Valproate use in low- and middle-income countries: Balancing reproductive safety, seizure control, and access to safer antiseizure medicines.

Valproate is highly effective for genetic generalized epilepsies but carries substantial dose-dependent risks of major congenital malformations and adverse neurodevelopment after in utero exposure. Guidelines therefore recommend avoiding it in individuals with pregnancy potential when effective alternatives are available. This dilemma is concentrated in generalized epilepsies; focal epilepsies should generally be treated with other appropriate antiseizure medicines irrespective of reproductive potential. In many low- and middle-income countries, however, inconsistent access to lamotrigine, levetiracetam, and ethosuximide, limited specialist and reproductive-health services, and weak procurement and pharmacovigilance constrain substitution. This narrative review integrates comparative efficacy, pregnancy-safety, health-economic, and implementation evidence. We distinguish cost-effectiveness from short-term budget impact and argue that restriction without reliable alternative supply may worsen seizure control and inequity. We propose syndrome-specific prescribing: prioritise safer alternatives, reserve valproate for documented cases in which they are ineffective, contraindicated, unavailable, or unaffordable, and pair its use with counselling, effective contraception, folic acid, lowest-effective-dose monotherapy, and regular review. National policies should combine reproductive safeguards with essentialmedicines inclusion, pooled procurement, quality assurance, and monitoring.