Prevalence of depression among school going adolescents in India:           a systematic review and meta-analysis of cross-sectional studies

The objective of this systematic review was to estimate the pooled prevalence of depression among schoolgoing adolescents in India by using Beck’s Depression Inventory (BDI 1 or BDI 2). A systematic literature search was conducted in PubMed, Ovid MEDLINE, Ovid EMBASE, CINAHL, Cochrane Library, PsycINFO and Google Scholar to identify cross-sectional school-based studies published during 1990-2020. Studies with pre-identified mental illness were excluded. Heterogeneity between studies were examined and estimates were pooled using a random-effects model. Subgroup and sensitivity analysis were performed. Publication bias was evaluated using funnel plot and Egger’s test. We included 13 studies in the meta-analysis. The random effect meta-analysis revealed that the pooled prevalence of depression among school going adolescents was 53% (95% CI: 41% - 65%). By gender, the prevalence was 50% (95 % CI: 38%–62%) in males and 57% (95% CI: 46% - 69%) in females. The subgroup analysis revealed that the pooled prevalence increased with the education levels (High school: 42%; High school and pre-university: 55%; and Pre-university: 67%). In this review we found that more than half of the school going adolescents in India suffered from depression that ranged from mild to severe. These results draw attention to re-look at the mental health policy and newer public health approaches to address depression. Further, strengthening school-based mental health services, along with the community and center-based care is crucial to prevent and effective management of depression among adolescents.

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Prevalence of Depression among Healthcare Workers during the COVID-19 Outbreak: A Systematic Review and Meta-Analysis

Journal of Clinical Medicine ◽

10.3390/jcm10153406 ◽

2021 ◽

Vol 10 (15) ◽

pp. 3406

Author(s):

Beatriz Olaya ◽

María Pérez-Moreno ◽

Juan Bueno-Notivol ◽

Patricia Gracia-García ◽

Isabel Lasheras ◽

...

Keyword(s):

Systematic Review ◽

Healthcare Workers ◽

Mental Health Problems ◽

Meta Analysis ◽

Medical Doctors ◽

Cross Sectional ◽

Random Effects Models ◽

Pooled Prevalence ◽

Prevalence Of Depression ◽

Common Mental Health Problems

Background: There is evidence of a high psychological toll from the COVID-19 pandemic in healthcare workers. This paper was aimed at conducting a systematic review and meta-analysis of studies reporting levels of depression among healthcare workers during the COVID-19 and estimating the pooled prevalence of depression. Methods: We searched for cross-sectional studies listed on PubMed from 1 December 2019 to 15 September 2020 that reported prevalence of depression in healthcare workers, nurses, medical doctors, and COVID-19 frontline professionals. The pooled proportions of depression were calculated with random effects models. Results: We identified 57 studies from seventeen countries. The pooled prevalence of depression in healthcare workers was 24% (95% CI: 20%−28%), 25% for nurses (95% CI: 18%−33%), 24% for medical doctors (95% CI: 16%−31%), and 43% for frontline professionals (95% CI: 28%−59%). Conclusions: The proportion of depression in nurses and medical doctors during the COVID-19 pandemic was similar to that found in the general population as previously reported in other meta-analyses conducted with smaller numbers of studies. Importantly, almost half of the frontline healthcare workers showed increased levels of depression. There is need for a comprehensive, international response to prevent and treat common mental health problems in healthcare workers.

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Association of parenting with suicidal ideation and attempts in children and youth: protocol for a systematic review and meta-analysis of observational studies

Systematic Reviews ◽

10.1186/s13643-021-01727-0 ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Florence Perquier ◽

Sarah Hetrick ◽

Terri Rodak ◽

Xin Jing ◽

Wei Wang ◽

...

Keyword(s):

Systematic Review ◽

Suicidal Ideation ◽

Observational Studies ◽

Meta Analysis ◽

Random Effect ◽

Children And Youth ◽

Cochrane Library ◽

Significant Heterogeneity ◽

Cross Sectional ◽

Wide Range

Abstract Background Suicide is a leading cause of death in children and youth, with suicidal thoughts and suicide attempts (referred to as non-fatal suicidal behaviors (NFSB)) being among its strongest predictors. Positive parenting (e.g., warmth, responsiveness), negative parenting (e.g., control, hostility), and parent-child relationship quality (e.g., trust, communication) have been reported to be associated with differences in NFSB in this population. To date, no comprehensive systematic review has considered together the wide range of parenting factors studied in relation to NFSB, and no meta-analysis of existing findings has been conducted. The present study will critically appraise and synthesize the existing evidence from observational studies that examine the relationships between parenting factors and (i) suicidal ideation and (ii) suicide attempt in children and youth. Methods Studies will be retrieved from APA PsycInfo, MEDLINE, CINAHL, Embase, Scopus, and the Cochrane Library databases. Retrospective, cross-sectional, and longitudinal studies, conducted in clinical and population settings, among youth aged less than 25 years and published as articles and dissertations in English or French will be eligible. Two reviewers will select articles using the Covidence Software after title and abstract screening and full-text assessment, will extract information using double data entry, and will appraise studies’ quality using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Any disagreements will be discussed with a third reviewer. Publication bias will be evaluated using funnel plots and Egger’s test. In addition to a narrative summary of results, meta-analyses will be conducted using results from at least three studies. Three-level random effect models will allow to derive pooled estimates from dependent effect sizes (from the same sample or study). In case of significant heterogeneity, moderation analyses will be performed considering participants’ characteristics and methodological aspects of studies. The results will be reported according to the PRISMA guidelines, and the certainty of evidence will be assessed using the GRADE approach. Discussion In highlighting parenting factors associated with NFSB and in estimating the overall strength of these associations in children and youth, our results will inform further intervention and prevention strategies designed for young people experiencing NFSB and their families. Systematic review registration PROSPERO CRD42020165345

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A systematic review and meta-analysis of HIV associated neurocognitive disorders (HAND) among people with HIV in Ethiopia

AIDS Research and Therapy ◽

10.1186/s12981-021-00424-1 ◽

2021 ◽

Vol 18 (1) ◽

Author(s):

Yosef Zenebe ◽

Baye Akele ◽

Mulugeta W/Selassie ◽

Mogesie Necho

Keyword(s):

Systematic Review ◽

Publication Bias ◽

Addis Ababa ◽

Meta Analysis ◽

Final Analysis ◽

Cochrane Library ◽

Early Screening ◽

Cross Sectional ◽

Pooled Prevalence ◽

Size Heterogeneity

Abstract Background Ethiopia, being in the Sub Saharan region of Africa, is one of the countries with a substantial burden of HIV infection. Because of the high burden of HIV and poor health care settings, HAND is prevalent as demonstrated in various cross-sectional studies. However, no review has been conducted to report the consolidated magnitude of HAND among people with HIV in Ethiopia. Therefore, this systematic review and meta-analysis aimed to estimate the prevalence of HAND in Ethiopia. Methods Following the PRISMA guidelines, we systematically reviewed and meta-analyzed studies that investigated the prevalence of HAND in Ethiopia from PubMed, Google Scholar, Science Direct, HINARI, EMBASE, and Cochrane library databases. We also looked at the reference lists of the included studies to include other relevant studies. Subgroup analysis was performed based on publication year, study location, and sample size. Heterogeneity across studies was evaluated using the I2 test. Potential publication bias was assessed using Egger’s test and visual inspection of symmetry in the funnel plots. Results In the present meta-analysis, 627 articles were initially identified and evaluated. Of these, 8 studies that met the inclusion criteria were included in the final analysis. The pooled prevalence of HAND in people with HIV in Ethiopia was 39.15% (95% CI 29.36, 48.94). The highest prevalence observed in the Southern Nations, Nationalities, and Peoples’ Region (SNNPR) with 53.20% (95% CI 25.96, 80.44) followed by others 34.87% (Tigray, Addis Ababa, and Oromia) (95% CI 33.49, 36.24) and Amhara 34.07% (95% CI 25.39, 42.74).The funnel plot was asymmetrical. However, Egger’s regression tests provided no evidence of publication bias in the prevalence of HAND. Conclusion In this meta-analysis, the pooled prevalence of HAND, in Ethiopia, was high. Older age, substance use, advanced stages of the disease, and lack of education were the main determinants of HAND in Ethiopia. Health education, early screening of people with HIV, and training of health professionals working in hospitals on HAND are highly recommended.

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Prevalence of home delivery and associated factors in Ethiopia: A systematic review and meta-analysis

10.21203/rs.3.rs-32343/v1 ◽

2020 ◽

Author(s):

Asteray Assmie Ayenew ◽

Azezu Nigussie ◽

Biruk Zewdu

Keyword(s):

Systematic Review ◽

Health Facility ◽

Associated Factors ◽

Meta Analysis ◽

Random Effect ◽

Home Delivery ◽

Cochrane Library ◽

Danger Sign ◽

Media Access ◽

Pooled Prevalence

Abstract BackgroundGlobally, maternal morbidity and mortality remained a major public health challenge. Delivering at home is associated with a higher risk of maternal deaths. Findings on the prevalence and associated factors of home delivery are highly variable and inconsistent across Ethiopia. Therefore, the aim of this systematic review and meta-analysis was to estimate the pooled prevalence of home delivery and its associated factors in Ethiopia.MethodPreferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed. The databases used were; PubMed, Google Scholar, Cochrane Library, African Journals Online, Ethiopian's university research repository online library, and manual searching. The search was further limited to studies conducted in Ethiopia and reported in English. Two authors independently extracted all necessary data using a standardized data extraction format. STATA 11 software was used to analyze the data. The Cochrane Q and I2 test were used to assess the heterogeneity of studies. The pooled estimate prevalence and the odds ratios with 95% confidence intervals were computed by a random effect model.ResultA total of 13 studies were included in this meta-analysis with a sample size of 13,535. The national pooled prevalence of home delivery was 48.53 % (95% CI:35, 62). The pooled adjusted odds ratio (AOR) of home delivery for Place of rural residence was 4.3(AOR = 4.3; 95% CI 2.7, 6.8), husband preference was 5(AOR=5.1 95%CI:1.1, 22), not having ANC follows up was 3.3(AOR= 3.3,95%CI:2,6), Women who cannot read & write was 4(AOR=4.36,95% CI:3.1, 6.12), Primary level was 4(AOR=4.21, 95%CI:1.5, 11.6) ,and secondary & above was 1.9(AOR=1.9,95%CI:1.1, 3.45), distance from the health facility was 7(AOR= 7.33, 95%CI:5.75, 9.35), age of mothers 15-24 was 4(AOR =3.7,95%CI:2, 6.6), knowledge of danger sign of pregnancy was 4(AOR=4.60 95%CI:3, 6.8), and no media access was 3.4(AOR=3.495%CI: 1.5, 7.5).ConclusionThis systematic review and meta-analysis showed that home delivery was high in Ethiopia. Place of residence, husband preference, no having ANC follows up, educational status of mothers, distance from health facility, age of mothers, knowledge of danger sign of pregnancy, and no media access increased the risk of home delivery.

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Prevalence of Spina Bifida among Newborns in Africa: A Systematic Review and Meta-Analysis

Scientifica ◽

10.1155/2020/4273510 ◽

2020 ◽

Vol 2020 ◽

pp. 1-12

Author(s):

Mohammed Oumer ◽

Molla Taye ◽

Hailu Aragie ◽

Ashenafi Tazebew

Keyword(s):

Systematic Review ◽

Spina Bifida ◽

Meta Analysis ◽

Random Effect ◽

Random Effect Model ◽

Fetal Loss ◽

Cochrane Library ◽

Forest Plot ◽

Birth Prevalence ◽

Pooled Prevalence

Spina bifida is an abnormal closure of the neural tube during the fourth week of development. It is the major cause of fetal loss and considerable disabilities in newborns. The aim of this review is to determine the pooled prevalence of spina bifida among newborns in Africa. PubMed/Medline, Google Scholar, Science Direct, Joanna Briggs Institute (JBI) Library, Cochrane Library, Web of Science, African Journals Online, and Embase databases were systematically searched. Cochran Q test and I2 test statistics were applied to assess heterogeneity across studies. A random-effect model was applied to calculate the pooled prevalence of spina bifida. Forest plot and Galbraith’s plot were used to visualize heterogeneity. Subgroup, sensitivity, meta-regression, and meta-cumulative analyses were performed. All essential data were extracted using a standardized data extraction format, and the JBI quality appraisal checklist was used to assess the quality of studies. Egger’s test and Begg’s test were used in order to detect the publication bias. In the present systematic review and meta-analysis, 6,587,298 births in twenty-seven studies were included. The pooled birth prevalence of spina bifida in Africa was 0.13% with a range between 0.12% and 0.14%. In Africa, the highest burden of spina bifida was detected in Algeria (0.43%), Ethiopia (0.32%), Tanzania (0.26%), Cameron (0.12%), Egypt (0.10%), and South Africa (0.10%). The lowest burden of spina bifida was detected in Libya (0.006%) and Tunisia (0.009%). The high birth prevalence of spina bifida was detected in Africa. There was a significant variation in the prevalence of spina bifida among study countries in Africa. The authors recommend that special awareness creation with the help of health education intervention should be provided for mothers to focus on prevention in order to reduce the burden of spina bifida.

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The Prevalence of Depression among Diabetic Patients in Ethiopia: A Systematic Review and Meta-Analysis, 2018

Depression Research and Treatment ◽

10.1155/2018/6135460 ◽

2018 ◽

Vol 2018 ◽

pp. 1-8 ◽

Cited By ~ 7

Author(s):

Henok Mulugeta Teshome ◽

Getenet Dessie Ayalew ◽

Fasil Wagnew Shiferaw ◽

Cheru Tesema Leshargie ◽

Dube Jara Boneya

Keyword(s):

Diabetes Mellitus ◽

Systematic Review ◽

Addis Ababa ◽

Data Extraction ◽

Meta Analysis ◽

Cochrane Library ◽

Diabetic Patients ◽

Comorbid Depression ◽

Pooled Prevalence ◽

Prevalence Of Depression

Background. Diabetes mellitus is a chronic metabolic disorder characterized by hyperglycemia. Depression is one of the major important public health problems that is often comorbid with diabetes. Despite the huge effect of comorbid depression and diabetes, the overall pooled prevalence of depression among diabetic patients in the country level remains unknown. Therefore, the objective of this systematic review and meta-analysis is to estimate the pooled prevalence of depression among patients with diabetes mellitus in Ethiopia.Method. Data extraction was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were accessed through electronic web-based search from PubMed, Cochrane Library, Google Scholar, Embase, and PsycINFO. All statistical analyses were done using STATA version 11 software using random effects model. The pooled prevalence was presented in forest plots.Results. A total of 9 studies with 2944 participants were included in this meta-analysis and the overall pooled estimated prevalence of depression among diabetic patients in Ethiopia was 39.73% (95% CI (28.02%, 51.45%)). According to subgroup analysis the estimated prevalence of depression in Addis Ababa was 52.9% (95% CI: 36.93%, 68.88%) and in Oromia region was 45.49% (95% CI: 41.94, 49.03%).Conclusion. The analysis revealed that the overall prevalence of comorbid depression among diabetic patients in Ethiopia was high. Therefore, Ministry of Health should design multisectorial approach and context specific interventions that address this comorbid depression in this specific group as well as general population.

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Prevalence and predictors of self-medication among University students in Ethiopia: A systematic review and Meta-analysis

10.21203/rs.2.13118/v1 ◽

2019 ◽

Author(s):

Getahun Fetensa ◽

Tadesse Tolossa ◽

Werku Etafa Ebi

Keyword(s):

Systematic Review ◽

University Students ◽

Meta Analysis ◽

Random Effect ◽

Systemic Review ◽

Cochrane Library ◽

Self Medication ◽

Medication Practice ◽

Manual Search ◽

Pooled Prevalence

Abstract Background Self-medication is the global issue especially on those having access and education about medication irrespective of its side effect. It has a significant impact on resistance and medication-related complication. There are limited and inconsistent studies regarding self-medication practice in Ethiopia. The aim of this systematic review and meta-analysis was to estimates the pooled prevalence of self-medication and its predictors among Ethiopian university students. Method A systematic review and meta-analysis were conducted to assess the prevalence and predictors of self-medication among university students in Ethiopia. We searched literature from the databases of Medline, Hinari, Scopes, PubMed CINAHL, PopLine, MedNar, Embase, Cochrane library, the JBI Library, the Web of Science, Google Scholar and manual search. A total of nine studies reporting the prevalence of self-medication among university students were included. Data were extracted using a standardized data extraction format prepared in Microsoft Excel and the analysis was done using STATA 14 statistical software. To assess heterogeneity, I2 test was used since the included studies exhibit high heterogeneity, a random effect meta-analysis model was computed to estimate the pooled prevalence of self-medication. In another way, the association between predictor variables, and self-medication practice were examined. Result A total of 3513 study respondents from nine studies in Ethiopia published between 2010-2017 were included in the study. The result of our study reveals that a pooled prevalence of self-medication among university students was 45.61% (95%CI: 30.66, 60.57). Included studies have a sample size ranged from 250 to 548 with lowest prevalence (19.81%) of self-medication from University of Gondar, whereas the highest prevalence (77.01%) recorded in a study conducted at Arsi University. Conclusion Prevalence of Ethiopian university students was 45.61%, which is very high with the current global health problem with Anti-microbial resistance increment and other toxicity. In addition to this in this study, the association between self-medication and year of study was insignificant and statistically significant with the sex of participants and income level. Systemic review registration PROSPERO International prospective register of systematic reviews: CRD42018099975

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Serial interval and incubation period of COVID-19: a systematic review and meta-analysis

BMC Infectious Diseases ◽

10.1186/s12879-021-05950-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Muluneh Alene ◽

Leltework Yismaw ◽

Moges Agazhe Assemie ◽

Daniel Bekele Ketema ◽

Wodaje Gietaneh ◽

...

Keyword(s):

Systematic Review ◽

Incubation Period ◽

Meta Analysis ◽

Random Effect ◽

Public Health Intervention ◽

Cochrane Library ◽

Cross Sectional ◽

Serial Interval ◽

The Mean

Abstract Background Understanding the epidemiological parameters that determine the transmission dynamics of COVID-19 is essential for public health intervention. Globally, a number of studies were conducted to estimate the average serial interval and incubation period of COVID-19. Combining findings of existing studies that estimate the average serial interval and incubation period of COVID-19 significantly improves the quality of evidence. Hence, this study aimed to determine the overall average serial interval and incubation period of COVID-19. Methods We followed the PRISMA checklist to present this study. A comprehensive search strategy was carried out from international electronic databases (Google Scholar, PubMed, Science Direct, Web of Science, CINAHL, and Cochrane Library) by two experienced reviewers (MAA and DBK) authors between the 1st of June and the 31st of July 2020. All observational studies either reporting the serial interval or incubation period in persons diagnosed with COVID-19 were included in this study. Heterogeneity across studies was assessed using the I2 and Higgins test. The NOS adapted for cross-sectional studies was used to evaluate the quality of studies. A random effect Meta-analysis was employed to determine the pooled estimate with 95% (CI). Microsoft Excel was used for data extraction and R software was used for analysis. Results We combined a total of 23 studies to estimate the overall mean serial interval of COVID-19. The mean serial interval of COVID-19 ranged from 4. 2 to 7.5 days. Our meta-analysis showed that the weighted pooled mean serial interval of COVID-19 was 5.2 (95%CI: 4.9–5.5) days. Additionally, to pool the mean incubation period of COVID-19, we included 14 articles. The mean incubation period of COVID-19 also ranged from 4.8 to 9 days. Accordingly, the weighted pooled mean incubation period of COVID-19 was 6.5 (95%CI: 5.9–7.1) days. Conclusions This systematic review and meta-analysis showed that the weighted pooled mean serial interval and incubation period of COVID-19 were 5.2, and 6.5 days, respectively. In this study, the average serial interval of COVID-19 is shorter than the average incubation period, which suggests that substantial numbers of COVID-19 cases will be attributed to presymptomatic transmission.

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Prevalence of endocrine disorders in obese patients: systematic review and meta-analysis

Acta Endocrinologica ◽

10.1530/eje-19-0666 ◽

2020 ◽

Vol 182 (1) ◽

pp. 11-21 ◽

Cited By ~ 7

Author(s):

L T van Hulsteijn ◽

R Pasquali ◽

F Casanueva ◽

M Haluzik ◽

S Ledoux ◽

...

Keyword(s):

Systematic Review ◽

Meta Analysis ◽

Free Testosterone ◽

Cochrane Library ◽

Total Testosterone ◽

Endocrine Disorders ◽

Cross Sectional ◽

Pooled Prevalence ◽

Cross Sectional Design ◽

Underlying Mechanisms

Objective The increasing prevalence of obesity is expected to promote the demand for endocrine testing. To facilitate evidence guided testing, we aimed to assess the prevalence of endocrine disorders in patients with obesity. The review was carried out as part of the Endocrine Work-up for the Obesity Guideline of the European Society of Endocrinology. Design Systematic review and meta-analysis of the literature. Methods A search was performed in MEDLINE, EMBASE, Web of Science and COCHRANE Library for original articles assessing the prevalence of hypothyroidism, hypercortisolism, hypogonadism (males) or hyperandrogenism (females) in patients with obesity. Data were pooled in a random-effects logistic regression model and reported with 95% confidence intervals (95% CI). Results Sixty-eight studies were included, concerning a total of 19.996 patients with obesity. The pooled prevalence of overt (newly diagnosed or already treated) and subclinical hypothyroidism was 14.0% (95% CI: 9.7–18.9) and 14.6% (95% CI: 9.2–20.9), respectively. Pooled prevalence of hypercortisolism was 0.9% (95% CI: 0.3–1.6). Pooled prevalence of hypogonadism when measuring total testosterone or free testosterone was 42.8% (95% CI: 37.6–48.0) and 32.7% (95% CI: 23.1–43.0), respectively. Heterogeneity was high for all analyses. Conclusions The prevalence of endocrine disorders in patients with obesity is considerable, although the underlying mechanisms are complex. Given the cross-sectional design of the studies included, no formal distinction between endocrine causes and consequences of obesity could be made.

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Magnitude and determinants of neural tube defect in Africa: a systematic review and meta-analysis

BMC Pregnancy and Childbirth ◽

10.1186/s12884-021-03848-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Daniel Atlaw ◽

Yohannes Tekalegn ◽

Biniyam Sahiledengle ◽

Kenbon Seyoum ◽

Damtew Solomon ◽

...

Keyword(s):

Systematic Review ◽

Neural Tube ◽

Meta Analysis ◽

Random Effect ◽

Random Effect Model ◽

Folic Acid Supplementation ◽

Maternal Exposure ◽

X Ray ◽

Effect Model ◽

Pooled Prevalence

Abstract Background Neural tube defects (NTDs) are a group of disorders that arise from the failure of the neural tube close between 21 and 28 days after conception. About 90% of neural tube defects and 95% of death due to these defects occurs in low-income countries. Since these NTDs cause considerable morbidity and mortality, this study aimed to determine the prevalence and associated factors of NTDs in Africa. Methods The protocol of this study was registered in the International Prospective Register of Systematic Reviews (PROSPERO number: CRD42020149356). All major databases such as PubMed/MEDLINE, EMBASE, CINAHL, Web of Science, African Journals Online (AJOL), and Google Scholar search engine were systematically searched. A random-effect model was used to estimate the pooled prevalence of NTDs in Africa, and Cochran’s Q-statistics and I2 tests were used to assess heterogeneity between included studies. Publication bias was assessed using Begg ’s tests, and the association between determinant factors and NTDs was estimated using a random-effect model. Results Of the total 2679 articles, 37 articles fulfilled the inclusion criteria and were included in this systematic review and meta-analysis. The pooled prevalence of NTDs in Africa was 50.71 per 10,000 births (95% CI: 48.03, 53.44). Folic acid supplementation (AOR: 0.40; 95% CI: 0.19–0.85), maternal exposure to pesticide (AOR: 3.29; 95% CI: 1.04–10.39), mothers with a previous history of stillbirth (AOR: 3.35, 95% CI: 1.99–5.65) and maternal exposure to x-ray radiation (AOR 2.34; 95% CI: 1.27–4.31) were found to be determinants of NTDs. Conclusions The pooled prevalence of NTDs in Africa was found to be high. Maternal exposure to pesticides and x-ray radiation were significantly associated with NTDs. Folic acid supplementation before and within the first month of pregnancy was found to be a protective factor for NTDs.

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