The prevalence of selected major external birth defects from a population- based surveillance program in Haryana, India, 2015–2019

The prevalence of selected major external birth defects from a population- based surveillance program in Haryana, India, 2015–2019 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The prevalence of selected major external birth defects from a population- based surveillance program in Haryana, India, 2015–2019 P N Mohanty, Rakesh Gupta, Minakshi Sharma, Suresh Dalpath, Neelanja Chaturvedi, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7608088/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Most published birth defects (BDs) prevalence estimates in India are estimated from hospital-based surveillance studies. We estimated the prevalence of selected major external BDs using data from active, population-based surveillance in two districts of Haryana- Ambala and Yamunanagar, India. Methods: Active surveillance of all deliveries between 2015–2019 was led by the Foundation for Survival of Women and Children (SWACH) and conducted by community healthcare workers in rural Haryana. Cases were defined as any live birth or stillbirth with a selected major external BD born to a mother residing in one of the 10 rural subdistricts of Ambala or Yamuna Nagar at the time of delivery. The prevalence of BDs was estimated overall and stratified by birth outcome, infant sex, and birth year. Results: Among 124,942 live and stillbirths, 611 infants had a major external BD. The highest prevalence (per 10,000 births) included talipes (18.6), neural tube defects (NTDs, 15.9), and orofacial clefts (9.2). The lowest prevalence included hypospadias (0.5), gastroschisis (0.5), and omphalocele (0.4). Among these cases, 533 (87.2% ) survived, and 78 (12.8%) were stillborn. Males had a higher prevalence of imperforate anus compared to females. NTDs and limb reduction defects decreased from 2015 to 2019 (p<0.004 trend). Conclusions: This study demonstrated the feasibility of implementing BD surveillance at birth through a network of community healthcare workers and provide. Findings provide first population-based estimates of major external BD prevalence among live births and stillbirths from India. In Haryana, major external BDs are common and contribute to perinatal mortality. In addition to determining burden and distribution of birth defects, the findings will help with planning prevention and clinical care activities related to BDs in Haryana. Birth defects Congenital anomalies Congenital malformations Birth prevalence Community based Surveillance Haryana India Background Globally, over 8 million children each year (> 6% of total births annually) are born with a serious birth defect (structural or functional abnormality), which may result in death or lifelong disability 1 . The 2010 Global Burden of Disease (GBD) Study ranks birth defects 17th among the leading causes of disease burden worldwide 2 and 23rd among all causes of mortality (~ 6%of neonatal and infant deaths up to 1 year of age, and 2.5% of child deaths 1–4 years) 3 . In 2015, among the 2.68 million neonatal deaths (within the first 28 days of life) worldwide, 303,000 were due to birth defects, accounting for 11% of neonatal mortality 4 . Disproportionately impacted are low- and middle-income countries bearing 94% of all severe birth defects 1 , 4 . Rigorous surveillance programs are crucial for accurately estimating the prevalence of birth defects and effective planning and implementation of prevention programs and their clinical and surgical management. In India, reported estimates of birth defects prevalence have varied widely. Previous estimates from the March of Dimes report (2006) an estimated 1.7 million birth defects occurred annually in India, corresponding to 6–7% of all births in the country 5 . A meta-analysis of available data published between 1960–2015 estimated that 472,000 births (421,652–522,676 out of ~ 25 million births) in India each year were affected by a birth defect (estimated prevalence: ~184 cases per 10,000 births; 95% CI: 165–204) 6 . The primary source of information on birth defects in India are hospital-based studies with several programs 7 , 8 . These include three hospital-based databases: (1) the Birth Defect Registry of India (BDRI),which relies on passive reporting from participating hospitals across India; (2) a sub-national hospital-based database which provides real-time monitoring and tracking of sick newborns ( https://sncuindiaonline.org ) 9 ; and (3) the National Neonatal Perinatal Database (NNPD), which focuses on neonatal morbidities but includes some birth defects data 7 , 10 . Additionally, Rashtriya Bal Swasthya Karyakram (RBSK), a community and health facility based initiative launched by the Government of India in 2013 as part of the national child health program, aims at screening for early identification and intervention of birth defects, deficiencies, diseases, and developmental delays among children from birth to 18 years of age 7 , 8 . The focus of these systems either on hospital-based data alone or on medical treatment and management may limit representativeness of the true prevalence of birth defects in a population. Furthermore, several of the systems include only a few birth defects as their primary objective is not birth defects surveillance. An active, population-based birth defects surveillance program with rigorously established case specificity is required to understand the prevalence of birth defects in India. In July 2015, the Foundation for Survival of Women and Children, a national non-governmental organization in India, launched an active, population-based birth defects surveillance system in Haryana in collaboration with the Haryana state government and the National Health Mission (NHM), and with support from the World Health Organization South-East Asia Regional Office (WHO-SEARO) and the U.S. Centers for Disease Control and Prevention (CDC) 11 . The objective of this system was to estimate the prevalence of selected major external birth defects in two rural sub-districts, Ambala and Yamunanagar, located in the state of Haryana, surveying births between July 1, 2015 and December 31, 2019. Methods Birth defects surveillance program and study population The Haryana population-based surveillance program was conducted in the rural areas (10 subdistricts known as community blocks) of Ambala and Yamuna Nagar districts of Haryana state. An estimated 1.66 million people are covered under this surveillance program, making up 65% of the total population of these two districts. In this geographical area, there are 2 district hospitals, 3 sub-districts hospitals, 12 community health centers, 44 primary health centers and 216 sub-centers. Nearly 98% of the births in Haryana occur in health care facilities (59% government, 39% private) and 2% are home births (based on SWACH analysis of the live births from June, 2013 to November, 2022). Among government health facilities, most deliveries (36%) take place in district and sub-district hospital followed by community health centers (9%) and primary health centers (8%). Active birth defects surveillance was carried out using existing community health workers known as Accredited Social Health Activists (ASHAs) working under India’s national Home Based Newborn Care (HBNC) program 12 – 14 . ASHAs are women who are recruited and trained within local communities by the Government of India to help address the health needs and improve health outcomes, particularly among women and children 15 . ASHAs serve as health activists, educators, and basic essential health service providers through home-based visits which occur at least once a month. They provide health counseling and support and accompany families, when needed, to seek medical care from health facilities. Additionally, ASHAs maintain health records and participate in community-level health events and planning. Within their villages, ASHAs registers all new pregnancies, births, and deaths. They ensure that pregnant women receive at least 4 antenatal check-ups by an auxiliary nurse midwife or a higher-level medical provider before delivery. They provide counseling to pregnant women and make birth plans to support safe delivery. ASHAs accompany the pregnant woman to a hospital or health center for delivery. If an institutional delivery is not possible or a home delivery is preferred, ASHAs advise the mother and provide appropriate linkages to have the delivery under the care of a skilled birth attendant. After delivery, ASHAs assist the mother with initiation of breast-feeling and (under HBNC) follow the status of the mother and baby during the post-partum period on days 3, 7, 14, 21, 28 and 42 days after birth. Beyond the post-partum period, ASHAs will also conduct additional home visits to families with children under the age of 2 to provide and support health counseling, preventive care, first-aid, immunizations, treatment of simple illnesses and referrals for more complicated conditions. Each ASHA serves a population of ~ 1,000 individuals. A total of 1,656 ASHAs serve the rural populations covered under the Haryana population-based surveillance program. Throughout the time period of the present analyses, only rural areas were covered in this surveillance since there were insufficient number of ASHAs operating in urban areas. For the Haryana population-based surveillance birth defects program, ASHAs, in groups of 25–30 individuals, underwent a one-day training facilitated by the Haryana government, the district, and SWACH, on maternal and child health, home-based postnatal care, and birth defects surveillance. During this training, their roles and responsibilities were explained, including the specific information required to be reported to SWACH via a mobile phone provided by the Haryana government. To assist with the identification of birth defects, each ASHA received a folder on birth defects developed by NHM and a laminated chart on major external birth defects developed by SWACH. In addition, a structured format was provided to guide reporting on pregnancy registration, pregnancy outcome, place of delivery, birth weight, timing of initiation of breast feeding, visible birth defects, and status of the mother through 42 days after birth. Using mobile phones, ASHAs report all birth defects identified by the hospital/birthing facility staff, a family member, or the ASHA herself to a supervising general nurse midwives. Upon receiving notification of a birth defect case, the supervising general nurse midwife contacts the ASHA and the family to obtain detailed descriptions of the case along with available photographs of any visible birth defects in the infant along with medical records. SWACH team contacts ASHAs twice a month to get information of birth defect babies in their areas, followed by calling the parents of the affected child for confirmation of the birth defect. Parents were also asked to share investigation reports with SWACH team which include Doctors to make the final diagnosis. If photographs were not available, a sketch was drawn by SWACH team based on the description of the case by the parents. For live births, all case infants were followed-up by ASHAs under the HBPNC program to record their health and survival status. When a stillbirth or a neonatal death was reported, a detailed description of the circumstances and documentation were obtained by the ASHA and shared with SWACH team for review, including observations from family members and healthcare providers who attended the delivery or cared for the infant (e.g., presence of one or more birth defects, ultrasound reports, discharge cards, etc.,). Verbal autopsy data collection and classification followed the World Health Organization (WHO) 2016 Verbal Autopsy Standards.Repeated interactions between families, healthcare providers, and ASHAs were required to obtain complete case descriptions, photographs, and results of medical/discharge reports. Additional follow-up was conducted as needed to obtain all required information for complete and accurate data reporting. Ongoing interactions also provided the opportunity to counsel and assist families with accessing and utilizing medical or rehabilitative services based on the health needs of the infant. All reported birth defects were verified by the birth defects team at SWACH (project manager/coordinator and principal investigator) using the case description, photographs, and medical reports. SWACH birth defects team classified each case according to the International Classification of Diseases 10th Revision (ICD-10) 16 and then uploaded the data to the Southeast Asia Region Newborn Birth Defects Database (SEAR-NBBD), housed within WHO-SEARO’s online portal 17 , 18 . WHO-SEARO team reviewed the data and provided feedback to SWACH on data quality, diagnoses, and coding. Based on the feedback, corrections were made, and the revised information was uploaded again. Diagnoses and coding were compared against the case description, photographs, and findings of medical investigations in third level of review and verification by birth defects experts from the CDC in preparation for analyses. A standard form was developed and used to collect the following data on each case: subdistrict of birth; maternal and paternal age; previous history of stillbirth or spontaneous abortion; parental consanguinity, defined as a relationship between individuals who are second cousins or closer; date and mode of delivery; birth outcome (live birth vs stillbirth); infant sex, birth weight, gestation, and head circumference; plurality; description, diagnosis, and ICD-10 code of birth defects, and results of an autopsy or any medical investigations. A case was defined as (1) alive born infant or a fetus (stillbirth at least 20 weeks of gestation or > 500 grams) with a selected major externally visible birth defect; (2) born to a mother residing at the time of delivery in one of the 10 rural subdistricts of Ambala or Yamunanagar districts, (3) with a birth defect that was noted by a health care provider, family member or a community health worker (ASHA) up to a month after birth. Selected major external visible birth defects which included neural tube defects (NTDs; anencephaly, cranioraschisis, encephalocele, spina bifida, and iniencephaly), orofacial clefts, limb reduction defects, talipes (club foot), abdominal wall defects (omphalocele and gastroschisis), imperforate anus, and hypospadias (Table 1 ). These major external birth defects were further classified as isolated birth defect (having only one major birth defect), multiple birth defects (having two or more major birth defects), or a syndrome (occurring as part of a genetic or chromosomal condition). Table 1 Disease classification codes for selected major external birth defects in the Haryana population-based surveillance program, India, July, 2015–December, 2019 Birth Defect ICD-10 Code Neural tube defects - Anencephaly, Craniorachischisis, Iniencephaly Q00.0, Q00.1, Q00.2 Encephalocele Q01.0–Q01.2, Q01.8–Q01.9 Spina bifida Q05.0–Q05.9, Q07.0 Orofacial clefts - Cleft palate only Q35.1–Q35.9, Q87.0 Cleft lip only Q36.0, Q36.9 Cleft palate + cleft lip Q37.0–Q37.9 Gastrointestinal defects Imperforate anus Q42.3 Genitourinary defects - Hypospadias Q54.0–Q54.3, Q54.8–Q54.9 Musculoskeletal defects Talipes Q66.0, Q66.1, Q66.4, Q66.8 Limb reduction defects Q71.0–Q73.8 Abdominal wall defects Omphalocele Q79.2 Gastroschisis Q79.3 All methods were carried out in accordance with the Indian Council of Medical Research (ICMR) National Ethical Guidelines for Biomedical and Health Research Involving Human Participants (2017). Data collection using verbal autopsy tools adhered to the World Health Organization (WHO) 2016 Verbal Autopsy Standards. Reporting of observational data followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Data analysis We used SAS 9.4 (Cary, NC) to estimate the prevalence with 95% confidence intervals (CI) for each selected major external birth defect, overall, and stratified by birth outcome, infant sex, birth year, and district. Chi-square tests were used to assess differences in prevalence by birth outcome, infant sex, and district. For cells with values < 5, Fisher’s exact test was used and exact confidence intervals were provided. The Cochrane-Armitage test was used to evaluate trends across birth years. Analyses were conducted in duplicate and independently validated by two data analysts. Results Table 2 Characteristics of infants with selected major external birth defects in the Haryana population-based surveillance program, India, July 2015–December 2019 N Proportion (%) Total 611 100 Birth Outcome Live births 533 87.2 Stillbirths 78 12.8 Infant sex 1 Male 354 57.9 Female 251 41.1 District Ambala 263 43.0 Yamunanagar 348 57.0 Gestational age ≥ 37 weeks 403 66.0 <37 weeks 208 34.0 Birth weight ≥ 2500 g 404 66.1 1500–2499 g 122 20.0 <1500 g 85 13.9 Plurality 2 Singleton 602 98.5 Multiple 8 1.3 Maternal age (years) 3 <20 9 1.5 20–24 283 46.3 25–29 257 42.1 30–34 47 7.7 ≥ 35 14 2.3 Parental consanguinity Yes 4 5 0.8 No 598 97.9 1 Six cases were of indeterminate sex. 2 One missing case. 3 One missing case. 4 Yes indicates second cousins or closer. Eight cases missing data on consanguinity. A total of 124,942 births occurred over the study period: 122,753 (98.2%) were live births and 2,189 (1.8%) were stillbirths. Of these, 611 infants (5 infants per 1000) had at least one of the major external birth defects included in the surveillance. Among cases, 87.2% (n = 533) were live births and 78 (12.8%) were stillbirths (Table 2 ). More than half of the cases were male (57.9% male. 41.1% female, and < 1.0% indeterminate sex) and more than half were reported from Yamunanagar district (Yamunanagar 57.0%, Ambala 43.0%). Most of the cases were singleton births (98.5%) with the remaining being twins or triplets. Most case mothers (96.1%) were between ages 20–34 years; while 1.5% were < 20 years of age and 2.3% were 35 years or older. Parental consanguinity was reported in < 1% of cases. Table 3 Prevalence of selected major external birth defects in the Haryana population-based surveillance program, India, July 2015–December 2019 Birth Defect N All births (n = 124,942) Prevalence 1 (95% CI) N Live births (n = 122,753) Prevalence 1 (95% CI) Neural tube defects 2 199 15.9 (13.7, 18.1) 131 10.7 (8.9, 12.5) Anencephaly 35 2.8 (1.9, 3.7) 6 0.5 (0.1, 0.9) Encephalocele 33 2.6 (1.7, 3.5) 17 1.4 (0.7, 2.0) Spina bifida 133 10.6 (8.8, 12.5) 108 8.8 (7.1, 10.5) Orofacial clefts 115 9.2 (7.5, 10.9) 110 9.0 (7.3, 10.6) Cleft palate only 19 1.5 (0.8, 2.2) 19 1.6 (0.9, 2.2) Cleft lip only 57 4.6 (3.4, 5.8) 52 4.2 (3.1, 5.4) Cleft palate + cleft lip 39 3.1 (2.1, 4.1) 39 3.2 (2.2, 4.2) Gastrointestinal defects Imperforate anus 50 4.0 (2.9, 5.1) 49 4.0 (2.9, 5.1) Genitourinary defects Hypospadias 3 3 0.5 (0.1, 1.3) 3 - Musculoskeletal defects Talipes 236 18.9 (16.5, 21.3) 229 18.7 (16.2, 21.1) Limb reduction defects 4 31 2.5 (1.6, 3.4) 28 2.3 (1.4, 3.1) Upper limb reduction 24 1.9 (1.2, 2.7) 21 1.7 (1.0, 2.4) Lower limb reduction 13 1.0 (0.5, 1.6) 12 1.0 (0.4, 1.5) Abdominal wall defects Omphalocele 5 0.4 (0.0, 0.8) 4 0.3 (0.1, 0.8) Gastroschisis 6 0.5 (0.1, 0.9) 5 0.4 (0.1, 0.8) 1 Prevalence reported as cases per 10,000 births 2 Two cases of craniorachischisis included in anencephaly. No iniencephaly were reported among cases. Two case infants had anencephaly and spina bifida. One case infant had encephalocele and spina bifida. 3 Birth prevalence among males only. No live birth prevalence reported due to lack of male live birth denominator. 4 Six case infants had upper and lower limb reduction defects. Among all live and stillbirths examined, talipes was the most common birth defect with a prevalence of 18.9 per 10,000 births (95% CI: 16.5, 21.3; Table 3 ). NTDs were the second most common birth defect with a prevalence of 15.9 per 10,000 births (95% CI: 13.7, 18.1) followed by orofacial clefts (9.2 per 10,000 births; 95% CI: 7.5, 10.9). Among the different types of NTDs, the prevalence of anencephaly, encephalocele, and spina bifida were 2.8 (95% CI: 1.9, 3.7), 2.6 (95% CI: 1.7, 3.5), and 10.6 per 10,000 births (95%CI: 8.8, 12.5), respectively. The major external birth defects with the lowest observed prevalence included hypospadias (0.5 per 10,000 births; 95%CI: 0.1, 1.3; n = 3); gastroschisis (0.5 per 10,000 births; 95% CI: 0.1, 0.9; n = 6), and omphalocele (0.4 per 10,000 births; 95% CI: 0.0, 0.8; n = 5). The most common major external BDs, which restricting to just live births, show a slightly lower prevalence (Table 3 ): talipes (18.7 per 10,000 live births; 95% CI: 16.2, 21.1), NTDs (10.7 per 10,000; 95% CI: 8.9, 12.5), and orofacial clefts (9.0 per 10,000 live births; 95% CI: 7.3, 10.6). Over 25% of birth defects cases (n = 156) were stillbirths (n = 78) or deaths within 28 days of birth (n = 78). The survival of case infants varied by type of birth defects. The majority of birth defects cases that were stillborn or died during the neonatal period occurred among infants with a neural tube defect (109 NTDs / 156 stillbirths and neonatal deaths; 69.9%). More than half of NTD cases were stillborn (68 NTD stillbirths/199 NTDs; 34.2%) or died within 28 days after birth (41 NTD neonatal deaths/199 NTDs; 20.6%). As Anencephaly is incompatible with life, 82.9%, n = 29 were stillborn and 17.1%, n = 6 died within the neonatal period. Among cases of encephalocele (n = 33), more than three quarters were stillborn (48.5%, n = 16) or died within the neonatal period (30.3%, n = 10) and remaining cases are alive (21.2%, n = 7). Among cases of orofacial clefts (n = 115), most were live births and survived past the neonatal period (85.2%, n = 98). Far fewer orofacial clefts were stillborn (4.4%, n = 5) or died within the neonatal period (10.4%, n = 12). Overall, we observed very few cases of omphalocele (n = 4) or gastroschisis (n = 3). Most cases of omphalocele and gastroschisis were stillborn (omphalocele: 25.0%, n = 1; gastroschisis: 25.0%, n = 1) or died within the neonatal period (omphalocele: 50.0%, n = 2; gastroschisis: 75.0%, n = 3). Table 4 Prevalence of selected major external birth defects by infant sex in the Haryana population-based surveillance program, India, July 2015–December 2019 Birth Defect Male ( n = 66,164 ) Female ( n = 58,736 ) N Cases per 10,000 births (95%CI) N Cases per 10,000 births (95%CI) Neural tube defects 106 16.0 (13.0, 19.1) 87 14.8 (11.7, 17.9) Anencephaly 15 2.3 (1.1, 3.4) 17 2.9 (1.5, 4.3) Encephalocele 12 1.8 (0.8, 2.8) 18 3.1 (1.7, 4.5) Spina bifida 78 11.8 (9.2, 14.4) 55 9.4 (6.9, 11.8) Orofacial clefts 71 10.7 (8.2, 13.2) 44 7.5 (5.3, 9.7) Cleft palate only 12 1.8 (0.8, 2.8) 7 1.2 (0.3, 2.1) Cleft lip only 35 5.3 (3.5, 7.0) 22 3.8 (2.2, 5.3) Cleft palate + cleft lip 24 3.6 (2.2, 5.1) 15 2.6 (1.3, 3.9) Gastrointestinal defects - - - - Imperforate anus 1 37 5.6 (3.8, 7.4) 13 2.2 (1.0, 3.4) Genitourinary defects - - - - Hypospadias 3 0.5 (0.1, 1.3) - - Musculoskeletal defects - - - - Talipes 133 20.1 (16.7, 23.5) 103 17.5 (14.2, 20.9) Limb reduction defects 20 3.0 (1.7, 4.4) 11 1.9 (0.8, 3.0) Upper limb reduction 14 2.1 (1.0, 3.2) 10 1.7 (0.6, 2.8) Lower limb reduction 9 1.4 (0.5, 2.3) 4 0.7 (0.2, 1.7) Abdominal wall defects Omphalocele 4 0.6 (0.1, 1.6) 1 0.2 (0.0, 0.9) Gastroschisis 3 0.5 (0.1, 1.3) 3 0.5 (0.1, 1.5) 1 Chi-square test for difference by sex; p = 0.0029 for imperforate anus. When examining the prevalence of selected major external birth defects by infant sex, males had significantly higher prevalence of imperforate anus compared to females (5.6 per 10,000; 95%CI:3.8,7.4 v. 2.2 per 10,000; 95%CI: 1.0, 3.4; p = 0.0029; Table 4 ). The prevalence of common birth defects such as talipes (20.1; 95% CI: 16.7, 23.5 v. 17.5; 95% CI: 14.2, 20.9), NTDs (16.0; 95% CI: 13.0, 19.1 v. 14.8; 95%CI: 11.7, 17.9), and orofacial clefts (10.7; 95%CI: 8.2, 13.2 v. 7.5; 95% CI: 5.3, 9.7) did not significantly differ between males compared with females. Table 5 Prevalence of selected major external birth defects by birth year in the Haryana population-based surveillance program, India, July 2015–December 2019 Birth Defect 2015 ( n = 15,484 ) 2016 ( n = 27,166 ) 2017 ( n = 27,372 ) 2018 ( n = 26,774 ) 2019 ( n = 28,146 ) N Cases per 10,000 births (95%CI) N Cases per 10,000 births (95%CI) N Cases per 10,000 births (95%CI) N Cases per 10,000 births (95%CI) N Cases per 10,000 births (95%CI) Neural tube defects 1 36 22.3 (15.7, 30.8) 53 19.5 (14.3, 24.8) 53 19.4 (14.2, 24.6) 28 10.5 (6.6, 14.3) 29 10.3 (6.6, 14.1) Anencephaly 1 6 3.9 (1.4, 6.4) 12 4.4 (1.9, 6.9) 10 3.7 (1.4, 5.9) 6 2.2 (0.4, 4.0) 1 0.4 (0.0, 2.0) Encephalocele 5 3.2 (1.1, 7.5) 10 3.7 (1.4, 6.0) 8 2.9 (0.9, 5.0) 6 2.2 (0.4, 4.0) 4 1.4 (0.4, 3.6) Spina bifida 1 26 16.8 (10.3, 23.2) 32 11.8 (7.7, 15.9) 36 13.2 (8.9, 17.5) 15 5.6 (2.8, 8.4) 24 8.5 (5.1, 11.9) Orofacial clefts 20 12.9 (7.3, 18.6) 24 8.8 (5.3, 12.4) 27 9.9 (6.2, 13.6) 16 6.0 (3.1, 8.9) 28 10.0 (6.3, 13.6) Cleft palate only 0 - 5 1.8 (0.2, 3.5) 5 1.8 (0.2, 3.4) 5 1.9 (0.2, 3.5) 4 1.4 (0.4, 3.6) Cleft lip only 14 9.0 (4.3, 13.8) 10 3.7 (1.4, 6.0) 15 5.5 (2.7, 8.3) 6 2.2 (0.4, 4.0) 12 4.3 (1.9, 6.7) Cleft palate + cleft lip 6 3.9 (0.8, 7.0) 9 3.3 (1.2, 5.5) 7 2.6 (0.7, 4.5) 5 1.9 (0.2, 3.5) 12 4.3 (1.9, 6.7) Gastrointestinal defects - - - - - - - - - - Imperforate anus 6 3.9 (0.8, 7.0) 11 4.1 (1.7, 6.4) 17 6.2 (3.3, 9.2) 5 1.9 (0.2, 3.5) 11 3.9 (1.6, 6.2) Musculoskeletal defects - - - - - - - - - - Talipes 30 19.4 (12.5, 26.3) 49 18.0 (13.0, 23.1) 52 19.0 (13.8, 24.2) 42 15.7 (11.0, 20.4) 63 22.4 (16.9, 27.9) Limb reduction defects 1 9 5.8 (2.0, 9.6) 9 3.3 (1.2, 5.5) 7 2.6 (0.7, 4.5) 4 1.5 (0.4, 3.8) 2 0.7 (0.1, 2.6) Upper limb reduction 1 9 5.8 (2.0, 9.6) 8 2.9 (0.9, 4.5) 4 1.5 (0.4, 3.7) 1 0.4 (0.0, 2.1) 2 0.7 (0.1, 2.6) Lower limb reduction 3 1.9 (0.4, 5.7) 2 0.7 (0.1, 2.7) 5 1.8 (0.2, 3.4) 3 1.1 (0.2, 3.3) 0 - Abdominal wall defects - - - - - - - - - - Omphalocele 2 1.3 (0.2, 4.7) 2 0.7 (0.1, 2.7) 0 - 0 - 1 0.4 (0.0, 2.0) Gastroschisis 2 1.3 (0.2, 4.7) 0 - 2 0.7 (0.1, 2.6) 0 - 2 0.7 (0.1, 2.6) 1 Cochran-Armitage test for trend; p < 0.004. The proportion of births occurring across each year of when data was collected are similar: 12.4% (6 months, July-December 2015), 21.7% (2016), 21.9% (2017), 21.4% (2018), and 22.5% (2019). The overall prevalence of neural tube defects (p trend <0.0001) and limb reduction defects (p trend =0.0007) decreased over time (Table 5 ). Specific reductions in prevalence over time were observed for spina bifida (p trend =0.002) and upper limb reduction defects (p trend <0.0001). No significant changes in prevalence over time were observed among other major external birth defects. Between 2015–2019, 57, 918 births occurred in Ambala and 67,024 births occurred in Yamunanagar. Among the major external defects, the prevalence of neural tube defects overall was higher in Yamunanagar compared to Ambala (18.5 per 10,000; 95% CI: 15.3, 21.8 v. 13.0 per 10,000; 95% CI: 10.0, 15.9; p = 0.01; Supplemental Table ). Spina bifida (12.4; 95% CI: 9.7, 15.1 v. 8.6; 95% CI: 6.2, 11.0) and cleft lip (5.7; 95% CI: 3.9, 7.5 v. 3.3; 95% CI: 1.8, 4.8) were also more prevalent in Yamunanagar compared to Ambala (p < 0.05). The prevalence of the other major external birth defects did not differ significantly by district. Discussion Our analyses provide the first estimation of the prevalence of major external birth defects in the rural areas of two districts in Haryana, India. This is also the first data on population-based birth defects surveillance from India among live births and stillbirths as there has been no previously published data of its kind. Our analyses indicated that major external birth defects are common and contribute to perinatal mortality in Haryana. Among all reported major external birth defects, talipes and NTDs were the most reported defects and hypospadias, and the abdominal wall defects (omphalocele and gastroschisis) were among the least commonly reported defects. Due to the small numbers observed for hypospadias (n = 3), omphalocele (n = 5), and gastroschisis (n = 6), interpreting data on these birth defects should be conducted cautiously. The prevalence of talipes reported in our study was similar to published estimates from a recent meta-analysis (17.9 per 10,000 births; 95% CI 15.1, 20.7) 6 . However, the prevalence for NTDs from our analyses was lower than previously reported. Based on modelled estimates from the March of Dimes, India has ~ 1/3 of the world’s burden of neural tube defects (with a prevalence of ~ 47 per 10,000 births) 1 . Similar to the modelled estimate, a meta-analysis of mostly hospital-based studies across India reported an overall birth prevalence of NTDs in India (~ 41 cases per 10,000 total births) which is higher than estimates reported in our study 19 .In this meta-analysis, anencephaly was the most common form of NTDs at 21 per 10,000 births, and the prevalence of spina bifida was 19 per 10,000 births. The estimated overall NTD prevalence from North India (73 per 10,000 births) including a retrospective hospital-based study from the city of Rohtak in Haryana (182 per 10,000 births) were also much higher than that our estimates 19 .Our NTD prevalence estimates were also lower than a 2015 population-based survey (24 per 10,000 live births) of women from one subdistrict of the Faridabad district in Haryana who recalled having a previous pregnancy affected by an NTD between 2001–2014 20 . Data on NTDs from this study were based on self-reports from women (or reports by a relative or neighbor if the woman was not available at the time of survey). Some explanations for why our estimates might be lower could be that data from many of the published studies were older and may lack standardized definitions, methodology and data quality monitoring for case identification and verification. A few estimates were based on retrospective population-based surveys which relied on questionnaires, interviews, and recall of past events. Most estimates were hospital-based which may not be representative of estimates from population-based surveillance covering all births. Large tertiary hospitals may serve as referral centers and may receive women at higher risk of birth defects and receive a higher volume of diagnosed and more complicated birth defects cases. Thus, estimates of birth defects and stillbirths would be higher from these facilities and not representative of the population. Additionally, high patient mobility in and out of catchment areas may also account for the higher prevalence observed in hospital-based surveillance studies compared to population-based surveillance. It should also be noted that presently an ultrasound is commonly performed at 18–20 weeks gestation in India, even among rural populations. Prenatal diagnosis of any lethal birth defects detected, including NTDs, would often result in elective pregnancy terminations. Our surveillance system did not include birth defects among elective terminations of pregnancies; therefore, these cases would have been excluded in our estimates. While the prevalence of NTDs from our study are lower than other estimates in India, the NTD prevalence from the Haryana population-based surveillance program are considerably higher (~ 2 times higher for encephalocele and spina bifida) compared to estimates from the United States where folic acid fortification is mandated 21 , 22 . In addition, from our study, among birth defects cases, almost 70% of the stillbirths and deaths within the first 28 days of birth among occurred in infants with neural tube defects, a birth defect that we know can be effectively prevented with folic acid. The high prevalence and mortality of NTDs suggest a need and an opportunity for a prevention measure or health policy intervention such as folic acid fortification which can bring benefit to all women of reproductive age. Ongoing surveillance through a population-based birth defects surveillance program like the one in Haryana can help to monitor time trends and progress and targeted prevention efforts where they are most needed. Our prevalence estimates of orofacial clefts from the Haryana population-based surveillance program are lower than estimates from the recent meta-analysis of birth defects prevalence in India (orofacial clefts: 14.9 per 10,000 births; 95% CI: 12.6, 17.2). 6 The prevalence of hypospadias, omphalocele, and gastroschisis were also much lower in our study than reports from other studies. 6 A meta-analyses of hospital-based studies estimated the prevalence of hypospadias, omphalocele, and gastroschisis at 12.2 (95% CI: 9.8, 14.6), 4.7 (95% CI: 3.2, 6.1) and 7.0 (95% CI: 4.6, 18.6), respectively. The prevalence of these defects may have been lower in our study due to differences in methodology, data quality, and representativeness as described above. For hypospadias, there might be a chance of this birth defect being missed if the infant was not examined from head to toe with clothing removed by the ASHA or another healthcare provider and if the family does not recognize it as a major problem. There are several strengths of this study. First, population-based birth defects surveillance systems where stillbirths were also recorded and also first study that allow cases to be captured regardless of the location of delivery, whether in large government hospitals or private hospitals, smaller nursing or maternity homes, or at an individual’s home. Second, surveillance was established using a network of community health care workers (ASHAs) through the use of mobile phone technology. With mobile phones, photographs of birth defects and medical records could be captured to help with verification of cases. In addition, ASHAs usually reside in the same villages as the population so they would have an opportunity to identify women who become pregnant and follow them throughout pregnancy. Third, all cases were followed up to assess the outcome of the affected infant. All birth defects cases were followed up at one month of age and then periodically up through the age of 1 year. Follow-up provided an opportunity to gather information on the health and survival status of the child and any treatments the child may have received as well as provide referrals for additional services they may need. As with any surveillance system, there are some limitations in this program. Urban areas were not covered since ASHAs were not available there during the time of interest. Also, incomplete ascertainment may have contributed to under-reporting of some birth defects. In Haryana, less than 5% of births occur in the home and ASHAs follow up all pregnancies. We have confidence all births are captured by ASHAs as women are followed from time of pregnancy. However, if a child was stillborn, ASHAs relied on medical records or reporting by the parents, which may or may not include accurate information about the presence of a birth defect. The lack of including birth defects among elective pregnancy terminations and spontaneous abortions in this dataset would also likely contribute to under-ascertainment. Conclusions Overall, our study demonstrated that it is feasible to implement population-based surveillance of birth defects in rural areas in Haryana through home-based visits via a network of community-based healthcare workers known as ASHAs. ASHAs serve as an important intermediary to ensure the collection of case descriptions, photographs, and medical/discharge reports for complete and accurate reporting of birth defects cases. The system also offers the opportunity to follow the health and survival status of children with birth defects through the 1 year of age to provide additional support and guidance to affected families. Our analyses of data from the Haryana population-bases surveillance system showed that major external birth defects were common, and we observed a high prevalence of NTDs, talipes and orofacial clefts. Data gathered through this surveillance system can be used to help the state of Haryana monitor trends and assess population-level activities related to the prevention of major external birth defects. Abbreviations ASHAs Accredited Social Health Activists BDRI Birth Defect Registry of India CDC Centers for Disease Control and Prevention:Global Burden of Disease GOI Government of India HBNC Home Based Newborn Care ICD-10 International Classification of Diseases 10th Revision NHM National Health Mission NNPD National Neonatal Perinatal Database NTDs neural tube defects RBSK Rashtriya Bal Swasthya Karyakram SEAR-NBBD Southeast Asia Region Newborn Birth Defects Database SWACH Survival for Women & Children Foundation WHO-SEARO World Health Organization South-East Asian Regional Office. Declarations Acknowledgements We are grateful to Dr. (late) Vijay Kumar who conceived and supervised the study. We are grateful to the numerous families, ASHAs, and other healthcare workers who contributed the necessary data for this study. We also express our gratitude to the World Health Organization South-East Asia Regional Office for providing funding and technical support for the Newborn Birth Defects Database (NBBD) and for this study. Funding Funds were provided by the World Health Organization South-East Asia Regional Office under a cooperative agreement with the US Centers for Disease Control and Prevention (CDC-RFA-GH14-1420, Global Prevention of Non-Communicable Disease Prevention and Promotion of Health). Availability of data and materials Data available upon reasonable request. Ethics approval and consent to participate Clearances have been obtained from the ethics committee of the Foundation for Survival of Women and Children (reference ID SWACH/IEC/0101/2025). State approvals are available through a Memorandum of Understanding signed with the National Health Mission in Haryana (http://www.nrhmharyana.gov.in/). Prior to study initiation, informed Consent was obtained from caregivers. Clinical trial number Not applicable. Competing interests The authors declare that they have no competing interests. Consent for publication Not applicable. Author Contribution N.C : Conceptualization, Methodology, Writing – original draftP.M: Investigation, Formal analysis, Data curation, Validation, Visualization, Investigation, Writing – original draft. R.G: review & editingM.S: Investigation, Data curation, Project administrationA.G: Investigation, Data curation, Project administration A.R: Investigation, Formal analysis, Data curation, Writing – original draft. B.S: Investigation, Formal analysis, Data curationC.M: review & editing.R.K: review & editing.R.M: review & editing.All authors approved the manuscript. S.D: review & editing.P.K: Methodology, Validation, Formal analysis, review & editing.V.J: review & editing.N.R: Conceptualization, review & editing References Christianson A, Howson CP, Modell B. March of Dimes global report on birth defects, the hidden toll of dying and disabled children . March of Dimes Birth Defects Foundation; 2006. Accessed 3 February 2022. https://www.marchofdimes.org/mission/march-of-dimes-global-report-on-birth-defects.aspx Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet Dec. 2012;15(9859):2197–223. 10.1016/S0140-6736(12)61689-4 . Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet Dec. 2012;15(9859):2095–128. 10.1016/S0140-6736(12)61728-0 . World Health Organization. Congenital anomalies fact sheet. Accessed 3. February 2022, https://www.who.int/en/news-room/fact-sheets/detail/congenital-anomalies World Health Organization. Birth defects in South-East Asia a public health challenge: Situation analysis. World Health Organization. 2013. Accessed 25 September 2020. https://apps.who.int/iris/handle/10665/204821 Bhide P, Kar A. A national estimate of the birth prevalence of congenital anomalies in India: systematic review and meta-analysis. BMC Pediatr. May 2018;25(1):175. 10.1186/s12887-018-1149-0 . Gupta N, Kabra M, Kapoor S. Establishing National Neonatal Perinatal Database and birth defects registry network - need of the hour! Indian Pediatr Sep. 2014;51(9):693–6. 10.1007/s13312-014-0483-z . Kar A. Birth defects in India: magnitude, public health impact and prevention. JKIMSU. 2014;3(2):7–16. Facility Based Newborn Care Database. Accessed 3. February 2022, https://sncuindiaonline.org/d_loginAction. Sharma R. Birth defects in India: hidden truth, need for urgent action. Indian J Hum Genet. 2013;19(2):125–9. Survival for Women & Children Foundation. Population based surveillance of birth defects. Accessed 3. February 2022, http://www.swach.org/project-pbs-bd/ Ministry of Health and Family Welfare Government of India. Home based care of new born and young child. Accessed 3. February 2022, https://hbnc-hbyc.nhp.gov.in/AboutUs/aboutHBNC ASHA support mechanism. Accessed 3. February 2022, https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=176&lid=249 About Accredited Social Health Activist (ASHA). Accessed 3. February 2022, https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=150&lid=226 National Health Mission. ASHA training modules. Accessed 3. February 2022, https://www.nhm.gov.in/index1.php?lang=1&level=3&sublinkid=184&lid=257 International statistical classification of diseases and related health problems 10th revision. Accessed 3. February 2022, https://icd.who.int/browse10/2019/en Newborn and Birth Defects Database. Accessed 3. February 2022, https://apps.searo.who.int/npn/ New-born and Birth Defects (NBBD) Surveillance Initiative. Accessed 3. February 2022, https://www.who.int/southeastasia/sear-nbbd Bhide P, Sagoo GS, Moorthie S, Burton H, Kar A. Systematic review of birth prevalence of neural tube defects in India. Birth Defects Res Clin Mol Teratol Jul. 2013;97(7):437–43. 10.1002/bdra.23153 . Kant S, Malhotra S, Singh AK, Haldar P, Kaur R, Misra P, Gupta N. Prevalence of neural tube defects in a rural area of north india from 2001 to 2014: A population-based survey. Birth Defects Res Feb. 2017;15(3):203–10. 10.1002/bdra.23578 . Williams J, Mai CT, Mulinare J, et al. Updated estimates of neural tube defects prevented by mandatory folic Acid fortification - United States, 1995–2011. MMWR Morb Mortal Wkly Rep Jan. 2015;16(1):1–5. Mai CT, Isenburg JL, Canfield MA, et al. National population-based estimates for major birth defects, 2010–2014. Birth Defects Res Nov. 2019;1(18):1420–35. 10.1002/bdr2.1589 . Additional Declarations No competing interests reported. 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13:43:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1549986,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7608088/v1/7ed01105-29c7-4394-9f91-a4097b4a2821.pdf"},{"id":94758628,"identity":"8a9a7bbb-7657-49ad-b699-68b2e28d4287","added_by":"auto","created_at":"2025-10-30 11:49:09","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17676,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalTable.docx","url":"https://assets-eu.researchsquare.com/files/rs-7608088/v1/77d316895c33c6c2f31d90ff.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The prevalence of selected major external birth defects from a population- based surveillance program in Haryana, India, 2015–2019","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, over 8\u0026nbsp;million children each year (\u0026gt;\u0026thinsp;6% of total births annually) are born with a serious birth defect (structural or functional abnormality), which may result in death or lifelong disability\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The 2010 Global Burden of Disease (GBD) Study ranks birth defects 17th among the leading causes of disease burden worldwide\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e and 23rd among all causes of mortality (~\u0026thinsp;6%of neonatal and infant deaths up to 1 year of age, and 2.5% of child deaths 1\u0026ndash;4 years)\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In 2015, among the 2.68\u0026nbsp;million neonatal deaths (within the first 28 days of life) worldwide, 303,000 were due to birth defects, accounting for 11% of neonatal mortality\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Disproportionately impacted are low- and middle-income countries bearing 94% of all severe birth defects\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Rigorous surveillance programs are crucial for accurately estimating the prevalence of birth defects and effective planning and implementation of prevention programs and their clinical and surgical management.\u003c/p\u003e\u003cp\u003eIn India, reported estimates of birth defects prevalence have varied widely. Previous estimates from the March of Dimes report (2006) an estimated 1.7\u0026nbsp;million birth defects occurred annually in India, corresponding to 6\u0026ndash;7% of all births in the country\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. A meta-analysis of available data published between 1960\u0026ndash;2015 estimated that 472,000 births (421,652\u0026ndash;522,676 out of ~\u0026thinsp;25\u0026nbsp;million births) in India each year were affected by a birth defect (estimated prevalence: ~184 cases per 10,000 births; 95% CI: 165\u0026ndash;204)\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. The primary source of information on birth defects in India are hospital-based studies with several programs\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. These include three hospital-based databases: (1) the Birth Defect Registry of India (BDRI),which relies on passive reporting from participating hospitals across India; (2) a sub-national hospital-based database which provides real-time monitoring and tracking of sick newborns (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://sncuindiaonline.org\u003c/span\u003e\u003cspan address=\"https://sncuindiaonline.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e)\u003csup\u003e9\u003c/sup\u003e; and (3) the National Neonatal Perinatal Database (NNPD), which focuses on neonatal morbidities but includes some birth defects data\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Additionally, Rashtriya Bal Swasthya Karyakram (RBSK), a community and health facility based initiative launched by the Government of India in 2013 as part of the national child health program, aims at screening for early identification and intervention of birth defects, deficiencies, diseases, and developmental delays among children from birth to 18 years of age\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. The focus of these systems either on hospital-based data alone or on medical treatment and management may limit representativeness of the true prevalence of birth defects in a population. Furthermore, several of the systems include only a few birth defects as their primary objective is not birth defects surveillance. An active, population-based birth defects surveillance program with rigorously established case specificity is required to understand the prevalence of birth defects in India.\u003c/p\u003e\u003cp\u003eIn July 2015, the Foundation for Survival of Women and Children, a national non-governmental organization in India, launched an active, population-based birth defects surveillance system in Haryana in collaboration with the Haryana state government and the National Health Mission (NHM), and with support from the World Health Organization South-East Asia Regional Office (WHO-SEARO) and the U.S. Centers for Disease Control and Prevention (CDC)\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. The objective of this system was to estimate the prevalence of selected major external birth defects in two rural sub-districts, Ambala and Yamunanagar, located in the state of Haryana, surveying births between July 1, 2015 and December 31, 2019.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eBirth defects surveillance program and study population\u003c/h2\u003e\u003cp\u003eThe Haryana population-based surveillance program was conducted in the rural areas (10 subdistricts known as community blocks) of Ambala and Yamuna Nagar districts of Haryana state. An estimated 1.66\u0026nbsp;million people are covered under this surveillance program, making up 65% of the total population of these two districts. In this geographical area, there are 2 district hospitals, 3 sub-districts hospitals, 12 community health centers, 44 primary health centers and 216 sub-centers. Nearly 98% of the births in Haryana occur in health care facilities (59% government, 39% private) and 2% are home births (based on SWACH analysis of the live births from June, 2013 to November, 2022). Among government health facilities, most deliveries (36%) take place in district and sub-district hospital followed by community health centers (9%) and primary health centers (8%).\u003c/p\u003e\u003cp\u003eActive birth defects surveillance was carried out using existing community health workers known as Accredited Social Health Activists (ASHAs) working under India\u0026rsquo;s national Home Based Newborn Care (HBNC) program\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. ASHAs are women who are recruited and trained within local communities by the Government of India to help address the health needs and improve health outcomes, particularly among women and children\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. ASHAs serve as health activists, educators, and basic essential health service providers through home-based visits which occur at least once a month. They provide health counseling and support and accompany families, when needed, to seek medical care from health facilities. Additionally, ASHAs maintain health records and participate in community-level health events and planning. Within their villages, ASHAs registers all new pregnancies, births, and deaths. They ensure that pregnant women receive at least 4 antenatal check-ups by an auxiliary nurse midwife or a higher-level medical provider before delivery. They provide counseling to pregnant women and make birth plans to support safe delivery. ASHAs accompany the pregnant woman to a hospital or health center for delivery. If an institutional delivery is not possible or a home delivery is preferred, ASHAs advise the mother and provide appropriate linkages to have the delivery under the care of a skilled birth attendant. After delivery, ASHAs assist the mother with initiation of breast-feeling and (under HBNC) follow the status of the mother and baby during the post-partum period on days 3, 7, 14, 21, 28 and 42 days after birth. Beyond the post-partum period, ASHAs will also conduct additional home visits to families with children under the age of 2 to provide and support health counseling, preventive care, first-aid, immunizations, treatment of simple illnesses and referrals for more complicated conditions. Each ASHA serves a population of ~\u0026thinsp;1,000 individuals. A total of 1,656 ASHAs serve the rural populations covered under the Haryana population-based surveillance program. Throughout the time period of the present analyses, only rural areas were covered in this surveillance since there were insufficient number of ASHAs operating in urban areas.\u003c/p\u003e\u003cp\u003eFor the Haryana population-based surveillance birth defects program, ASHAs, in groups of 25\u0026ndash;30 individuals, underwent a one-day training facilitated by the Haryana government, the district, and SWACH, on maternal and child health, home-based postnatal care, and birth defects surveillance. During this training, their roles and responsibilities were explained, including the specific information required to be reported to SWACH via a mobile phone provided by the Haryana government. To assist with the identification of birth defects, each ASHA received a folder on birth defects developed by NHM and a laminated chart on major external birth defects developed by SWACH. In addition, a structured format was provided to guide reporting on pregnancy registration, pregnancy outcome, place of delivery, birth weight, timing of initiation of breast feeding, visible birth defects, and status of the mother through 42 days after birth.\u003c/p\u003e\u003cp\u003eUsing mobile phones, ASHAs report all birth defects identified by the hospital/birthing facility staff, a family member, or the ASHA herself to a supervising general nurse midwives. Upon receiving notification of a birth defect case, the supervising general nurse midwife contacts the ASHA and the family to obtain detailed descriptions of the case along with available photographs of any visible birth defects in the infant along with medical records. SWACH team contacts ASHAs twice a month to get information of birth defect babies in their areas, followed by calling the parents of the affected child for confirmation of the birth defect. Parents were also asked to share investigation reports with SWACH team which include Doctors to make the final diagnosis. If photographs were not available, a sketch was drawn by SWACH team based on the description of the case by the parents. For live births, all case infants were followed-up by ASHAs under the HBPNC program to record their health and survival status. When a stillbirth or a neonatal death was reported, a detailed description of the circumstances and documentation were obtained by the ASHA and shared with SWACH team for review, including observations from family members and healthcare providers who attended the delivery or cared for the infant (e.g., presence of one or more birth defects, ultrasound reports, discharge cards, etc.,).\u003c/p\u003e\u003cp\u003eVerbal autopsy data collection and classification followed the World Health Organization (WHO) 2016 Verbal Autopsy Standards.Repeated interactions between families, healthcare providers, and ASHAs were required to obtain complete case descriptions, photographs, and results of medical/discharge reports. Additional follow-up was conducted as needed to obtain all required information for complete and accurate data reporting. Ongoing interactions also provided the opportunity to counsel and assist families with accessing and utilizing medical or rehabilitative services based on the health needs of the infant.\u003c/p\u003e\u003cp\u003eAll reported birth defects were verified by the birth defects team at SWACH (project manager/coordinator and principal investigator) using the case description, photographs, and medical reports. SWACH birth defects team classified each case according to the International Classification of Diseases 10th Revision (ICD-10)\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e and then uploaded the data to the Southeast Asia Region Newborn Birth Defects Database (SEAR-NBBD), housed within WHO-SEARO\u0026rsquo;s online portal\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. WHO-SEARO team reviewed the data and provided feedback to SWACH on data quality, diagnoses, and coding. Based on the feedback, corrections were made, and the revised information was uploaded again. Diagnoses and coding were compared against the case description, photographs, and findings of medical investigations in third level of review and verification by birth defects experts from the CDC in preparation for analyses.\u003c/p\u003e\u003cp\u003eA standard form was developed and used to collect the following data on each case: subdistrict of birth; maternal and paternal age; previous history of stillbirth or spontaneous abortion; parental consanguinity, defined as a relationship between individuals who are second cousins or closer; date and mode of delivery; birth outcome (live birth vs stillbirth); infant sex, birth weight, gestation, and head circumference; plurality; description, diagnosis, and ICD-10 code of birth defects, and results of an autopsy or any medical investigations.\u003c/p\u003e\u003cp\u003eA case was defined as (1) alive born infant or a fetus (stillbirth at least 20 weeks of gestation or \u0026gt;\u0026thinsp;500 grams) with a selected major externally visible birth defect; (2) born to a mother residing at the time of delivery in one of the 10 rural subdistricts of Ambala or Yamunanagar districts, (3) with a birth defect that was noted by a health care provider, family member or a community health worker (ASHA) up to a month after birth. Selected major external visible birth defects which included neural tube defects (NTDs; anencephaly, cranioraschisis, encephalocele, spina bifida, and iniencephaly), orofacial clefts, limb reduction defects, talipes (club foot), abdominal wall defects (omphalocele and gastroschisis), imperforate anus, and hypospadias (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). These major external birth defects were further classified as isolated birth defect (having only one major birth defect), multiple birth defects (having two or more major birth defects), or a syndrome (occurring as part of a genetic or chromosomal condition).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDisease classification codes for selected major external birth defects in the Haryana population-based surveillance program, India, July, 2015\u0026ndash;December, 2019\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBirth Defect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eICD-10 Code\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNeural tube defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnencephaly, Craniorachischisis, Iniencephaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ00.0, Q00.1, Q00.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEncephalocele\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ01.0\u0026ndash;Q01.2, Q01.8\u0026ndash;Q01.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpina bifida\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ05.0\u0026ndash;Q05.9, Q07.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOrofacial clefts\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCleft palate only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ35.1\u0026ndash;Q35.9, Q87.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCleft lip only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ36.0, Q36.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCleft palate\u0026thinsp;+\u0026thinsp;cleft lip\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ37.0\u0026ndash;Q37.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGastrointestinal defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImperforate anus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ42.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGenitourinary defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypospadias\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ54.0\u0026ndash;Q54.3, Q54.8\u0026ndash;Q54.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMusculoskeletal defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTalipes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ66.0, Q66.1, Q66.4, Q66.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLimb reduction defects\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ71.0\u0026ndash;Q73.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAbdominal wall defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOmphalocele\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ79.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGastroschisis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQ79.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e All methods were carried out in accordance with the Indian Council of Medical Research (ICMR) National Ethical Guidelines for Biomedical and Health Research Involving Human Participants (2017). Data collection using verbal autopsy tools adhered to the World Health Organization (WHO) 2016 Verbal Autopsy Standards. Reporting of observational data followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eWe used SAS 9.4 (Cary, NC) to estimate the prevalence with 95% confidence intervals (CI) for each selected major external birth defect, overall, and stratified by birth outcome, infant sex, birth year, and district. Chi-square tests were used to assess differences in prevalence by birth outcome, infant sex, and district. For cells with values\u0026thinsp;\u0026lt;\u0026thinsp;5, Fisher\u0026rsquo;s exact test was used and exact confidence intervals were provided. The Cochrane-Armitage test was used to evaluate trends across birth years. Analyses were conducted in duplicate and independently validated by two data analysts.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of infants with selected major external birth defects in the Haryana population-based surveillance program, India, July 2015\u0026ndash;December 2019\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProportion (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e611\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBirth Outcome\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLive births\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e533\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStillbirths\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInfant sex\u003c/b\u003e\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e354\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e251\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDistrict\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAmbala\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e263\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYamunanagar\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e348\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGestational age\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e37 weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e403\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;37 weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e208\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBirth weight\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e2500 g\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e404\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1500\u0026ndash;2499 g\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;1500 g\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePlurality\u003c/b\u003e\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingleton\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e602\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e98.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMultiple\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMaternal age (years)\u003c/b\u003e \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u0026ndash;24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e283\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25\u0026ndash;29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e257\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u0026ndash;34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParental consanguinity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e598\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e97.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Six cases were of indeterminate sex.\u003c/p\u003e\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e One missing case.\u003c/p\u003e\u003cp\u003e\u003csup\u003e3\u003c/sup\u003e One missing case.\u003c/p\u003e\u003cp\u003e\u003csup\u003e4\u003c/sup\u003e Yes indicates second cousins or closer. Eight cases missing data on consanguinity.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA total of 124,942 births occurred over the study period: 122,753 (98.2%) were live births and 2,189 (1.8%) were stillbirths. Of these, 611 infants (5 infants per 1000) had at least one of the major external birth defects included in the surveillance. Among cases, 87.2% (n\u0026thinsp;=\u0026thinsp;533) were live births and 78 (12.8%) were stillbirths (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). More than half of the cases were male (57.9% male. 41.1% female, and \u0026lt;\u0026thinsp;1.0% indeterminate sex) and more than half were reported from Yamunanagar district (Yamunanagar 57.0%, Ambala 43.0%). Most of the cases were singleton births (98.5%) with the remaining being twins or triplets. Most case mothers (96.1%) were between ages 20\u0026ndash;34 years; while 1.5% were \u0026lt;\u0026thinsp;20 years of age and 2.3% were 35 years or older. Parental consanguinity was reported in \u0026lt;\u0026thinsp;1% of cases.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePrevalence of selected major external birth defects in the Haryana population-based surveillance program, India, July 2015\u0026ndash;December 2019\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBirth Defect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAll births (n\u0026thinsp;=\u0026thinsp;124,942)\u003c/p\u003e\u003cp\u003ePrevalence\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLive births (n\u0026thinsp;=\u0026thinsp;122,753)\u003c/p\u003e\u003cp\u003ePrevalence\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e (95% CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNeural tube defects\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e199\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.9 (13.7, 18.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e131\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.7 (8.9, 12.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnencephaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.8 (1.9, 3.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5 (0.1, 0.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEncephalocele\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.6 (1.7, 3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.4 (0.7, 2.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpina bifida\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e133\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.6 (8.8, 12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.8 (7.1, 10.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOrofacial clefts\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e115\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.2 (7.5, 10.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.0 (7.3, 10.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCleft palate only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.5 (0.8, 2.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.6 (0.9, 2.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCleft lip only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.6 (3.4, 5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.2 (3.1, 5.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCleft palate\u0026thinsp;+\u0026thinsp;cleft lip\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.1 (2.1, 4.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.2 (2.2, 4.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGastrointestinal defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImperforate anus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.0 (2.9, 5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.0 (2.9, 5.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGenitourinary defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypospadias\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.5 (0.1, 1.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMusculoskeletal defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTalipes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e236\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.9 (16.5, 21.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e229\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.7 (16.2, 21.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLimb reduction defects\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.5 (1.6, 3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.3 (1.4, 3.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUpper limb reduction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.9 (1.2, 2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.7 (1.0, 2.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLower limb reduction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0 (0.5, 1.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0 (0.4, 1.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAbdominal wall defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOmphalocele\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.4 (0.0, 0.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.3 (0.1, 0.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGastroschisis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.5 (0.1, 0.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.4 (0.1, 0.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Prevalence reported as cases per 10,000 births\u003c/p\u003e\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Two cases of craniorachischisis included in anencephaly. No iniencephaly were reported among cases. Two case infants had anencephaly and spina bifida. One case infant had encephalocele and spina bifida.\u003c/p\u003e\u003cp\u003e\u003csup\u003e3\u003c/sup\u003e Birth prevalence among males only. No live birth prevalence reported due to lack of male live birth denominator.\u003c/p\u003e\u003cp\u003e\u003csup\u003e4\u003c/sup\u003e Six case infants had upper and lower limb reduction defects.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAmong all live and stillbirths examined, talipes was the most common birth defect with a prevalence of 18.9 per 10,000 births (95% CI: 16.5, 21.3; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). NTDs were the second most common birth defect with a prevalence of 15.9 per 10,000 births (95% CI: 13.7, 18.1) followed by orofacial clefts (9.2 per 10,000 births; 95% CI: 7.5, 10.9). Among the different types of NTDs, the prevalence of anencephaly, encephalocele, and spina bifida were 2.8 (95% CI: 1.9, 3.7), 2.6 (95% CI: 1.7, 3.5), and 10.6 per 10,000 births (95%CI: 8.8, 12.5), respectively. The major external birth defects with the lowest observed prevalence included hypospadias (0.5 per 10,000 births; 95%CI: 0.1, 1.3; n\u0026thinsp;=\u0026thinsp;3); gastroschisis (0.5 per 10,000 births; 95% CI: 0.1, 0.9; n\u0026thinsp;=\u0026thinsp;6), and omphalocele (0.4 per 10,000 births; 95% CI: 0.0, 0.8; n\u0026thinsp;=\u0026thinsp;5).\u003c/p\u003e\u003cp\u003eThe most common major external BDs, which restricting to just live births, show a slightly lower prevalence (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e): talipes (18.7 per 10,000 live births; 95% CI: 16.2, 21.1), NTDs (10.7 per 10,000; 95% CI: 8.9, 12.5), and orofacial clefts (9.0 per 10,000 live births; 95% CI: 7.3, 10.6). Over 25% of birth defects cases (n\u0026thinsp;=\u0026thinsp;156) were stillbirths (n\u0026thinsp;=\u0026thinsp;78) or deaths within 28 days of birth (n\u0026thinsp;=\u0026thinsp;78). The survival of case infants varied by type of birth defects. The majority of birth defects cases that were stillborn or died during the neonatal period occurred among infants with a neural tube defect (109 NTDs / 156 stillbirths and neonatal deaths; 69.9%). More than half of NTD cases were stillborn (68 NTD stillbirths/199 NTDs; 34.2%) or died within 28 days after birth (41 NTD neonatal deaths/199 NTDs; 20.6%). As Anencephaly is incompatible with life, 82.9%, n\u0026thinsp;=\u0026thinsp;29 were stillborn and 17.1%, n\u0026thinsp;=\u0026thinsp;6 died within the neonatal period. Among cases of encephalocele (n\u0026thinsp;=\u0026thinsp;33), more than three quarters were stillborn (48.5%, n\u0026thinsp;=\u0026thinsp;16) or died within the neonatal period (30.3%, n\u0026thinsp;=\u0026thinsp;10) and remaining cases are alive (21.2%, n\u0026thinsp;=\u0026thinsp;7). Among cases of orofacial clefts (n\u0026thinsp;=\u0026thinsp;115), most were live births and survived past the neonatal period (85.2%, n\u0026thinsp;=\u0026thinsp;98). Far fewer orofacial clefts were stillborn (4.4%, n\u0026thinsp;=\u0026thinsp;5) or died within the neonatal period (10.4%, n\u0026thinsp;=\u0026thinsp;12). Overall, we observed very few cases of omphalocele (n\u0026thinsp;=\u0026thinsp;4) or gastroschisis (n\u0026thinsp;=\u0026thinsp;3). Most cases of omphalocele and gastroschisis were stillborn (omphalocele: 25.0%, n\u0026thinsp;=\u0026thinsp;1; gastroschisis: 25.0%, n\u0026thinsp;=\u0026thinsp;1) or died within the neonatal period (omphalocele: 50.0%, n\u0026thinsp;=\u0026thinsp;2; gastroschisis: 75.0%, n\u0026thinsp;=\u0026thinsp;3).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePrevalence of selected major external birth defects by infant sex in the Haryana population-based surveillance program, India, July 2015\u0026ndash;December 2019\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBirth Defect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u0026thinsp;=\u0026thinsp;66,164\u003c/em\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u0026thinsp;=\u0026thinsp;58,736\u003c/em\u003e)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCases per 10,000 births\u003c/p\u003e\u003cp\u003e(95%CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCases per 10,000 births\u003c/p\u003e\u003cp\u003e(95%CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNeural tube defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.0 (13.0, 19.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.8 (11.7, 17.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnencephaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.3 (1.1, 3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.9 (1.5, 4.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEncephalocele\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.8 (0.8, 2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.1 (1.7, 4.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpina bifida\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.8 (9.2, 14.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.4 (6.9, 11.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOrofacial clefts\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.7 (8.2, 13.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.5 (5.3, 9.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCleft palate only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.8 (0.8, 2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.2 (0.3, 2.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCleft lip only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.3 (3.5, 7.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.8 (2.2, 5.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCleft palate\u0026thinsp;+\u0026thinsp;cleft lip\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.6 (2.2, 5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.6 (1.3, 3.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGastrointestinal defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImperforate anus\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.6 (3.8, 7.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.2 (1.0, 3.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGenitourinary defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypospadias\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.5 (0.1, 1.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMusculoskeletal defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTalipes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e133\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.1 (16.7, 23.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17.5 (14.2, 20.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLimb reduction defects\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.0 (1.7, 4.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.9 (0.8, 3.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUpper limb reduction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.1 (1.0, 3.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.7 (0.6, 2.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLower limb reduction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.4 (0.5, 2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.7 (0.2, 1.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAbdominal wall defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOmphalocele\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.6 (0.1, 1.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.2 (0.0, 0.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGastroschisis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.5 (0.1, 1.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5 (0.1, 1.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Chi-square test for difference by sex; p\u0026thinsp;=\u0026thinsp;0.0029 for imperforate anus.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhen examining the prevalence of selected major external birth defects by infant sex, males had significantly higher prevalence of imperforate anus compared to females (5.6 per 10,000; 95%CI:3.8,7.4 v. 2.2 per 10,000; 95%CI: 1.0, 3.4; p\u0026thinsp;=\u0026thinsp;0.0029; Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The prevalence of common birth defects such as talipes (20.1; 95% CI: 16.7, 23.5 v. 17.5; 95% CI: 14.2, 20.9), NTDs (16.0; 95% CI: 13.0, 19.1 v. 14.8; 95%CI: 11.7, 17.9), and orofacial clefts (10.7; 95%CI: 8.2, 13.2 v. 7.5; 95% CI: 5.3, 9.7) did not significantly differ between males compared with females.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePrevalence of selected major external birth defects by birth year in the Haryana population-based surveillance program, India, July 2015\u0026ndash;December 2019\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBirth Defect\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e2015\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u0026thinsp;=\u0026thinsp;15,484\u003c/em\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e2016\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u0026thinsp;=\u0026thinsp;27,166\u003c/em\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e2017\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u0026thinsp;=\u0026thinsp;27,372\u003c/em\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e2018\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u0026thinsp;=\u0026thinsp;26,774\u003c/em\u003e)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003cp\u003e(\u003cem\u003en\u0026thinsp;=\u0026thinsp;28,146\u003c/em\u003e)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCases per 10,000 births\u003c/p\u003e\u003cp\u003e(95%CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCases per 10,000 births\u003c/p\u003e\u003cp\u003e(95%CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCases per 10,000 births\u003c/p\u003e\u003cp\u003e(95%CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eCases per 10,000 births\u003c/p\u003e\u003cp\u003e(95%CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eCases per 10,000 births\u003c/p\u003e\u003cp\u003e(95%CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNeural tube defects\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.3 (15.7, 30.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19.5 (14.3, 24.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e19.4 (14.2, 24.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e10.5 (6.6, 14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e10.3 (6.6, 14.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnencephaly\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.9 (1.4, 6.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.4 (1.9, 6.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.7 (1.4, 5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2.2 (0.4, 4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.4 (0.0, 2.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEncephalocele\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.2 (1.1, 7.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.7 (1.4, 6.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.9 (0.9, 5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2.2 (0.4, 4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e1.4 (0.4, 3.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpina bifida\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.8 (10.3, 23.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.8 (7.7, 15.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e13.2 (8.9, 17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e5.6 (2.8, 8.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e8.5 (5.1, 11.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOrofacial clefts\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.9 (7.3, 18.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.8 (5.3, 12.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e9.9 (6.2, 13.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e6.0 (3.1, 8.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e10.0 (6.3, 13.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCleft palate only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.8 (0.2, 3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.8 (0.2, 3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.9 (0.2, 3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e1.4 (0.4, 3.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCleft lip only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.0 (4.3, 13.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.7 (1.4, 6.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5.5 (2.7, 8.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2.2 (0.4, 4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e4.3 (1.9, 6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCleft palate\u0026thinsp;+\u0026thinsp;cleft lip\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.9 (0.8, 7.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.3 (1.2, 5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.6 (0.7, 4.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.9 (0.2, 3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e4.3 (1.9, 6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGastrointestinal defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImperforate anus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.9 (0.8, 7.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.1 (1.7, 6.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6.2 (3.3, 9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.9 (0.2, 3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e3.9 (1.6, 6.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMusculoskeletal defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTalipes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.4 (12.5, 26.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.0 (13.0, 23.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e19.0 (13.8, 24.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e15.7 (11.0, 20.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e22.4 (16.9, 27.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLimb reduction defects\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.8 (2.0, 9.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.3 (1.2, 5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.6 (0.7, 4.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.5 (0.4, 3.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.7 (0.1, 2.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUpper limb reduction\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.8 (2.0, 9.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.9 (0.9, 4.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.5 (0.4, 3.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.4 (0.0, 2.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.7 (0.1, 2.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLower limb reduction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.9 (0.4, 5.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.7 (0.1, 2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.8 (0.2, 3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.1 (0.2, 3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAbdominal wall defects\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOmphalocele\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.3 (0.2, 4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.7 (0.1, 2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.4 (0.0, 2.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGastroschisis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.3 (0.2, 4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.7 (0.1, 2.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.7 (0.1, 2.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Cochran-Armitage test for trend; p\u0026thinsp;\u0026lt;\u0026thinsp;0.004.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe proportion of births occurring across each year of when data was collected are similar: 12.4% (6 months, July-December 2015), 21.7% (2016), 21.9% (2017), 21.4% (2018), and 22.5% (2019). The overall prevalence of neural tube defects (p\u003csub\u003etrend\u003c/sub\u003e\u0026lt;0.0001) and limb reduction defects (p\u003csub\u003etrend\u003c/sub\u003e=0.0007) decreased over time (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Specific reductions in prevalence over time were observed for spina bifida (p\u003csub\u003etrend\u003c/sub\u003e=0.002) and upper limb reduction defects (p\u003csub\u003etrend\u003c/sub\u003e\u0026lt;0.0001). No significant changes in prevalence over time were observed among other major external birth defects.\u003c/p\u003e\u003cp\u003eBetween 2015\u0026ndash;2019, 57, 918 births occurred in Ambala and 67,024 births occurred in Yamunanagar. Among the major external defects, the prevalence of neural tube defects overall was higher in Yamunanagar compared to Ambala (18.5 per 10,000; 95% CI: 15.3, 21.8 v. 13.0 per 10,000; 95% CI: 10.0, 15.9; p\u0026thinsp;=\u0026thinsp;0.01; \u003cb\u003eSupplemental Table\u003c/b\u003e). Spina bifida (12.4; 95% CI: 9.7, 15.1 v. 8.6; 95% CI: 6.2, 11.0) and cleft lip (5.7; 95% CI: 3.9, 7.5 v. 3.3; 95% CI: 1.8, 4.8) were also more prevalent in Yamunanagar compared to Ambala (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The prevalence of the other major external birth defects did not differ significantly by district.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur analyses provide the first estimation of the prevalence of major external birth defects in the rural areas of two districts in Haryana, India. This is also the first data on population-based birth defects surveillance from India among live births and stillbirths as there has been no previously published data of its kind. Our analyses indicated that major external birth defects are common and contribute to perinatal mortality in Haryana. Among all reported major external birth defects, talipes and NTDs were the most reported defects and hypospadias, and the abdominal wall defects (omphalocele and gastroschisis) were among the least commonly reported defects. Due to the small numbers observed for hypospadias (n\u0026thinsp;=\u0026thinsp;3), omphalocele (n\u0026thinsp;=\u0026thinsp;5), and gastroschisis (n\u0026thinsp;=\u0026thinsp;6), interpreting data on these birth defects should be conducted cautiously.\u003c/p\u003e\u003cp\u003eThe prevalence of talipes reported in our study was similar to published estimates from a recent meta-analysis (17.9 per 10,000 births; 95% CI 15.1, 20.7)\u003csup\u003e6\u003c/sup\u003e. However, the prevalence for NTDs from our analyses was lower than previously reported. Based on modelled estimates from the March of Dimes, India has ~\u0026thinsp;1/3 of the world\u0026rsquo;s burden of neural tube defects (with a prevalence of ~\u0026thinsp;47 per 10,000 births)\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Similar to the modelled estimate, a meta-analysis of mostly hospital-based studies across India reported an overall birth prevalence of NTDs in India (~\u0026thinsp;41 cases per 10,000 total births) which is higher than estimates reported in our study\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.In this meta-analysis, anencephaly was the most common form of NTDs at 21 per 10,000 births, and the prevalence of spina bifida was 19 per 10,000 births. The estimated overall NTD prevalence from North India (73 per 10,000 births) including a retrospective hospital-based study from the city of Rohtak in Haryana (182 per 10,000 births) were also much higher than that our estimates\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.Our NTD prevalence estimates were also lower than a 2015 population-based survey (24 per 10,000 live births) of women from one subdistrict of the Faridabad district in Haryana who recalled having a previous pregnancy affected by an NTD between 2001\u0026ndash;2014\u003csup\u003e20\u003c/sup\u003e. Data on NTDs from this study were based on self-reports from women (or reports by a relative or neighbor if the woman was not available at the time of survey).\u003c/p\u003e\u003cp\u003eSome explanations for why our estimates might be lower could be that data from many of the published studies were older and may lack standardized definitions, methodology and data quality monitoring for case identification and verification. A few estimates were based on retrospective population-based surveys which relied on questionnaires, interviews, and recall of past events. Most estimates were hospital-based which may not be representative of estimates from population-based surveillance covering all births. Large tertiary hospitals may serve as referral centers and may receive women at higher risk of birth defects and receive a higher volume of diagnosed and more complicated birth defects cases. Thus, estimates of birth defects and stillbirths would be higher from these facilities and not representative of the population. Additionally, high patient mobility in and out of catchment areas may also account for the higher prevalence observed in hospital-based surveillance studies compared to population-based surveillance. It should also be noted that presently an ultrasound is commonly performed at 18\u0026ndash;20 weeks gestation in India, even among rural populations. Prenatal diagnosis of any lethal birth defects detected, including NTDs, would often result in elective pregnancy terminations. Our surveillance system did not include birth defects among elective terminations of pregnancies; therefore, these cases would have been excluded in our estimates.\u003c/p\u003e\u003cp\u003eWhile the prevalence of NTDs from our study are lower than other estimates in India, the NTD prevalence from the Haryana population-based surveillance program are considerably higher (~\u0026thinsp;2 times higher for encephalocele and spina bifida) compared to estimates from the United States where folic acid fortification is mandated\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. In addition, from our study, among birth defects cases, almost 70% of the stillbirths and deaths within the first 28 days of birth among occurred in infants with neural tube defects, a birth defect that we know can be effectively prevented with folic acid. The high prevalence and mortality of NTDs suggest a need and an opportunity for a prevention measure or health policy intervention such as folic acid fortification which can bring benefit to all women of reproductive age. Ongoing surveillance through a population-based birth defects surveillance program like the one in Haryana can help to monitor time trends and progress and targeted prevention efforts where they are most needed.\u003c/p\u003e\u003cp\u003eOur prevalence estimates of orofacial clefts from the Haryana population-based surveillance program are lower than estimates from the recent meta-analysis of birth defects prevalence in India (orofacial clefts: 14.9 per 10,000 births; 95% CI: 12.6, 17.2).\u003csup\u003e6\u003c/sup\u003e The prevalence of hypospadias, omphalocele, and gastroschisis were also much lower in our study than reports from other studies.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e A meta-analyses of hospital-based studies estimated the prevalence of hypospadias, omphalocele, and gastroschisis at 12.2 (95% CI: 9.8, 14.6), 4.7 (95% CI: 3.2, 6.1) and 7.0 (95% CI: 4.6, 18.6), respectively. The prevalence of these defects may have been lower in our study due to differences in methodology, data quality, and representativeness as described above. For hypospadias, there might be a chance of this birth defect being missed if the infant was not examined from head to toe with clothing removed by the ASHA or another healthcare provider and if the family does not recognize it as a major problem.\u003c/p\u003e\u003cp\u003eThere are several strengths of this study. First, population-based birth defects surveillance systems where stillbirths were also recorded and also first study that allow cases to be captured regardless of the location of delivery, whether in large government hospitals or private hospitals, smaller nursing or maternity homes, or at an individual\u0026rsquo;s home. Second, surveillance was established using a network of community health care workers (ASHAs) through the use of mobile phone technology. With mobile phones, photographs of birth defects and medical records could be captured to help with verification of cases. In addition, ASHAs usually reside in the same villages as the population so they would have an opportunity to identify women who become pregnant and follow them throughout pregnancy. Third, all cases were followed up to assess the outcome of the affected infant. All birth defects cases were followed up at one month of age and then periodically up through the age of 1 year. Follow-up provided an opportunity to gather information on the health and survival status of the child and any treatments the child may have received as well as provide referrals for additional services they may need.\u003c/p\u003e\u003cp\u003eAs with any surveillance system, there are some limitations in this program. Urban areas were not covered since ASHAs were not available there during the time of interest. Also, incomplete ascertainment may have contributed to under-reporting of some birth defects. In Haryana, less than 5% of births occur in the home and ASHAs follow up all pregnancies. We have confidence all births are captured by ASHAs as women are followed from time of pregnancy. However, if a child was stillborn, ASHAs relied on medical records or reporting by the parents, which may or may not include accurate information about the presence of a birth defect. The lack of including birth defects among elective pregnancy terminations and spontaneous abortions in this dataset would also likely contribute to under-ascertainment.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOverall, our study demonstrated that it is feasible to implement population-based surveillance of birth defects in rural areas in Haryana through home-based visits via a network of community-based healthcare workers known as ASHAs. ASHAs serve as an important intermediary to ensure the collection of case descriptions, photographs, and medical/discharge reports for complete and accurate reporting of birth defects cases. The system also offers the opportunity to follow the health and survival status of children with birth defects through the 1 year of age to provide additional support and guidance to affected families. Our analyses of data from the Haryana population-bases surveillance system showed that major external birth defects were common, and we observed a high prevalence of NTDs, talipes and orofacial clefts. Data gathered through this surveillance system can be used to help the state of Haryana monitor trends and assess population-level activities related to the prevention of major external birth defects.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASHAs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAccredited Social Health Activists\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBDRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBirth Defect Registry of India\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCDC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCenters for Disease Control and Prevention:Global Burden of Disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGOI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGovernment of India\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHBNC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHome Based Newborn Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICD-10\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternational Classification of Diseases 10th Revision\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNHM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational Health Mission\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNNPD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational Neonatal Perinatal Database\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNTDs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eneural tube defects\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRBSK\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRashtriya Bal Swasthya Karyakram\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSEAR-NBBD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSoutheast Asia Region Newborn Birth Defects Database\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSWACH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSurvival for Women \u0026amp; Children Foundation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO-SEARO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization South-East Asian Regional Office.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to Dr. (late) Vijay Kumar who conceived and supervised the study. We are grateful to the numerous families, ASHAs, and other healthcare workers who contributed the necessary data for this study. We also express our gratitude to the World Health Organization South-East Asia Regional Office for providing funding and technical support for the Newborn Birth Defects Database (NBBD) and for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunds were provided by the World Health Organization South-East Asia Regional Office under a cooperative agreement with the US Centers for Disease Control and Prevention (CDC-RFA-GH14-1420, Global Prevention of Non-Communicable Disease Prevention and Promotion of Health).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData available upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClearances have been obtained from the ethics committee of the Foundation for Survival of Women and Children (reference ID SWACH/IEC/0101/2025). State approvals are available through a Memorandum of Understanding signed with the National Health Mission in Haryana (http://www.nrhmharyana.gov.in/). Prior to study initiation, informed Consent was obtained from caregivers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eN.C : Conceptualization, Methodology, Writing \u0026ndash; original draftP.M: Investigation, Formal analysis, Data curation, Validation, Visualization, Investigation, Writing \u0026ndash; original draft. R.G: review \u0026amp; editingM.S: Investigation, Data curation, Project administrationA.G: Investigation, Data curation, Project administration A.R: Investigation, Formal analysis, Data curation, Writing \u0026ndash; original draft. B.S: Investigation, Formal analysis, Data curationC.M: review \u0026amp; editing.R.K: review \u0026amp; editing.R.M: review \u0026amp; editing.All authors approved the manuscript. S.D: review \u0026amp; editing.P.K: Methodology, Validation, Formal analysis, review \u0026amp; editing.V.J: review \u0026amp; editing.N.R: Conceptualization, review \u0026amp; editing\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChristianson A, Howson CP, Modell B. \u003cem\u003eMarch of Dimes global report on birth defects, the hidden toll of dying and disabled children\u003c/em\u003e. March of Dimes Birth Defects Foundation; 2006. Accessed 3 February 2022. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.marchofdimes.org/mission/march-of-dimes-global-report-on-birth-defects.aspx\u003c/span\u003e\u003cspan address=\"https://www.marchofdimes.org/mission/march-of-dimes-global-report-on-birth-defects.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMurray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990\u0026ndash;2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet Dec. 2012;15(9859):2197\u0026ndash;223. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(12)61689-4\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(12)61689-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet Dec. 2012;15(9859):2095\u0026ndash;128. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(12)61728-0\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(12)61728-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Congenital anomalies fact sheet. Accessed 3. February 2022, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/en/news-room/fact-sheets/detail/congenital-anomalies\u003c/span\u003e\u003cspan address=\"https://www.who.int/en/news-room/fact-sheets/detail/congenital-anomalies\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Birth defects in South-East Asia a public health challenge: Situation analysis. World Health Organization. 2013. Accessed 25 September 2020. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apps.who.int/iris/handle/10665/204821\u003c/span\u003e\u003cspan address=\"https://apps.who.int/iris/handle/10665/204821\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBhide P, Kar A. A national estimate of the birth prevalence of congenital anomalies in India: systematic review and meta-analysis. BMC Pediatr. May 2018;25(1):175. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12887-018-1149-0\u003c/span\u003e\u003cspan address=\"10.1186/s12887-018-1149-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGupta N, Kabra M, Kapoor S. Establishing National Neonatal Perinatal Database and birth defects registry network - need of the hour! Indian Pediatr Sep. 2014;51(9):693\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s13312-014-0483-z\u003c/span\u003e\u003cspan address=\"10.1007/s13312-014-0483-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKar A. Birth defects in India: magnitude, public health impact and prevention. JKIMSU. 2014;3(2):7\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFacility Based Newborn Care Database. Accessed 3. February 2022, https://sncuindiaonline.org/d_loginAction.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSharma R. Birth defects in India: hidden truth, need for urgent action. Indian J Hum Genet. 2013;19(2):125\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSurvival for Women \u0026amp; Children Foundation. Population based surveillance of birth defects. Accessed 3. February 2022, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.swach.org/project-pbs-bd/\u003c/span\u003e\u003cspan address=\"http://www.swach.org/project-pbs-bd/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health and Family Welfare Government of India. Home based care of new born and young child. Accessed 3. February 2022, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://hbnc-hbyc.nhp.gov.in/AboutUs/aboutHBNC\u003c/span\u003e\u003cspan address=\"https://hbnc-hbyc.nhp.gov.in/AboutUs/aboutHBNC\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eASHA support mechanism. Accessed 3. February 2022, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nhm.gov.in/index1.php?lang=1\u0026amp;level=2\u0026amp;sublinkid=176\u0026amp;lid=249\u003c/span\u003e\u003cspan address=\"https://nhm.gov.in/index1.php?lang=1\u0026amp;level=2\u0026amp;sublinkid=176\u0026amp;lid=249\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbout Accredited Social Health Activist (ASHA). Accessed 3. February 2022, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nhm.gov.in/index1.php?lang=1\u0026amp;level=1\u0026amp;sublinkid=150\u0026amp;lid=226\u003c/span\u003e\u003cspan address=\"https://nhm.gov.in/index1.php?lang=1\u0026amp;level=1\u0026amp;sublinkid=150\u0026amp;lid=226\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Health Mission. ASHA training modules. Accessed 3. February 2022, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nhm.gov.in/index1.php?lang=1\u0026amp;level=3\u0026amp;sublinkid=184\u0026amp;lid=257\u003c/span\u003e\u003cspan address=\"https://www.nhm.gov.in/index1.php?lang=1\u0026amp;level=3\u0026amp;sublinkid=184\u0026amp;lid=257\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eInternational statistical classification of diseases and related health problems 10th revision. Accessed 3. February 2022, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://icd.who.int/browse10/2019/en\u003c/span\u003e\u003cspan address=\"https://icd.who.int/browse10/2019/en\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNewborn and Birth Defects Database. Accessed 3. February 2022, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apps.searo.who.int/npn/\u003c/span\u003e\u003cspan address=\"https://apps.searo.who.int/npn/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNew-born and Birth Defects (NBBD) Surveillance Initiative. Accessed 3. February 2022, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/southeastasia/sear-nbbd\u003c/span\u003e\u003cspan address=\"https://www.who.int/southeastasia/sear-nbbd\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBhide P, Sagoo GS, Moorthie S, Burton H, Kar A. Systematic review of birth prevalence of neural tube defects in India. Birth Defects Res Clin Mol Teratol Jul. 2013;97(7):437\u0026ndash;43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/bdra.23153\u003c/span\u003e\u003cspan address=\"10.1002/bdra.23153\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKant S, Malhotra S, Singh AK, Haldar P, Kaur R, Misra P, Gupta N. Prevalence of neural tube defects in a rural area of north india from 2001 to 2014: A population-based survey. Birth Defects Res Feb. 2017;15(3):203\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/bdra.23578\u003c/span\u003e\u003cspan address=\"10.1002/bdra.23578\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilliams J, Mai CT, Mulinare J, et al. Updated estimates of neural tube defects prevented by mandatory folic Acid fortification - United States, 1995\u0026ndash;2011. MMWR Morb Mortal Wkly Rep Jan. 2015;16(1):1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMai CT, Isenburg JL, Canfield MA, et al. National population-based estimates for major birth defects, 2010\u0026ndash;2014. Birth Defects Res Nov. 2019;1(18):1420\u0026ndash;35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/bdr2.1589\u003c/span\u003e\u003cspan address=\"10.1002/bdr2.1589\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Birth defects, Congenital anomalies, Congenital malformations, Birth prevalence, Community based Surveillance, Haryana, India","lastPublishedDoi":"10.21203/rs.3.rs-7608088/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7608088/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost published birth defects (BDs) prevalence estimates in India are estimated from hospital-based surveillance studies. We estimated the prevalence of selected major external BDs using data from active, population-based surveillance in two districts of Haryana- Ambala and Yamunanagar, India.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eActive surveillance of all deliveries between 2015–2019 was led by the Foundation for Survival of Women and Children (SWACH) and conducted by community healthcare workers in rural Haryana. Cases were defined as any live birth or stillbirth with a selected major external BD born to a mother residing in one of the 10 rural subdistricts of Ambala or Yamuna Nagar at the time of delivery. The prevalence of BDs was estimated overall and stratified by birth outcome, infant sex, and birth year.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong 124,942 live and stillbirths, 611 infants had a major external BD. The highest prevalence (per 10,000 births) included talipes (18.6), neural tube defects (NTDs, 15.9), and orofacial clefts (9.2). The lowest prevalence included hypospadias (0.5), gastroschisis (0.5), and omphalocele (0.4). Among these cases, 533 (87.2% ) survived, and 78 (12.8%) were stillborn. Males had a higher prevalence of imperforate anus compared to females. NTDs and limb reduction defects decreased from 2015 to 2019 (p\u0026lt;0.004 trend).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study demonstrated the feasibility of implementing BD surveillance at birth through a network of community healthcare workers and provide. Findings provide first population-based estimates of major external BD prevalence among live births and stillbirths from India. In Haryana, major external BDs are common and contribute to perinatal mortality. In addition to determining burden and distribution of birth defects, the findings will help with planning prevention and clinical care activities related to BDs in Haryana.\u003c/p\u003e","manuscriptTitle":"The prevalence of selected major external birth defects from a population- based surveillance program in Haryana, India, 2015–2019","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-30 11:49:05","doi":"10.21203/rs.3.rs-7608088/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c5d9a31f-c779-4c91-8283-ab5c73159a82","owner":[],"postedDate":"October 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-07T09:55:07+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-30 11:49:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7608088","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7608088","identity":"rs-7608088","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}