to conception leads

to the offspring displaying significantly lower blood glucose levels (Anderson Lucy M.,2006)

8. Physical Restraint

External physical shocks or constraints due to growth in a restricted space may result in

unintended deformation or separation of cellular structures resulting in an abnormal final shape

or damaged structures unable to function as expected. An example is Potter syndrome due to

oligohydramnios. This finding is important for future understanding of how genetics may

predispose individuals for diseases such as obesity, diabetes, and cancer.

For multicellular organisms that develop in a womb, the physical interference or presence of

other similarly developing organisms such as twins can result in the two cellular masses being

integrated into a larger whole, with the combined cells attempting to continue to develop in a

manner that satisfies the intended growth patterns of both cell masses. The two cellular masses

can compete with each other, and may either duplicate or merge various structures. This results

in conditions such as conjoined twins, and the resulting merged organism may die at birth when

it must leave the life-sustaining environment of the womb and must attempt to sustain its

biological processes independently.

9. Genetics

Genetic causes of birth defects include inheritance of abnormal genes from the mother or the

father, as well as new mutations in one of the germ cells that gave rise to the fetus. Male germ

cells mutate at a much faster rate than female germ cells, and as the father ages, the DNA of the

germ cells mutates quickly (Sartorius G. A., Nieschlag E., 2009). If an egg is fertilized with perm
that has damaged DNA, a possibility exists that the fetus could develop abnormally (Savitz

David A.,1991).

Genetic disorders are all congenital (present at birth), though they may not be expressed or

recognized until later in life. Genetic disorders may be grouped into single-gene defects,

multiple-gene disorders, or chromosomal defects. Single-gene defects may arise from

abnormalities of both copies of an autosomal gene (a recessive disorder) or of only one of the

two copies (a dominant disorder). Some conditions result from deletions or abnormalities of a

few genes located contiguously on a chromosome. Chromosomal disorders involve the loss or

duplication of larger portions of a chromosome (or an entire chromosome) containing hundreds

of genes. Large chromosomal abnormalities always produce effects on many different body parts

and organ systems.

10. Radiation

For the survivors of the atomic bombing of Hiroshima and Nagasaki, who are known as the

Hibakusha, no statistically demonstrable increase of birth defects/congenital malformations was

found among their later conceived children, or found in the later conceived children of cancer

survivors who had previously received radiotherapy (WHO,2013) The surviving women of

Hiroshima and Nagasaki who were able to conceive, though exposed to substantial amounts of

radiation, later had children with no higher incidence of abnormalities/birth defects than in the

Japanese population as a whole (Voosen Paul, 2011).

Relatively few studies have researched the effects of paternal radiation exposure on offspring.

Following the Chernobyl disaster, it was assumed in the 1990s that the germ line of irradiated
fathers suffered minisatellite mutations in the DNA, which was inherited by descendants

(Dubrova Yuri E.et al.,1996). More recently, however, the World Health Organization states,

"children conceived before or after their father's exposure showed no statistically significant

differences in mutation frequencies"(Bennett Burton, Repacholi Michael, Carr Zhanat, eds.

2006). This statistically insignificant increase was also seen by independent researchers

analyzing the children of the liquidators (Furitsu Katsumi,2005). Animal studies have shown that

incomparably massive doses of X-ray irradiation of male mice resulted in birth defects of the

offspring.

11. Parent's Age

Certain birth complications can occur more often in advanced maternal age (greater than 35

years). Complications include fetal growth restriction, preeclampsia, placental abruption, pre-

mature births, and stillbirth. These complications not only may put the child at risk, but also the

mother (Lean Samantha C.et al.,2017)

The effects of the father's age on offspring are not yet well understood and are studied far less

extensively than the effects of the mother's age (Olshan Andrew F.et al.,1994). Fathers

contribute proportionally more DNA mutations to their offspring via their germ cells than the

mother, with the paternal age governing how many mutations are passed on. This is because, as

humans age, male germ cells acquire mutations at a much faster rate than female germ cells.

Around a 5% increase in the incidence of ventricular septal defects, atrial septal defects, and

patent ductus arteriosus in offspring has been found to be correlated with advanced paternal age.

Advanced paternal age has also been linked to increased risk of achondroplasia and Apert
syndrome. Offspring born to fathers under the age of 20 show increased risk of being affected by

patent ductus arteriosus, ventricular septal defects, and the tetralogy of Fallot. It is hypothesized

that this may be due to environmental exposures or lifestyle choices (Olshan Andrew F.et

al.,1994).

Research has found that there is a correlation between advanced paternal age and risk of birth

defects such as limb anomalies, syndromes involving multiple systems, and Down syndrome

(Yang Q.,2006).

Preventive measures for congenital malformation

Preventive public health measures work to decrease the frequency of certain birth defects

through the removal of risk factors or the reinforcement of protective factors. Important

interventions and efforts include:

 Ensuring adolescent girls and mothers have a healthy diet including a wide variety of

vegetables and fruit, and maintain a healthy weight;

 Ensuring an adequate dietary intake of vitamins and minerals, particularly folic acid in

adolescent girls and mothers;

 Ensuring mothers avoid harmful substances, particularly alcohol and tobacco;

 Avoidance of travel by pregnant women (and sometimes women of child-bearing age) to

regions experiencing outbreaks of infections known to be associated with birth defects;

 Reducing or eliminating environmental exposure to hazardous substances (such as heavy

metals or pesticides) during pregnancy;

  Controlling diabetes prior to and during pregnancy through counselling, weight

management, diet and administration of insulin when required;

 Ensuring that any exposure of pregnant women to medications or medical radiation (such

as imaging rays) is justified and based on careful health risk–benefit analysis;

 Vaccination, especially against the rubella virus, for children and women;

 Increasing and strengthening education of health staff and others involved in promoting

prevention of congenital anomalies; and

 Screening for infections, especially rubella, varicella and syphilis, and consideration of

treatment.

Theoretical review

According to the work of Davis, Streeter, and Kramer as well as on the study of pathologic

specimens from the Instituto Nacional de Cardiologia of Mexico, and from medical literature,

the theory, ontogenetic theory was proposed to explained congenital truncoconal malformations.

The ontogentic theory considers truncoconal congenital malformations as a consequence of

developmental alterations ridges, and the primordia of the aortic and pulmonary cusps. Old

concepts are reevaluated and new ones are established in relation to lateral positions,

transposition, unequal partitioning at the expense of the aorta or pulmonary artery, common

truncus and valvular defects. Anatomic and embryologic correlations are made in order to permit

the pathologic diagnosis of these malformations. The different pictures of isolated and combined

truncoconal malformations (which actually exist or may theoretically exist according to the

proposed theory) are described.

APPLICATION OF THE THEORY TO THE STUDY

Truncoconal theory explain the close proximity between the truncal ridges and the origins of the

pulmonary arches. If one ridge should arise from a more dorsal position than is normal, the sixth

arch on that side would be incorporated in the anterior vessel resulting from the division of the

truncus (aorta). Only one lateral pulmonary artery would then arise from the posterior vessel

(pulmonary trunk). The absence of a primary division of the pulmonary trunk is thus due to

defective septation of the truncus and not to a developmental error of the sixth arch. The truncal

ridges arise from two diametrically opposite regions on a plane oblique to the sagittal, the left

ridge being more ventral than the right. Therefore. the degree of shifting required for the left

ridge to arise dorsally to the origin of the left sixth arch is greater than that required for the

opposite ridge to bypass the right sixth arch.

Normal Heart, Left Aortic Arch, and Absent Right Division

According to the theory just outlined, this anomaly results from dorsal shifting of the right

truncal ridge: the right sixth arch is then incorporated into the newly formed ascending aorta. The

pulmonary trunk gives rise solely to the left pulmonary artery. If the dorsorotation of the right

ridge affects only the most cephalad portion of the truncus, no additional cardiovascular

anomalies will occur. Essentially normal hemodynamic still result in a predominance of the left

dorsal aorta and, consequently, in a left-sided aortic arch.

The destiny of the right sixth arch is de pendent on hemodynamic and mechanical factors. With

the resorption of the right dorsal aorta, the right fourth arch (innominate artery) acquires

cephalad orientation. The right sixth arch is then pulled in three different directions: cephalad

from the innominate, caudally from the right lung, and medially from the ascending aorta.

Depending on the direction of the resulting force, the primitive pulmonary artery aligns either
with the proximal or with the distal segment of the arch. In the first case, The distal segment,

under unfavourable mechanical and hemodynamic influences, would atrophy and the right

pulmonary artery would then depart from the ascending aorta. In the second event the anomalous

right pulmonary artery would arise from the innominate.

Fallot, Right Aortic Arch, and Absent Left Division

This complicated anatomic picture results from dorsorotation of the left truncoconal ridge. The

incorporation of the left sixth arch into the ascending aorta requires a degree of dorsorotation so

pronounced as to cause hypoplasia of the pulmonary trunk and of the right ventricular outflow

tract. The truncoconal and the muscular ventricular septa lying on different planes cannot fuse

and a ventricular defect, overridden by a large aorta, ensues. Cephalad, the abnormally cloven

ascending aorta is slanted to the right and thus imparts to the blood column a rightward swing.

Blood then flows preferentially into the right fourth arch and the right dorsal aorta. The left

dorsal aorta, receiving less of this blood and none from the pulmonary trunk, involutes.

Consequently, the fourth arch on the left becomes the innominate artery and on the right persists

as the definitive aortic arch. The aberrant left pulmonary artery will arise either from the

ascending aorta or from the left innominate, depending on whether the primitive pulmonary

vessel aligns with the proximal or the distal segment of the sixth arch.

Aberrant (Systemic) Pulmonary Artery

The present theory postulates the existence of both lateral pulmonary arteries, but while one

originates normally from the pulmonary trunk, the other is aberrant in that it from a systemic

vessel. The term "absence of a pulmonary artery" is thus inappropriate, and it would perhaps be
preferable to describe the syndrome morphologically as "absence of a primary division of the

pulmonary trunk."

Although some of the more recent reports have included a description of the aberrant vessel, in

many cases this has neither been visualized by angiocardiography nor demonstrated at autopsy.

Wagenvoort et al. have noted that the initial portion of the "systemic" pulmonary artery contains

ductal tissue with an inherent tendency to obliterate postnatally by a process of endothelial

proliferation. Depending on the extent of this process, which apparently does not always occur,

the terminal portion of the vessel (primitive pulmonary artery) is under less hemodynamic

stimulus or none at all, and thus either remains hypoplastic or atrophies. This might be the reason

why angiography so often fails to visualize the aberrant pulmonary artery which, at times, cannot

be recognized at the autopsy either. This might also explain the very large collateral circulation

to the "affected" lung in cases in which the aberrant pulmonary artery is hypoplastic or atrophic.

Ellis and associates 16 demonstrated in rats that ligation of one pulmonary artery causes a

striking enlargement of the bronchial arteries on the same side, and Liebow et al. have shown

that the establishment of a pulmonary collateral circulation occurs more rapidly the younger the

subject is at the time the pulmonary arterial flow is impaired. As has been discussed in detail, the

"systemic" pulmonary artery may originate either from the ascending aorta or from the

innominate. The actual site of origin depends on the interplay of forces responsible for aligning

the primitive pulmonary artery either with the proximal or with the distal portion of the sixth

arch.

Empirical Review
There are lots of literature that have been written in relation to this study but all cannot be

reviewed in this study. Therefore, some studies have been reviewed in relation to this work.

Congenital anomalies or birth defects are structural or functional anomalies, including metabolic

disorders, which are present at the time of birth. Some of the congenital anomalies may be life

threatening, may impair function or interfere with the cosmetic value of an individual, hence an

immediate management is required. The long-term disability caused by congenital anomalies

may have a significant impact not only on a child’s well-being and development, but also on

families, health care systems and societies. The impact of congenital anomalies is severe in

middle- and low-income countries. As a matter of fact, it is estimated that approximately 95% of

the children who die from birth defects are from those countries this can be seen in the work of

Florence mashuda (2014) where the data showed that among 445 young infants enrolled in the

study, the prevalence of congenital anomalies was 29%, with the Central Nervous System (CNS)

as the most commonly affected organ system. Maternal factors that were significantly associated

with congenital anomalies included the lack of peri-conceptional use of folic acid (OR = 3.1;

95% CI = 1.4-6.7; p = 0.005), a maternal age of above 35 years (OR = 2.2; 95% CI = 1.1-4.3; p = 

0.024) and an inadequate attendance to antenatal clinic (OR = 2.1; 95% CI = 1.4-3.3; p < 0.001).

Infant factors that were significantly associated with congenital anomalies were female sex, a

birth weight of 2.5 kg or more, singleton pregnancy and a birth order above 4. The study

concluded that Due to the high prevalence of congenital anomalies observed in this particular

context, the hospital should mobilize additional resources for an optimal and timely management

of the patients with congenital anomalies. In this study, the proportion of women taking folic

acid supplements during early pregnancy was very low. Efforts should be made to ensure that

more women use folic acid during the peri-conceptional period, as the use of folic acid
supplement has been linked by several authors to a reduced occurrence of some congenital

anomalies.

This is similar to Data that were collected using a structured questionnaire by Sozan with 35,803

recorded births in the Maternity Teaching Hospital, Erbil, 130 women delivered babies with at

least one congenital anomaly, giving a rate of 3.63/1000 deliveries. The most common area for

anomalies was the central nervous system (37.7%) followed by the musculoskeletal (23.1%) and

gastrointestinal systems (20.8%). And it concluded that Anomalies were most likely to be in the

central nervous system. Maternal history of previous congenital anomalies, parental

consanguinity, and history of medical disorders were the most important factors associated with

congenital anomalies. This study provides baseline information for future prevention and better

management of patients likely to have babies with congenital anomalies. More research is

required to identify the factors responsible for the different types of congenital anomalies.

Human embryo is well protected in the uterus by the embryonic membrane, although teratogens

may cause developmental disruptions after maternal exposure to them during early pregnancy.

Most of the risk factors contributing to the development of congenital anomalies are uncertain;

however, genetic factors, environmental factors and multifactorial inheritance are found to be

risk factors. Regardless of their clinical importance, there are little/no studies conducted directly

related to predisposing risk factors in southwestern Ethiopia.

Risk factors such as unidentified medicinal usage in the first three months of pregnancy (AOR =

3.435; 99% CI: 2.012–5.863), exposure to pesticide (AOR = 3.926; 99% CI: 1.266–12.176),

passive smoking (AOR = 4.104; 99% CI: 1.892–8.901), surface water as sources of drinking
(AOR = 2.073; 99% CI: 1.221–3.519), folic acid supplementation during the early pregnancy

(AOR = 0.428; 99% CI: 0.247–0.740) were significantly associated with the congenital

anomalies.

Conclusions

In this study, risk factors such as passive smoking, exposure to pesticides, chemicals and use of

surface water as a source of drinking during early pregnancy had a significant association with

congenital anomalies. There is a need to continuously provide health information for the

community on how to prevent and control predisposing risk factors

Results The birth prevalence of CAs was 412/10 000 births (95% CI 388.6 to 434.9), driven

mainly by congenital heart disease (148 per 10 000) (95% CI 134 to 162), renal malformations

(113, 95% CI 110 to 125), neural tube defects (19, 95% CI 25.3 to 38.3) and chromosomal

anomalies (27, 95% CI 21 to 33). In this study, the burden of potentially modifiable risk factors

included high rates of diabetes (7.3%, OR 1.98, 95% CI 1.04 to 2.12), maternal age >40 years

(7.0%, OR 2.1, 95% CI 1.35 to 3.3), consanguinity (54.5%, OR 1.5, 95% CI 1.28 to 1.81). The

mortality for live births with CAs at 2 years of age was 15.8%.

Conclusions This study documented specific opportunities to improve primary prevention and

care. Specifically, folic acid fortification (the neural tube defect prevalence was >3 times that

theoretically achievable by optimal fortification), preconception diabetes screening and

consanguinity-related counselling could have significant and broad health benefits in this cohort

and arguably in the larger Saudi population.

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Summary of the Chapter

Congenital malformations is one of the main causes of physical disabilities, stillbirths, and

neonatal deaths. The exact etiology of most congenital malformations is unidentified but genetic

and environmental causes which include; teratogens, toxic substances, alcohol, smoking, parent’s

age, physical restraint, lack of nutrients, infection etc. These factors contribute to different body

parts malformation during the embryonic stage of the fetus and this effects is possible because,

these substances can pass through the placenta barrier and affect the baby in utero causing

deformities like cleft palate, spinal bifida, down syndrome etc. These events can be prevented

when there is adequate information on congenital malformation risk factor and if they are

avoided.
CHAPTER THREE

METHODOLOGY

3.1. STUDY AREA AND SETTING

The Regional Hospital Buea is found in Buea in the Fako Division of the South West Cameroon

on the foot of the mount Cameroon

It is about 2km away from the mile 17 motor park. It is situated precisely between the

delegations of education and the army barracks, along the highway to the Bokwango

neighbourhood.

The hospital is made up of many units/departments/centres including the following unit (male

and female), the surgical unit, the paediatrics unit, the maternity unit, the Laboratory unit, the X-

ray unit, the haemodialysis centre, the Tuberculosis centre, the theatre department and the

Outpatient department (OPD).

Each of the Unit/Department/Centre is headed by a specialist doctor (Surgeons, Gynaecologists,

Paediatrician). But control of the wards is done by the ward charges like senior midwives

Also present in the hospital are nurses of all categories ranging from Nursing assistant (NAS)

State Registered Nurses (SRN). Higher National Diploma Nurses (HND), Degree (BNS) and

even master degree holder Nurses (MNE).

3.2. RESEARCH DESIGN AND DURATION

This study followed a descriptive research design and was carried out from May 2022 to October

2022.

3.3. STUDY POPULATION AND SAMPLING

The target population were patients undergoing anti natal care in Regional hospital in Buea in

which 30 participants was chosen by convenient sampling.

3.4. INCLUSION/EXCLUSION CRITERIA

The inclusion criteria are patients that are undergoing anti natal care in Regional hospital Buea.

The exclusion criteria are patients not receiving anti natal care in Regional hospital Buea.

3.5. ETHICAL CONSIDERATIONS

An authorization letter was collected from the administration of St monica university higher

institute and attached to it will be a hand written application to the Southwest regional delegation

of public health. After which the letter of permission will be taken to the Director of Regional

Hospital Buea, who hopefully grant a letter of permission to carry out research. This

authorization letter will be attached to another written application to the ward charges.

3.6. DATA COLLECTION AND TECHNIQUES

The study was carried out during working hours after an authorization letter has been gotten

during the study for any participants’ chosen. The purpose of the study with the explained Data

was collected with the use of structured questionnaire and it was formulated into open and close

ended questions. The questionnaire was based on the information from the literature review and
the stated objectives. It consists of 4 sections in which section A will be the demographic data of

the respondents, section B will be to assess the knowledge of pregnant women on congenital

malformations, section C will be to assess the awareness of pregnant women on congenital

malformation, section D will be on the assessment of pregnant women on the risk factors of

congenital malformations. After answering, questionnaire was well coded to maintain the

participant's confidentiality.

3.7.DATA ANALYSIS

After the collection of data through the use of questionnaire, the responses of the participants

will be analysed manually using stationaries like papers, pen, pencils, calculator and ruler, then

the findings will be presented using frequency tables.

Dear respondent,

Good day, I, IGE BLESSING IYANUOLUWA, an undergraduate of the department of

Nursing, at Saint Monica University Higher Institute, Buea is undertaking a research on
the topic “CONGENITAL MALFORMATION: KNOWLEDGE, AWARENESS AND
RISK FACTORS AMONG WOMEN AT THE REGIONAL HOSPITAL BUEA”.
I appreciate your involuntary participation.
This questionnaire will be treated with absolute confidentiality.

SECTION A

SOCIO-DEMOGRAPHIC DATA

Please tick the most appropriate response.

1 AGE: 2. LEVEL OF EDUCATION 3. MARITAL

STATUS

< 20 years primary level SINGLE

20-30 YEARS. O’ level MARRIED

31-40 years. Advanced level

41 and above University level

4. OCCUPATION 5. RESIDENCE:

STUDENT RURAL

CIVIL SERVANT URBAN

SELF EMPLOYED
 SECTION B

The following questions are to assess the knowledge of pregnant women on congenital
malformation. Indicate your agreement or disagreement by ticking your answers in the
appropriate space:

1. What are congenital abnormalities?

a. Congenital abnormalities are diseases of the genitals
b. Congenital abnormalities are abnormalities that occurs to a baby during pregnancy and
affects the structure and functional capacity of the unborn child
c. Congenital abnormalities are from the anger of the gods
d. Congenital abnormalities are abnormalities of congestion
2. Can congenital malformation be prevented?
YES [ ] NO [ ]
3. Is congenital malformation hereditary?
YES [ ] NO[ ]
4. Can it be caused by witchcraft?
YES [ ] NO[ ]
5. Can congenital malformation be the result of the mother’s punishment from the gods?
YES [ ] NO[ ]
6. Does congenital malformation affects the mother?

YES [ ] NO[ ]
SECTION C

The following questions talks about the risk factors of congenital malformations. Indicate
your agreement or disagreement by ticking your response in the appropriate space:
 7. Does the mother’s age predispose the unborn child to congenital malformation?

YES [ ] NO [ ]
8. Does alcohol consumption predispose an unborn child to congenital malformation?

YES [ ] NO [ ]
9. Does use of over the counter drugs without prescription predispose the child to congenital
malformation?

YES [ ] NO [ ]
10. Does exposure to solvents and chemicals have any effect on the unborn?

YES [ ] NO [ ]
11. Does cigarette smoking have an effect on the unborn child?

YES [ ] NO [ ]
12. Does infection caused by bacteria & viruses predispose an unborn child to congenital
malformation?

YES [ ] NO [ ]
The following questions talks about the prevention methods of congenital malformations.
Indicate your agreement or disagreement by ticking your response in the appropriate space:
13. Do you attend ANC as regularly as possible?

YES [ ] NO [ ]
14. Is the usage of folic acid important to the development of the fetus during pregnancy?

YES [ ] NO [ ]
15. Is it Important to follow the medical advice given in the hospital during pregnancy?

YES [ ] NO [ ]
16. Is it good to stop drinking alcohol during pregnancy for the maximum health of the
unborn child?
YES [ ] NO [ ]