Unveiling the Hidden Burden of Neural Tube Defects Crisis: A Triple-Lens Investigation of Prevalence, Risk Factors and Maternal Folate Deficiency in War-Torn Tigray, Northern Ethiopi

Abstract

Background: Neural tube defects (NTDs) are among the most severe congenital anomalies globally, with disproportionately high prevalence in low-resource settings. The Tigray regional state in northern Ethiopia, already facing one of the highest NTD burdens in sub-Saharan Africa, has endured an extensive armed conflict for several decades and as recently as in 2020, resulting in the collapse of its healthcare system, widespread famine, and profound maternal health challenges. Despite anecdotal reports of increased birth defects during the conflict, empirical data have been lacking. Objective: This dissertation aimed to assess the prevalence, and associated factors of NTDs in war affected areas of Tigray. It also evaluated maternal red blood cell (RBC) folate levels in NTD high-risk regions to explore biochemical risk factors contributing to these anomalies. Methods: A mixed-methods approach was employed across three interrelated studies. Quantitative data were obtained through hospital-based retrospective chart reviews, prospective observational assessments, and laboratory analyses of RBC folate concentrations in first-trimester pregnant women. Socio demographic, obstetric, nutritional, and biochemical variables were analyzed to identify risk factors associated with NTDs. Results: The findings revealed an alarmingly high prevalence of NTDs (262 per 10, 000 births) in the conflict-affected health facilities of Tigray, significantly exceeding national and regional estimates. Risk factor analysis of our study showed strong links between NTDs and factors such as young maternal age, rural residence, unplanned pregnancy, poor prenatal care, low education, high birth order, and lack of folic acid use. Additional risks included poor folate awareness, food insecurity, low dietary diversity, violence exposure, and limited healthcare access. Biochemical assays showed widespread deficiencies in RBC folate among pregnant women in high-risk areas, with levels frequently falling below WHO recommended thresholds for NTD prevention, with dietary diversity strongly influencing folate status, emphasizing the key role of nutrition in NTD prevention. Conclusion: This study demonstrates an alarming surge in NTDs in war-affected Tigray, primarily driven by widespread folate deficiency, poor dietary diversity, and the collapse of maternal health services. Additional risk was compounded by key socio demographic factors such as low education attainment, rural residence, and limited reproductive autonomy. These findings underscore how conflict magnifies preventable health crises through the convergence of nutritional, medical, and social failures. Hence, efforts should prioritize the restoration of antenatal care services, targeted folic acid supplementation for women of reproductive age, and community-based nutrition education to improve dietary diversity. In the longer term, food fortification with folic acid should be considered once health systems stabilize. These targeted interventions fall within the study’s evidence base and are feasible within conflict-affected and resource-limited contexts.