Modern Plastic Surgery, 2014, 4, 11-15
Published Online January 2014 (http://www.scirp.org/journal/mps)
http://dx.doi.org/10.4236/mps.2014.41003
OPEN ACCESS MPS
11
Usage of Potential Teratogenic Chemical Prepa rations
among Mothers of Children Attending the
Multidisciplinary Cleft Clinic at the Komfo Anok ye
Teaching Hospital, Ghana
Alexander Acheampong Oti1*, Gyikua Plange-Rhule2, Solomon Obiri-Yeboah3, Daniel Kwasi Sabbah3,
Peter Donkor2
1Dental School, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; 2Medical School, Kwame Nkrumah Un i-
versity of Science and Technology, Kumasi, Ghana ; 3Komfo Anokye Teaching Hospital, Kumasi, Ghana.
Received October 28th, 2013; revised November 25th, 2013; accepted December 4th, 2013
Copyright © 2014 Alexander Acheampong Oti et al. This is an open access article distributed under the Creative Commons Attribu-
tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited. In accordance of the Creative Commons Attribution License all Copyrights © 2014 are reserved for SCIRP and the owner of
the intellectual prope r ty Alexander Acheampong Oti et al. All Copyright © 2014 are guarded by law and by SCIRP as a guardian.
ABSTRACT
Objective: The purpose of this study is to determine the usage of potential teratogenic chemicals among cleft lip
and palate mothers attending a multidisciplinary cleft clinic at Komfo Anokye Teaching Hospital (KATH). Me-
thod: This is a retrospective study based on records o f consecutive patients attending the mu ltidisciplinary cleft
clinic at KATH. Mothers of children with cleft lip and palate formed the study sample. Information on the use of
chemical agents by the mothers either before or during the first three months of pregnancy was collected on to a
specially designed form. The study period was from January 2006 to December 2012. Setting: The study was
carried out in a multidisciplinary cleft clinic at Komfo Anokye Teaching Hospital in Ghana. The clinic is the
main referral centre for the northern sector of Ghana for cleft lip and palate care. Results: Chemical prepara-
tions usage ranged from 0.2% for tobacco to 25.3% for skin lightening creams. Other agents used include, enema ,
non-proprietary concoctions and prednisolone tablets. 2.1% of the mothers ingested alcohol during pregnancy.
Conclusion: There is a high level of usage of potentially teratogen ic chemicals among cleft mothers attending the
multidisciplinary cleft lip and palate clinic at the Komfo Anokye Teaching Hospital in Ghana. Further studies
are, however, required to clarify any relationship this may have with the development of orofacial clefts.
KEYWORDS
Cleft; Lip; Palate; Chemical; Teratogenic
1. Introduction
Cleft lip and palate (CLP) affects approximately 1/700
live births, with wide variability ac ross geographic o rigin,
racial and ethnic groups, as well as environmental expo-
sures and socioeconomic status. In general, the highest
reported birth prevalence rates are among Asian and
Amerindian populations, often as high as 1/500, Eu ro-
pean-derived populations have intermediate prevalence
rates at about 1/1000, and African-derived populations
have the lowest prevalence rates at about 1/2500. These
observations indicate the relative contribution of indi-
vidual susceptibility genes may vary across different
populations [1,2].
Traditionally, CLP has been divided into cleft palate
only and cleft lip with or without cleft palate (CLP).
However, recent epidemiologic studies suggest that cleft
lip only may have unique etiologic features, including
strong genetic associations, while some individuals with
cleft palate only show evidence of sub-clinical cleft lip
[3-5].
*Corresponding a uthor.

Usage of Potential Teratogenic Chemical Preparations among Mothers of Children Attending
the Multidisciplinary Cleft Clinic at the Komfo Anokye Teaching Hospital, Ghana
OPEN ACCESS MPS
12
Available evidence indicates that both genes and en-
vironmental factors, acting either independently or in
combination, are responsible for facial clefting. Non-gen-
tic risk factors implicated in cleft lip and palate include
folic acid deficiency, u se of anti-ep ileptic drugs, and ma-
ternal alcohol or cigarette use during pregnancy.
A lot of effort has also been concentrated on identify-
ing the genetic contribution to clefting.
The high familial prevalence rates, recurrence risks
and elevated concordance rates in monozygous versus
dizygous twins provide evidence for a strong genetic
component in CLP. Despite this, familial inheritance is
complex and simple Mendelian inheritance is considered
uncommon.
Maternal smoking has been associated with increased
risk of CLP and meta-analysis strong ly supports an over-
all odds ratio for having CLP of approximately 1.3
among offspring of mothers who smoke [6,7]. Maternal
smoking exposure during the peri-conceptual period is a
major risk factor and raises the possibility that genes in
certain metabolic pathways may play a role in the devel-
opment of CLP. Specifically, markers in the GSTT1
(glutathione S-transferase theta) or NOS3 (nitric oxide
synthase) genes appear to influence risk of CLP in the
presence of maternal smoking [6,7]. The GSTT1 markers
are a known gene deletion variant, which suggests defi-
ciencies in detoxification pathways may underlie some of
this susceptibility. Parents’ occupation usually deter-
mines their exposure to many potentially environmental
risk factors. Many studies have shown if mothers come
in contact with certain chemicals, and this can increase
the risk of cleft lip and palate in the child. Aliphatic al-
dehydes, ethyl ether, aliphatic acids, trichloroethylene
and pesticides can increase risk of CLP [8,9].
Maternal alcohol consumption has also been suggested
as a risk factor , but the evidence has been inconclusive
[10]. Studies suggest that high doses of alcohol in short
periods of time increase risk [11,12], and this is sup-
ported by associations with variation in the ADH1C al-
cohol dehydr ogenase ge ne [13].
Nutritional factors , su ch as folate deficiency, have also
been suggested to increase the risk of CLP, bas e d on b oth
observational studies and interventional trials using fo-
late supplementation to prevent recurrences of CLP in
families [14]. Studies of vitamin supplementation with
folate remain controversial [3,15] and recent studies of
levels of folate receptor antibodies did not find any sig-
nificant association with CLP [16]. Furthermore, food
fortification programs using folic acid have shown de-
tectable decreases in the rates of clefting in some studies
[17,14]. Besides nutrients and toxins, other environmen-
tal exposures have been implicated for their possible
roles in clefting. These exposures include hyperthermia,
stress, ma tern al obesity, occupational exposures, ionizing
radiation and infection. A study by Donkor et al. [18] in
Ghana showed that cleft lip and palate was associated
with low maternal income.
It is common knowledge that women of child-bearing
age in Ghana are exposed to a variety of chemical prepa-
rations which are either applied topically or ingested
systemically for a variety of reasons. These chemicals
include contraceptives prescribed for the prevention of
pregnancy. Other chemicals which are usually not pre-
scribed include alcohol, skin lightening creams, enemas
for a host of indications, prednisolone tablets for weight
gain, and concoctions for self-induced abortion. The ef-
fect of these chemical preparations on the developing
fetus is unknown. The purpose of this study is to deter-
mine the level of usage of chemical agents by mothers
and orofacial clefting in their offspring.
2. Methodology/Statistics
This is a retrospective study based on records of consec-
utive patients attending the multidisciplinary cleft clinic
at KATH. Relevant information relating to the use of
chemical agents by the mothers of the children with cleft
lip and palate before and during the pregnancy was ex-
tracted from the medical records of the patients on to
specially designed data collection forms. The study pe-
riod was from January 2006 to December 2012. Data
were entered into a Microsoft Excel spreadsheet, cleaned
and analysed. Analysis was conducted using SPSS for
windows V 170 (Chicago). Frequencies and descriptive
statistics were calculated for all variables.
3. Results
A total of 1368 records were studied. The mean age of
the mothers was 28 years with a range of 14 to 43 years.
The majority of them were unemployed (Table 1). Only
Table 1. Occupation of mothers with cleft child ren.
Occupation Percentage
None 27.3
Petty trading 18.0
Apprenticeship 17.3
Farming 15.7
Seamstress 12.3
Hairdresser 7.3
Teacher 1.3
Lawyer 0.3
Others 0.5

Usage of Potential Teratogenic Chemical Preparations among Mothers of Children Attending
the Multidisciplinary Cleft Clinic at the Komfo Anokye Teaching Hospital, Ghana
OPEN ACCESS MPS
13
12.4% of the mothers attended antenatal clinic during
pregnancy. Ten (10) of the mothers had a positive family
history of orofacial clefting. Out of these, four (4) moth-
ers had a cleft lip and palate deformity, three of whom
also had more than one child with cleft. Ch emical prep a-
rations most commonly used by the mothers were in the
form of skin lightening creams, enema, non-proprietary
concoctions for inducing abortion, and prednisolone tab-
lets (Table 2). Only 2.1% of the mothers ingested alco-
hol duri ng p regnancy .
4. Discussion
As a gen eral model, it is thought that both genes and en-
vironmental factors, acting either independently or in
combination, are responsible for facial clefting. In this
current study 27.3% of mothers were unemployed and
about 70.6% were involved in low income jobs like hair
dressing , farming, apprenticeship and seamstress (Table
1). In a related study by Donkor et al. [19] at KATH, it
was evident that CLP affected mostly mothers with low
educational background and low socioeconomic status.
This was corroborated by this study. Other worldwide
studies [20,21] have also reported similar findings. The
reason for this observation could be due to the fact
people in Ghana with low educational background may
also be handicapped in knowledge of maternal and re-
productive health. This coupled with low socioeconomic
status can affect mother’s ability to access and afford
health care.
Another concern which needs mention among our
farming mothers which form 15.7% of the study popula-
tion, is the increase indiscriminate usage of agro-che mi-
cal especially from vegetable and cocoa farmers. These
high carbon compounds made up of aliphatic aldehydes,
ethyl ether, aliphatic acids, trichloroethylene and pesti-
cides can increase risk of CLP. More studies will be
needed to know about how much these chemicals con-
tribute to orofacial clefting among our farming folks.
Table 2. Chemical usage among mothers of cleft children.
Chemical type Percentage
None 24.0
Skin lightening cream 25.3
Local enema 20.5
Contraceptive 5.2
Prednisolones 12.2
Chemical usage in self-induced
abortion
10.5
Alcohol 2.1
Tobacco/smoke 0.2
The usage of skin lightening cream accounted for the
highest (25.3%) potential teratogenic chemical used by
cleft mothers. The observation that the use of skin ligh-
tening creams is widespread is due to the fact that, fair-
skinned women in Ghana are considered to be beautiful
which thus encourages the use of skin bleaching creams
some of which contain high concentrations of mercury
and steroid.
The use of local enema which contains mostly local
herbs to cure all forms of ailments including waist pain
and constipation is also very common in Ghana and ac-
counted for 20.5% of chemical agents used by mothers.
The enema concoction may also contain steroids which
could be a p otential teratogenic.
Another interesting observation among Ghanaian wo-
men is the use of an over-the-counter prednisolone tablet
that is locally called “P” (Ta ble 2) to gain weight, which
is considered a sign of good living which accounted for
12.2%. Ster iod usage is a known risk factor in th e devel-
opment of orofacial cleft. In this case if its usage is not
directed by a qualified practioners, then the user is even
at a higher risk of developing orofacial cleft.
The role self-induced abortion with chemical concoc-
tions in orofacial cleft formation is not known. It is, how-
ever, conceivable that all these chemicals could either
directly induce genetic mutations or work in concert with
genetic predisposition to cause cleft lip and palate.
Alcohol and tobacco usage accounted for 2.1% and
0.2% respectively. These are known risk factors to the
development of orofacial clefts [22]. In Ghana, the use of
tobacco by women has negative cultural connotation and
this could mean the actual usage is likely to be higher
than what is stated. Again, apart from tobacco smoking
in the form of cigarette, some also use raw tobacco
leaves which has been soften by heat under their tongue
for recreational purposes.
The use of birth control piles and injectables ac-
counted for 5.2%. This is also a known risk factor.
There was also low usage of antenatal care among the
mothers which implies that they may not have benefited
from the cleft potential protection offered by folic acid
from development of cleft lip an d palate. As observed by
Donkor et al. [19], mothers from a low socioeconomic
background are likely to be malnourished, and coupled
with the high usage of self-administered and potentially
teratogenic chemical preparations, are at an increased of
risk of giving birth to children with cleft lip and palate
deformity.
5. Conclusion
There is a high usage of potentially teratogenic chemicals
among cleft mothers attending multidisciplinary cleft lip
and palate clinic at the Komfo Anokye Teaching Hospi-

Usage of Potential Teratogenic Chemical Preparations among Mothers of Children Attending
the Multidisciplinary Cleft Clinic at the Komfo Anokye Teaching Hospital, Ghana
OPEN ACCESS MPS
14
tal in Ghana. For this reason, there is the need for public
education of women of child bearing age against misuse
of chemical preparations. Health practioners should also
lead the nationwide campaign for free folic acid utiliza-
tion among women of child bearing age to reduce the
prevalence of CLP in our society.
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the Multidisciplinary Cleft Clinic at the Komfo Anokye Teaching Hospital, Ghana
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