Epidemiology of neural tube defects

I read with interest the study by Seidahmed et al 1 on the epidemiology of neural tube defects (NTDs). It has inspired me to throw light on the continuously growing health problem of NTDs in Iraq, and compare it with the data from the Kingdom of Saudi Arabia (KSA). I would like to address the following 3 points. First, Seidahmed et al 1 mentioned that the prevalence of NTDs was 1.2/1000 live births among their studied population. They considered that prevalence high in KSA despite the implementation of fortification of flour with folate since 2001. Seidahmed et al 1 did well in comparing that prevalence with those reported in other countries. Their study showed that NTDs prevalence was similar to those found in Gulf Cooperation Council countries and Jordan but it was much lower than those recorded in Palestine, Algeria, Northern Iran, and Sudan. 1 did not compare their reported NTDs prevalence with that recorded in Iraq. Iraq is currently considered the country with the highest reported prevalence rate of NTDs in the world, with a mean prevalence of 24.2/1000 live births. 2 Actually, the real NTDs magnitude in Iraq is higher than that previously reported. This is based on the following 3 points: 1) The estimated prevalence was related to live births only, and did not include macerated, or malformed babies who might have NTDs; 2) The aforementioned prevalence was estimated from hospital-based rather than community-based data; and 3) Substantial proportion of births in Iraq still take place at home, where home delivery with traditional birth attendant has been noticed to account 31.2% of total births. 3 Accordingly, a significant number of babies with NTDs born at home are expected to escape medical registration. Second, Seidahmed et al 1 attributed a high prevalence of NTDs in KSA (1.2/1000 live births) in spite of the implementation of fortification of flour with folate since 2001 to the impact of genetic, syndromic, and chromosomal causes of NTDs, which are not preventable by folate, in addition to other factors, such as unplanned pregnancy, and lack of awareness of the role of folate in preventing nonsyndromic causes of NTDs. Contrary to that, the spike in NTDs prevalence in Iraq (24.2/1000 live births) has been attributed to the cumulative effects of exposure to toxicants, including depleted uranium, maternal malnutrition, gestational folate deficiency, absent national program on dietary folate fortification, and marked psychosocial stress secondary to …