RELATIONSHIP OF PARENTAL HEALTH AND SOCIAL SUPPORT DURING PREGNANCY WITH THE RISK OF NON-SYNDROMIC ORAL CLEFTS : A CASE – CONTROL STUDY

Oral clefts are divided into cleft lip, cleft palate and cleft lip along with cleft palate. Cleft palate is defined as an inability of palatal shelves to approximate and close during the first months of embryogenic period thus leaving an opening in the roof of the mouth and forming communication between the nasal and oral cavities. Objective: To determine the relationship of risk of oral clefts with parental health and social support. Afzal S. Chairperson and Head of Community Medicine Department King Edward Medical University Lahore Bashir M. Chairman and Head of Plastic Surgery Department KEMU / Mayo Hospital, Lahore Khan M.A. APMO Community Medicine Department King Edward Medical University, Lahore Tehzeeb J. MBBS Student, King Edward Medical University, Lahore Manzoor A. MBBS Student, King Edward Medical University, Lahore Dar A.S. MBBS Student, King Edward Medical University, Lahore Umair M. MBBS Student, King Edward Medical University, Lahore Butt A.I. MBBS Student, King Edward Medical University, Lahore Iqbal A. MBBS Student, King Edward Medical University, Lahore Anwar A. MBBS Student, King Edward Medical University, Lahore Bashir M.J. MBBS Student, King Edward Medical University, Lahore Junaid M.M. MBBS Student, King Edward Medical University, Lahore Ashraf M.S. MBBS Student, King Edward Medical University, Lahore Original Article SAIRA AFZAL, MUSTEHSAN BASHIR, MUHAMMAD ARIF KHAN, et al 263 ANNALS VOL 21, ISSUE 4, OCT. – DEC. 2015 Study Design: Case Control Study. Study Setting and Duration: Various hospitals in Lahore and 3 month duration. Materials and Methods: A Case Control Study was conducted. A total of 100 subjects (50 cases, 50 controls) were included. Sampling was done by purposive method. Data was collected with the help of Cornell Medical Index Health Questionnaire and Social Support Questionnaire after taking their informed consent. Data was analyzed by using SPSS version 20.0. Mean and standard deviation were used to describe quantitative variables like age. Test of significance were applied. Results: 56% of cases were females and 44% were males. Mean age of mothers was 27 and fathers was 31. Most mothers were uneducated (36%) while most fathers were educated till matric (34%). Income of most parents was in the range of 10,000-20,000 PKR (44%). 24% of controls were females and 76% were males. The associations of oral cleft was found significant with parental respiratory, cardiovascular, gastrointestinal, musculoskeletal, skin-related, genitourinary health, easy fatigability, health habits, anxiety, anger, paternal nervous system health, sensitivity, and maternal frequency of illness, depression and feeling of inadequacy (p < 0.05). Maternal social support categories indicated that cases were less supported than controls: number of persons available and level of satisfaction (p < 0.05). Conclusion: Oral clefts have a multi-factorial etiology. Hence, an effective preventive program should take into account parental health and social support factors.


Introduction
This is a casecontrol study to establish the relationship of mental and physical health of both parents and social support both formally and informally by the family and community during pregnancy with nonsyndromic oral clefts.
Oral clefts are divided into cleft lip, cleft palate and cleft lip along with cleft palate.Cleft palate is defined as an inability of palatal shelves to approximate and close during the first months of embryogenic period thus leaving an opening in the roof of the mouth and forming communication between the nasal and oral cavities. 1Cleft lip results due to failure of fus-ion of both sides of fetal lip tissue by 35 days of gestation.The defect may affect one side or both. 2 Esthetic defects which are associated with cleft lip and cleft palate in infants results in feeding problems, infections of ear, hearing impairement, dentition problems, difficulty in articulation, social, psychological and behavioral problems. 3he incidence of cleft lip in Pakistan is one in 500 live births.This is fourth largest in the world after China, India and Indonesia.Every day 25 cases in Pakistan are born with this deformity and in a year 9000 cases are added. 4Many causative factors are found to be linked with cleft lip and palate.Researchers have majorly outlined risk factors like parental age, [5][6][7] family history, 8 consanguineous marriages, 9,10 co-morbidities like infections during pregnancy, 11 multigravida 12 in mothers of low socio-economic status, smoking, 13 alcohol, 14 drugs 15 (anti-epileptics, steroids, antineoplastics), occupational and environmental exposures. 16 research conducted in China studied oral clefts in relation to parental health and social support during pregnancy. 17However, no such study has been conducted in Pakistan.
Our study will outline the parental health and social support factors associated with the said defect.This can help shift the paradigm of approach for prevention of this health problem towards a more holistically oriented one.Moreover, various fruitful research efforts can be based on the results of this research to ascertain the risk factors in case of health of both parents and support of family and society.

Materials and Methods
The study was conducted in various hospitals of Lahore.Informed consent was taken.The risk and benefits were explained and the personal information of study subjects was kept confidential.The cases where consent was not granted by the parents are excluded from the study.Pretested and validated tools i.e.Cornell Medical Index Health Questionnaire and Social Support Performa were used.All data was collected , entered and analy-zed with the help of SPSS version 20.0.Value of p less than 0.05 was considered as significant.

Results
56% of cases were females and 44% were males.Mean age of mothers was 27 and fathers was 31.Most mothers were uneducated (36%) while most fathers were educated till matric (34%).Income of most parents was in the range of 10,000-20,000 PKR (44%).24% of controls were females and 76% were males.
The associations of oral cleft was found significant with parental respiratory, cardiovascular, gastrointestinal, musculoskeletal, skin-related, genitourinary health, easy fatigability, health habits, anxiety, anger, paternal nervous system health, sensitivity, and maternal frequency of illness, depression and feeling of inadequacy (p < 0.05).Maternal social support categories indicated that cases were less supported than controls: number of persons available and level of satisfaction (p< 0 .05).

Discussion
Oral clefts have been investigated by scholars from various fields.Our research on Pakistani population shows that status of health of both parents and moral support of family and society plays a leading role in determination of oral clefts.Maternal and paternal ages are believed to be independent risk factors for oral clefts.6][7] Our results also suggest an inclination along the same lines.However, we also find it mentionable that the data we collected has not been extensive enough to establish paternal age as a definite risk factor.Parental occupational exposures 16 and low socioeconomic status are also considered as risk factors for oral clefts 13 .However, such effects were not observed in our study.
Although many researchers have pointed out other risk factors like alcohol consumption, smoking, and specific vitamin deficiencies, 13,14 generalized parental health has rarely been discussed.In this study, it was seen that case parents had consistently poorer health status observed for each organ system subcategory.Studies conducted in past showed that smoking, 13 domestic air pollutants (e.g.stoves), commercial inha-lants 16 may be perceived as a provoking factor in causing respiratory problems and our study also showed promising results.Problems of musculoskeletal, cardiovascular, skinrelated and genitourinary health and illness frequency also may be considered as indicators for the generalized health of parents and are probably coupled with excessive physical work, approach to health care parental health and availability of medicines.Maternal stress has also been discussed as a risk factor for such congenital anomalies. 24All of its possible causes can lead to raised blood glucocorticoid levels and high blood steroids may be linked to the risk of oral clefts. 23Maternal stress levels were explored by assessing maternal perception of her own mental health and behavior as well as by employing the Social Support questionnaire.The results were found to be significant enough to consider the social support during pregnancy as a contributor towards the said risk.
As predictable for most case control studies, especially in case of less commonly encountered health problems, the main limitations of this study have been smaller sample size and recall bias.The smaller sample size reduces the ability to comment surely upon the debatable risk factors like parental age.The children with oral clefts require early surgical intervention mostly and hence present to the hospital at an earlier age.The same may not be true for the controls.Moreover, the parental educational status, understanding and memory regarding their health status during the pregnancy under discussion had to be relied upon and there remains the possibility of discrepancies in the accuracy on these accounts among the cases and controls.However, each step was carefully carried out to allow minimum hampering of accurate data collection.Certain measures were taken like explaining the questionnaires to the patients in their own language and according to their level of understanding and asking questions in more than one ways, to ensure that the exercise would be reliable enough.

20 Social Support Rating Scale: A
standardized questionnaire for collecting pertinent social support data. 21The children less or equal to 5years of age were divided in two groups.Patients having Cleft Lip, Cleft Palate or Cleft Lip and Palate is termed as a Case group while patients not having Cleft Lip, Cleft Palate or Cleft Lip and Palate constitute Control group.Patients having single minor associated anomalies except other craniofacial malformations (Patent Ductus Arteriosus, Inguinal hernia, Umbilical hernia, Undescended testes, Hydrocele).

Table 1 :
Statistical Analysis of Cornell Medical Indices and Social Support Scores for Males.

Table 2 :
Statistical Analysis of Cornell Medical Indices and Social Support Scores for Females.