Pattern of Congenital Malformations at Birth and Their Associated Maternal Characteristics

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Introduction
Congenital abnormalities are genetic and/or developmental problems that occur during embryonic development.Congenital anomalies, congenital abnormalities, and birth flaws are all synonyms for structural, behavioral, functional, and metabolic diseases.They are evident at birth, have a significant morbidity, and are a major cause of neonatal and infant death.Their etiology is correlated with genetic environmental factors like physical, chemical, and biological (1).
Congenital malformations refer to structural or functional defects that exist in a newborn and occurred during life in the womb.Babies who are born with congenital anomalies and survive are more at risk of developing physical, social and cognitive problems.Worldwide, congenital anomalies occur in approximately 2 to 4 percent of all births.Congenital anomalies have been recorded more in Arab countries than in non-Arab countries (2-4).Also, the main disease burden study identified congenital malformations among the top 10 causes of death in children under 5 years of age in 2013 (5).
In 2016, 303,000 infants were born with congenital abnormalities, according to the WHO.The overall incidence of congenital abnormalities is 3 per 1000 live births, with an expected number of 99 million births each year globally (6).
According to the Global Burden of Disease Study, congenital abnormalities caused 510,400 deaths globally in 2010 (7).Congenital abnormalities impact roughly one in every 33 births, resulting in 6.6 percent infant mortality and substantial illness in children.According to a WHO estimate, around 3 million fetuses and newborns are born each year with a serious congenital abnormality.Congenital abnormalities have a significant influence on the pregnancy and newborn babies, accounting for 495,000 deaths globally.The vast number of fatalities occurred within the first year of life, contributing significantly to the babies' death rates.Most significant population-based studies estimate that significant congenital abnormalities affect roughly 2-3% of all live newborns.It accounts for 15-30% of all pediatric hospitalizations and has a greater health-care value than other hospitalizations, imposing a major burden on family and communities (8).
More than 90% of babies with severe congenital malformations are born in middle-income and poor countries, while congenital malformations in Arab countries record a higher proportion than non-Arab countries (6).Unfortunately, in many developing countries, registration of birth defects is unclear and missing.(9).
The incidence rate and patterns of congenital anomalies are different based on the geographical area.A range of different congenital factors including genetics, environmental teratogenic factors, micronutrient deficiency and related multifactorial inheritance have been investigated and reported.These common risk factors include drugs, maternal age, alcohol consumption, consanguineous marriage, smoking, and maternal diseases, although congenital anomalies may be the result of one or more genetic, nutritional, infectious, or environmental factors, which are usually very difficult to diagnose.About 60-70% of these events are caused by unknown.(10).
For ages, birth malformations had been recognized and acknowledged.Due to the obvious and great frequency of their incidence and the disastrous impact they might have on the patient and his or her family, it is a motivating topic for study (11,12).This study aimed to investigate the spread and pattern of congenital abnormalities in newborn babies in AL-Hilla city from 2017 to 2021, and correlated factors of the congenital abnormalities in infants delivered at the Babylon teaching hospital for maternity and pediatrics.

Methods
This is retrospective hospital-based records, in which the database of the local records, from the database Babylon Health Directorate The study was conducted in the Babylon teaching hospital for maternity and pediatrics .inAL-Hilla city-Iraq.

Statistical Information Analysis
SPSS version 17 was the statistical tool utilized for data administration and analysis (SPSS, Inc., version 17, Chicago, IL, USA).To characterize the most prevalent forms of congenital abnormalities, percentages and frequencies were estimated.

Results
A total of 46,777 birth were recorded in the city of AL-Hilla for five years, of which 214 had a sort of congenital malformations, corresponding to a spread rate of 4.57 for every 1,000 live births throughout the time period that studied for these five years, 2019 high prevalence 6.23 followed 2020 5.42 per 1000 live birth (Figure 1).

Figure 1. Congenital Abnormalities Spread Rate Related to Study Year
The frequency distribution of the 214 cases of newborns with birth defects according to the diagnosis of the affected system or abnormality in shown in Figures (1) and (2), the most common detected anomalies were of nervous system (36.91%)followed by musculoskeletal system (33.64%).GIT (14 %), (7.94%) genitourinary malformations, head and neck (2.33 %), non-specified (1.86%), skin, eye and respiratory system (0.93%) and syndromes 0.46% (Figure 2).Details of the distribution of congenital anomalies types are shown in Tables (Tables 1 to 5).The most common central nervous system malformations were abnormalities of brain, spinal cord, and anencephaly.The most common musculoskeletal abnormalities were congenital malformations of lower limb.The most common gastrointestinal tract malformations were cleft lip.

Discussion
This research had been an epidemiological search to estimate the prevalence of congenital anomalies in the AL-Hilla city, Iraq, the prevalence of congenital defects in live births of the present study was 4.57 for every 1000 birth for five years from 2017 to 2021.True spread of CMs relies upon many factors like place of study, nature of model, ethnicity, geographical allocation and socioeconomic state; that is why, any two studies are never similar in the strict sense of the term (13).
There is no inclusive research into CA in Iraq for aim of comparing.Most researches in this field were made using different approaches and in different regions throughout the state.
In overall, the prevalence of CA in our study was more than in other areas of Iraq where the overall incidence of all types of congenital anomalies from 2013 to 2016 3.3 per 1000 live births in Sulaymaniyah city in Iraq (14).While in AL-Ramadi in western Iraq which reported the higher overall incidence 40.5 /1000 live birth (15).In Erbil city, congenital malformations for every 1000 births, were listed (0.36%) in the maternity teaching hospital in Erbil (16).In another study in Iraq for year 2011 in Bagdad congenital anomalies represent 4.8% of total admission (17) whereas the another study in Mosul city found the overall prevalence of congenital malformation among the newborns was 0.69% (18).These discrepancies might be attributed to changes in environmental conditions as well as the devices used to diagnose CAs, including as ultrasonography, x-ray, electrocardiograph, and magnetic resonance imaging (MRI scan).We did not employ a magnetic resonance imaging instrument in this investigation.Essentially, the current study in Iraq reveals that CAs are a major issue that requires immediate action.It should also be mentioned that Iraq lacks supervision and register mechanisms for CAs, which pose long-term threats to individuals.As a result, policymakers, coders, and healthcare professionals must plan to educate the society about CAs, establish monitoring and registry systems, track the incidence of the problem in the population, and give inclusive cure, care, and rehabilitation services to ill children.

Alaani et al. conducted a research on the prevalence of congenital anomalies in
Many researches and studies have been conducted in Saudi Arabia.,In a study conducted in the city of King Fahd in Saudi Arabia, mainly the prevalence of congenital anomalies before the birth of a baby in every 1000 women during pregnancy was about 52.17% and the prevalence of congenital anomalies at birth was about 46.45% in every 1000 babies born (31).

Volume 8, May -June 2023
Journal of Obstetrics, Gynecology and Cancer Research Congenital abnormalities have epidemiological significance since they cause death for 276,000 babies globally each year (32).According to global studies, the birth spread of CA ranges from 1.107 % in Japan to 4.3 percent in Taiwan (33).Our spread rate was lower than the 13 percent indicated before (34, 35).It was equivalent to a hospital neonatal based research (4.23 percent) (36) and high in comparison with worldwide statistics where spread has been recorded as 2.7 percent, Taiwan 4.3 %, Oman 2.46 percent, Bahrain 2.7 percent, and India 1.5 percent.In India, the occurrence of congenital abnormalities was determined to be 2.48 percent of the total number of fetuses and newborns delivered after fourteen weeks of pregnancy over a one-year period (37).Fatima et al. from Bangladesh discovered a relatively increased occurrence of 3.61 percent and 3.68 percent, respectively (38).
Comparison of the findings with the same methods for data collection in City of São Paulo (Brazil) from 2010 to 2014.found that the spread of congenital malformations in infants born was 1.6 for every 100 newborns.Brazil has 3 million newborns each year in general, with roughly sixty thousand having congenital malformations (39, 40).
In Africa, Nigeria is second only to India in terms of maximum quantity of newborn fatalities globally.CA affects 6.3 percent of the population.Another study in Nigeria indicated a strong incidence of CA, with Adeyemo et al. reporting a high frequency of 11.1 percent among hospital admissions in Ibadan, South-West Nigeria.Our conclusion was comparable to the 6.9 percent stated by Bakare et al., which was done in the same geographic area as our center; however, identical investigations made in Nigeria's South-East and South-South areas showed a reduction in spread rates of 2.8 and 0.4 percent, accordingly.According to descriptive cross-sectional research conducted in Addis Ababa and the Amhara area of Ethiopia, the total rate of CAs was 1.99 percent, or about 2 percent.This result is quite similar to the outcome of our earlier research on birth abnormalities (1.9 percent) (6, 41, 42).
The spread ratio of abnormalities varies significantly between researches due to changes in research population, geographical locations, case description and categorization, diagnosis process, and statistically computation (the denominator).Congenital abnormalities generated 9.4 percent of dead infants in Canada and 7 percent of dead infants in the UK among 22 European nations (2010), with a spread ratio of 23.9/1000 live births.In 2014, Rachel Sokal et al. in the United Kingdom recorded a spread ratio of 30.7/1000 infants born for boys (proportion rate: 51.4%) and 24.3/1000 infants born for girls (proportion rate: 48.6%) (6, 43).
Variation could be explained by different nature of various studies like hospital versus community based, difference in geographical, environment factors, genetic, racial background, nutritional and socioeconomic differences.The spread ratio of 4.57 percent gained in this research does not exemplify the impression in the normal community, because it was a hospital-based research with no effort to acquire a representative sample of the general population.However, it is feasible that a community-based research or one that includes all births in the greater community will provide a greater rate of spread.In our region of the globe, for example, certain kids with congenital defects who are taken to educational or specialized hospitals are not evaluated in the neonatal care facility, but rather in other specialized units like pediatric surgery or neurosurgery.Some children born outside of hospitals with congenital anomalies are not transported to hospitals for treatment, but rather to traditional healing or other unconventional specialists, while others are merely left at home to their destiny.
There is no population-based registration of congenital malformations in Iraq, which might also result to undervaluation.It is, however, probably that the majority of pregnant women that included congenital malformations in the city were controlled in this hospital, because it was the only government tertiary hospital in Babylon city center through the period of research where the premature unit indicated congenital malformations.
The CNS was the most often impacted system in our analysis, following by Musculoskeletal, Gastrointestinal, Genitourinary, face and Neck, Unspecified, Skin, Eye, Respiratory System, and Syndromes in order from highest to lowest of frequency.In comparison, a research from Egypt and Saudi Arabia (8, 44) found that CNS was the most usually impacted system, following by Musculoskeletal and finally Renal.Likewise, an Iranian research (42) revealed CNS, Musculoskeletal, Gastrointestinal, Urogenital, and Chromosomal problems in order from highest to lowest of prevalence.An Indian research (37) found that CNS was ranked top, following by Musculoskeletal and afterward CVS.Another research (45) found that CNS abnormalities were the most prevalent.In contrary, an Iranian research (46) found that the genitourinary system was the most commonly impacted.Musculoskeletal abnormalities were shown to be the most prevalent in research from Iran (47, 48) and India (13, 49).
Gastrointestinal problems were described as the most prevalent in Pakistani researches (34, 35), although CNS results were validated by others (36, 50).Because of the high prevalence of central nervous system abnormalities seen in our study, it becomes fair to focus further consideration on the function of preconception vitamin supplementation in the prevention and treatment of congenital malformations, especially neural tube abnormalities.
Through the research period, the most common congenital central nervous system malformations were brain and spinal cord (statistics identical to that reported in the literature), encephalopathy, and hydrocephalus may be related with spina bifida and myelomeningocele (neural tube malformations).Genetic variables, baby birth weight (low birth weight), gestation duration (prematurity), mother age (both extremes), and maternal folic acid insufficiency may all be connected to neural tube malformations (51,52).
CNS abnormalities are one of the most frequent congenital disorders, with a complicated etiology including complicated interactions between genetic and environmental variables.Sunitha  In the study conducted, the risk of congenital abnormalities in male increased by 50.69%, which is in full agreement with one study in India and two studies in England.Nevertheless, a research from China described a higher risk in female (14).In general, it can be said that men are at higher risk for congenital anomalies, which is consistent with previous research (40).
According to Ali Jahan et al. (54), paternal cognation increased the probability of malformed newborns by 2.3 and 8.7 times more than other variables.Cognation marriage is one of the risk variables for congenital malformations.The current study found mostly sample non-consanguineous.
The mortality rate among children with major CAs in the present study was 3.72% stillbirths were CNS.Child deaths were marginally greater in newborns with congenital malformations in comparison with those without (odds ratio 51.81; 95 percent confidence range, 0.95-3.46)(55).
The majority of the city sample is agreeing that premarital test and avoidance of cognation, as well as avoidance of radiation exposure throughout gestation, and minimizing exposure to stressful situations throughout gestation, may play a significant role in the controlling and preventing of congenital malformations, with an equal number of cases from rural and urban areas.
The study found that the majority of mothers who delivered babies with congenital anomalies had no previous abortions.No previous studies support this study result.The largest number of cases of congenital anomalies in multiple pregnancies congruent with study by Cosme et al., 2017 (40).Several gestations are correlated with an increased incidence of congenital malformations, which can lead to premature delivery, implying high morbidity and death rates, which can be clarified in part by failures in cell divisions (genetic factors) and environmental factors in utero, such as twin to twin transfusion syndrome, constricting of the amniotic band, or umbilical cord fatalities.
The higher percentage of congenital anomalies seen in within normal rate 77.67%.
In general, congenital malformations are common in all nations, and there is no culture in the world that is free of congenital malformations.In other words, neonates in all countries, developed or developing, are at danger of malformations.As a result, by enhancing detection and preventing of congenital problems, as well as providing rehabilitative methods and facilities, the spread of these malformations may decrease (6).

Study limitations
The recent research was based on a hospital newborn unit.All neonates were solely assessed for overt congenital abnormalities.This study is not indicative of the condition in a broad population, and further research is needed to understand the actual incidence of congenital defects and the variables that contribute to them.Furthermore, the hospital lacked pediatric cardiology services, and various situations of coronary heart disease are probably have been unnoticed.Chromosomal investigations on newborns are not performed on a regular basis at the institute, genetic disorders might have been undervalued.

Conclusion
Anomalies were most likely to be in the central nervous system.However, anomalies in the central nervous system were most apparent.This research can help to determine the approximate distribution of the prevalence of congenital anomalies in AL-Hilla city in Iraq.Also, by identifying their main types, information can be improved in order to improve the clinical performance and public policy of Iraq.Promotion of timely diagnosis of congenital anomalies during pregnancy should be immediately or as soon as possible after delivery, this should be considered very important.It is also necessary to strengthen the Volume 8, May -June 2023 Journal of Obstetrics, Gynecology and Cancer Research registration and records of all births and congenital anomalies.

22,23,24)
Moreover, the results of this research were smaller than those of researches are done in the USA, the UK, Italy, and Canada (25, 26).The spread rates of various congenital malformations in Iran between 2000 and 2016 were 18/1000 live births.In 2014, Shabbir Hussain et al. from Pakistan listed a spread rate of 70.4/1000 live births, with boys accounting for 80.99/1000 and girls accounting for 59.81/1000 (6).

51, 52). in
Whereas in the United States and Europe the predominance of malformation is osteoarticular malformations where are visible during the examination at the moment of birth (Mosul city, Iraq discovered that the proportion of congenital malformations rise substantially with age as observed in more than one third of the mothers (

12,20.23).
In contrast,Shawky and Sadik (20)found in current Egyptian research that more than 50% of children with congenital abnormalities had mothers who were beyond the age of 35.A growing body of research has also shown that excessive ages during gestation are a potential risk for producing a kid with congenital abnormalities (