In Kyrgyzstan, UNICEF bolsters flour fortification to prevent birth defects

Mothers with sufficient folic acid in their diets are less likely to bear children with neural tube defects

By Sven G. Simonsen
A baby asleep in a blanket
UNICEF Kyrgyzstan/2016/Vlad Ushakov
03 March 2017

Two-month-old Abdurahim was born with spina bifida and is awaiting surgery. The risk of birth defects such as these increases when a mother has a diet low in nutrients. In an effort to improve pregnant women’s nutrition, large mills in Kyrgyzstan are obliged by law to fortify flour with folic acid. UNICEF is working to help the Government enforce the law and raise awareness among mothers.

BISHKEK, Kyrgyzstan, 3 March 2017 – Ever since Abdurahim* was born two months ago, his mother Alima has been struggling to understand why. Why was her boy born with spina bifida, a severe neural defect. Was it because she took antibiotics when she had kidney problems two months into the pregnancy? Was it the tense atmosphere in the household? Was it all the hard physical work back home in the village?

Alima talks about the pregnancy and the questions she has been asking herself in a quiet voice. Sometimes a faint smile passes over her face, but she reveals the tension inside as she continues to squeeze her hands together.

“This was a planned pregnancy, my second one,” she says. “My husband and I had tried for seven years to have a child. Two years ago, we succeeded – our daughter was born. She is a healthy child. One year later, I was pregnant again.”

A doctor examining images of a child's brain
UNICEF Kyrgyzstan/2016/Vlad Ushakov
Dr Karachev explains how neural defects may express themselves in a child’s brain. He operates on some 20 cases of spina bifida and 80 cases of hydrocephalus every year.
First month of pregnancy

We’re at the neurology unit of the National Centre for Motherhood and Childhood in Bishkek, the capital of  Kyrgyzstan. Alima’s daughter is at home in their village in the southeast of the country. The mother has come to Bishkek alone with Abdurahim. They were sent here by a local hospital who could not treat the boy when he fell ill with a serious virus infection.

“We came here with the hope that he will get treatment,” says Alima. Now, 10 days later, the infection has been cured and she and the doctors have their minds solely on the boy’s neural defects.

On a bed next to her lies Abdurahim. As Alima watches, Dr Bakytbek Karachev, head of the neurology unit, gently lifts up Abdurahim’s shirt and releases a bandage that covers much of his spine to expose a thick bulge. The skin is reddish and stretched thin. Inside is fluid that has leaked out of the spine.

Spina bifida is one of the most common neural tube defects, which are defects that affect the brain, spine, or spinal cord. It is a result of the child’s spinal column not closing properly during pregnancy.

Abdurahim also suffers from hydrocephalus, sometimes called ‘water on the brain’. This is a condition where liquid does not properly drain from the brain and can cause severe brain damage.

Folic acid deficiency multiplies risk

In 2015, 2,938 children under 1 died in Kyrgyzstan. Out of them, 63 children died because of neural tube defects. The defects appear in the very first month of pregnancy when the woman may not even know she is pregnant. It is not known exactly what causes the condition. However, the risk of a child being born with it is dramatically higher if the mother is deficient in folic acid, one of the B vitamins.

Hydrocephalus, too, occurs more frequently when the mother is deficient in folic acid and has also been linked to other nutritional deficiencies.

Among the factors Alima can think of that may have caused Abdurahim’s condition, she does not mention nutrition. It is brought up by Dr. Elmira Kabylova, a paediatrician and nutrition specialist at the Ministry of Health, who has come with us to the hospital.

“When I was pregnant with my daughter I took iodine, because the doctor recommended it. This time, the doctor didn’t say anything, so I just ate normal food,” says Alima.

“People in remote areas are not given good health advice,” says Dr. Karachev. “The good specialists have already left to work elsewhere.”

UNICEF health consultant with an expectant mother
Zamir Shakirov, UNICEF health consultant (right), discusses diet with Asel in the maternity hospital in the city of Batken, Kyrgyzstan. UNICEF advocates for early screening of pregnant women to prevent as many neural tube defect cases as possible.
Fortification is the law – in principle

Families who live in poverty tend to have a diet low in nutrients, negatively affecting the health of the pregnant woman and the development of the child during pregnancy and later.

A UNICEF-supported survey in 2009 showed that as many as 42 per cent of non-pregnant women in Kyrgyzstan suffered from folic acid deficiency and 27 per cent from iron deficiency anaemia; 61.6 per cent of pregnant women were iodine deficient.

Following UNICEF advocacy, large mills in Kyrgyzstan are obliged by law to fortify flour with folic acid since 2009. However, the country has many mills, and the law is difficult to enforce.

A lot of flour is imported from Kazakhstan and Russia where fortification is not done. Alima says that this imported, cheaper flour is what’s on offer in her village and what her family has been using.

Enforcing the law, raising awareness

Every year, Dr Karachev operates on some 20 cases of spina bifida and 80 cases of hydrocephalus. In a few weeks, it will be Abdurahim’s turn. At the moment, the doctor’s main concern is the hydrocephalus and it is not yet clear how intrusive a procedure it will require.

A child born with neural tube defects entails a heavy financial burden on the family. Back home, Alima’s family is struggling. “It’s just me and my husband and we are both unemployed. His brother also lives with us. He is disabled and cannot work,” says Alima. With very little money, the family lives off what they can produce on a small piece of agricultural land.

UNICEF Kyrgyzstan, with funding from the Swiss National Committee for UNICEF, is working to prevent as many neural tube defect cases as possible and advocates for the early screening of pregnant women. To help the Government enforce the law on fortification, UNICEF is supporting the preparation of by-laws to sanction millers who don’t comply. At the same time, UNICEF is working with the media and civil society to monitor implementation of the law.

Perhaps most importantly, UNICEF continues its efforts to raise awareness among mothers, so that they will seek out the best foods for themselves and their children.

* Name of mother and child have been changed.