Folic acid awareness and intake among women in areas with high prevalence of neural tube defects in China: a cross-sectional study

Knowledge, awareness, and use of folic acid among women of childbearing age living in a peri-urban community in Ghana: a cross-sectional survey

BACKGROUND

Folic acid, a water-soluble B-complex vitamin, plays a crucial role in DNA synthesis and maintenance, making it particularly significant during reproduction. Its well-known ability to reduce the risk of congenital anomalies during the periconceptional period underscores its importance. The increased requirement for folate during pregnancy and lactation is essential to support the physiological changes of the mother and ensure optimal growth and development of the foetus and offspring. This study assessed the knowledge, awareness, and use of folic acid among pregnant and lactating women of reproductive age residing in Dodowa in the Shai Osu-Doku District, Accra, Ghana.

METHODS

The study was a cross-sectional design that involved 388 randomly selected participants (97 pregnant and 291 lactating women). Structured questionnaires were administered to gather information on the socioeconomic demographic characteristics, knowledge, awareness, and use of folic acid of the participants. Dietary intake was assessed using a food frequency questionnaire. The data were analysed using descriptive statistics and Pearson's chi-square analysis tests and are presented as frequencies and percentages, means, standard deviations, bar graphs, and pie charts. The significance of the results was determined at a 95% confidence interval.

RESULTS

The mean age of the participants was 31 ± 5.0 years. Among the study participants, 46.1% demonstrated knowledge of folic acid deficiency, while approximately 68.3% had a high awareness of folic acid supplementation. Approximately 75% of the participants indicated that they had not used folic acid supplements within the week, and 15.5% reported consuming folic acid-fortified food per week.

CONCLUSIONS

The women exhibited high awareness but poor knowledge regarding the usage of folic acid supplementation during pregnancy and lactation. Consequently, this lack of knowledge influenced the low use of folic acid supplements and low intake of folate-rich foods among pregnant and lactating mothers.

Enablers and barriers to women's lifestyle behavior change during the preconception period: A systematic review

Healthy lifestyle behaviors during the preconception period are important to optimize maternal and child outcomes, including weight. However, the majority of women do not have optimal preconception lifestyle behaviors. This systematic review explored enablers and barriers to women's preconception lifestyle behaviors using the Capability, Opportunity, Motivation, Behaviour (COM-B) model and Theoretical Domains Framework (TDF). Preconception was defined as the time before conception, capturing planned and unplanned pregnancies. Medline Complete, EMBASE, PsycINFO, and CINAHL were searched for peer-reviewed, quantitative and qualitative primary studies (English, 2006-2020) that explored enablers and barriers to lifestyle behaviors (diet, physical activity, smoking, alcohol use, supplement intake). Forty-two studies (of 3406) were included, assessing supplement use (n = 37), diet (n = 10), smoking (n = 10), alcohol use (n = 8), and physical activity (n = 5). All three COM-B components were identified only for diet and supplement use. Of the 14 TDF domains, 7 were identified: knowledge, beliefs about capabilities, beliefs about consequences, goals, intentions, social support, and environmental context and resources. The presence/absence of knowledge on healthy behaviors was the most commonly assessed enabler/barrier. Future studies should explore a wider range of factors influencing preconception women's capability, opportunity, and motivation to modify their lifestyle behaviors.

Knowledge and intake of folic acid to prevent neural tube defects among pregnant women in urban China: a cross-sectional study

BACKGROUND

The prevalence of neural tube defects (NTDs) in China declined during 2000-2017 with periconceptional folic acid (FA) supplementation, which is effective in reducing the risk of birth defects. We aimed to assess the knowledge and actual use of FA among Chinese pregnant women and to explore factors associated with FA use before pregnancy.

METHODS

All data were collected in face-to-face interviews during health visits among pregnant women. We collected information about knowledge and use of FA supplements and demographic, socioeconomic, and health status. One maternity and childcare hospital was chosen in each of four cities: Beijing, Huaibei, Kunming, and Haikou. In total, 435 pregnant women were randomly recruited for interviews conducted from June to December 2016.

RESULTS

A total of 428 pregnant women were included in this survey. Of these, 82.0% (351/428) knew that FA can prevent NTDs, and 75.9% (325/428) knew the correct time to take FA. Overall, 65.9% (282/428) of women knew both that FA can prevent NTDs and the recommended time to take FA before pregnancy. Approximately 95.1% (407/428) of women reported having ever taken FA, only 46.3% (198/428) had begun to take FA supplementation before conception, and 64.5% (109/169) of women from rural areas failed to take FA before pregnancy. Women living in northern China (odds ratio [OR] = 1.81, 95% confidence interval [CI], 1.18-2.77), those with unplanned pregnancy (OR = 1.99, 95% CI 1.30-3.04), and highly educated women (OR = 2.37, 95% CI 1.45-3.88) were more likely to know about FA. Women who were homemakers (OR = 1.94, 95% CI 1.21-3.11) and had unplanned pregnancy (OR = 6.18, 95% CI 4.01-9.53) were less likely to begin taking FA before pregnancy.

CONCLUSIONS

Our survey showed that most pregnant women knew about FA. Although preconception intake of FA can help to reduce NTDs, improving the rate of FA intake before pregnancy is needed in urban areas of China, especially among homemakers and women from rural areas or with unplanned pregnancy. Campaigns are needed to increase awareness about FA and FA use before pregnancy among rural women, homemakers, and those with unplanned pregnancy and lower education levels.

Update on the prevalence and determinants of folic acid use in Japan evaluated with 91,538 pregnant women: the Japan Environment and Children's Study

Objective: To provide the latest and most promising evidence on the prevalence and determinants for folic acid supplementation in pregnant women in Japan, including differences in prevalence between interview years and determinants across regions.Materials and methods: The study participants were enrolled from 15 regional centers across Japan between January 2011 and March 2014. Information on the use of folic acid supplementation before and during pregnancy and the characteristics of the participants were collected using questionnaires, medical chart reviews, and interviews by research coordinators.Results: Data for 91,538 women who provided sufficient data on folic acid supplementation were analyzed. The prevalence of adequate users was 8.0%, which, although low, tended to improve over the 4-year recruitment period. Various kinds of sociodemographic factors, lifestyle habits, and obstetrical and medication use history were significant and independent determinants for folic acid use. Associations between adequate preconception folic acid use and its major determinants tended to be similar across regions.Conclusions: Although the prevalence of adequate folic acid use was low, it increased from 2011 to 2014. Reproductive-aged women who have determinants for inadequate folic acid use should be informed about the need for preconception folic acid supplementation to help prevent neural tube defects.

Awareness, use and information sources of folic acid supplementation to prevent neural tube defects in pregnant Japanese women

OBJECTIVE

Folic acid supplementation and folate-rich diets are recommended for women of childbearing age worldwide to prevent congenital anomalies. We aimed to determine the current status of folic acid supplementation among pregnant Japanese women and identify means to increase the intake of these supplements.

DESIGN

Cross-sectional study.

SUBJECTS

A total of 1862 pregnant women who consulted the perinatal centre from September 2014 to December 2015 completed a questionnaire concerning knowledge about folic acid, sources of information and the use of folic acid supplements.

SETTING

Osaka Medical Center and Research Institute for Maternal and Child Health (Japan).

RESULTS

In our study population, only 20·5 % of pregnant women took folic acid supplements periconceptionally even though 70·4 % knew about the protective effect of folic acid. A multivariate analysis demonstrated that age ≥35 years (OR=2·80; 95 % CI 1·24, 6·29) and knowledge of the benefits of folic acid (OR=2·64; 95 % CI 1·92, 3·62) were associated with periconceptional folic acid use, and multiparity was negatively associated with such use. Compared with those who took folic acid supplements periconceptionally, women who did not take supplements received information through passive and less interactive media.

CONCLUSIONS

Although folic acid awareness was relatively high among pregnant Japanese women, folic acid supplementation before conception was insufficient. To increase the intake of folic acid supplements in countries in which foods are not fortified with folic acid, an effective public health approach promoting behavioural change is necessary for women of reproductive age.

Preconception health behaviours: A scoping review

Preconception health refers to the health of males and females at any point in time prior to a potential pregnancy. A goal of preconception health research is to use preventive behaviour and healthcare to optimize the health of future offspring that result from both planned and unplanned pregnancies. This paper briefly reviews evidence of the importance of various preconception health behaviours, and examines the extent to which specific preconception health behaviours have been included in recent studies of such knowledge, behaviours, and intentions. To describe this recent research in highly developed countries, a scoping review of the literature was completed of studies published within the past seven years. A total of 94 studies on preconception health were identified and reviewed: (a) 15 examined knowledge and attitudes, (b) 68 studied behaviours, (c) 18 examined interventions designed to improve knowledge or behaviour, and (d) no studies examined intentions to engage in preconception health behaviours. Over 40% of studies examining preconception health behaviour focussed exclusively on folic acid. Overall, folic acid, alcohol, and cigarettes have consistently been topics of focus, while exposure to harmful environmental substances, stress, and sleep have been largely neglected. Despite strong evidence for the importance of men's health during the preconception period, only 11% of all studies included male participants. Based on existing gaps in the research, recommendations are provided, such as including men in future research, assessing a wider variety of behaviours, consideration of behavioural intentions, and consideration of the relationships between preconception health knowledge, intentions, and behaviour.

Consumption of dietary supplements by Chinese women during pregnancy and postpartum: A prospective cohort study

The objectives of this study were to investigate usage patterns and factors associated with maternal dietary supplementation by Chinese women. A prospective cohort study of 695 mothers, who gave birth to a singleton baby, was conducted in Jiangyou, Sichuan Province of China. Information on dietary supplement use was collected from participants by personal interview at hospital discharge and followed up by telephone at 1, 3, and 6 months postpartum. Logistic regression analysis and generalised linear-mixed modelling were performed to determine factors affecting dietary supplementation during pregnancy and the first 6 months postpartum, respectively. A total of 81.8 and 32.1% of women consumed dietary supplements during pregnancy and postpartum, respectively. Calcium was the most popular supplement (pregnancy 63.9%; postpartum 28.1%), whereas folic acid was only taken during pregnancy (62.3%) with an average usage duration of 2.5 (standard deviation 1.3) months among users. High school and above education, adjusted odds ratio (OR) = 2.67, 95% confidence interval (CI) [1.63, 4.38], and attendance at prenatal classes (adjusted OR = 1.99, 95% CI [1.05, 3.76]) were associated with dietary supplementation during pregnancy. Mothers with a higher level of education (adjusted OR = 3.10, 95% CI [1.81, 5.30]) were also more likely to use dietary supplements in the postpartum period. Although dietary supplementation appeared to be common among Chinese mothers, maternal intake of folic acid was well below the guidelines. There is a need for further nutrition education on maternal use of micronutrient supplements, especially targeting mothers who are less educated.

Pre-conceptional intake of folic acid supplements is inversely associated with risk of preterm birth and small-for-gestational-age birth: a prospective cohort study

Associations of folic acid supplementation with risk of preterm birth (PTB) and small-for-gestational-age (SGA) birth were unclear for the Chinese populations. The aim of the present study was to investigate the associations in a large Chinese prospective cohort study: the Jiaxing Birth Cohort. In the Jiaxing Birth Cohort, 240 954 pregnant women visited local clinics or hospitals within their first trimester in Southeast China during 1999-2012. Information on anthropometric parameters, folic acid supplementation and other maternal characteristics were collected by in-person interviews during their first visit. Pregnancy outcomes were recorded during the follow-up of these participants. Multinomial logistic regression was used to examine the association of folic acid supplementation with pregnancy outcomes. The prevalence of folic acid supplementation was 24·9% in the cohort. The prevalence of PTB and SGA birth was 3·48 and 9·2%, respectively. Pre-conceptional folic acid supplementation was associated with 8% lower risk of PTB (relative risk (RR) 0·92; 95% CI 0·85, 1·00; P=0·04) and 19% lower risk of SGA birth (RR 0·81; 95% CI 0·70, 0·95; P=0·008), compared with non-users. Higher frequency of pre-conceptional folic acid use was associated with lower risk of PTB (P trend=0·032) and SGA birth (P trend=0·046). No significant association between post-conceptional initiation of folic acid supplementation and either outcome was observed. In conclusion, the present study suggests an association between pre-conceptional, but not post-conceptional, folic acid supplementation and lower risk of PTB and SGA birth in the Jiaxing Birth Cohort. Further research in other cohorts of large sample size is needed to replicate these findings.

Changes in the Incidence of Congenital Anomalies in Henan Province, China, from 1997 to 2011

Aim

To investigate changes in incidence and characteristics of congenital anomalies in infants in Henan Province of China over a period of 15 years.

Methods

Population-based surveillance in Henan Province was conducted from 1997 to 2011 in 75 hospitals (40 urban districts and 35 rural counties, comprising about 20% of the total births). Basic population information was obtained from the healthcare network. All live births, intrauterine deaths after 28 weeks, and stillbirths were included. Congenital anomalies were diagnosed and reported to Henan Provincial Maternal and Pediatric Healthcare Hospital.

Results

Of 1,815,920 births from 1997 to 2011, 15,660 cases of congenital anomalies were identified, resulting in an average incidence of 86.2 cases per 10,000 births. The incidence of congenital anomalies showed a significant downward trend (p < 0.0001) in rural areas and the whole province (p < 0.0001), but an increase in urban areas (p = 0.003). The incidence was much higher in rural than in urban areas in 1997, but this discrepancy decreased rapidly and no difference was seen between rural and urban areas in 2003. The incidence in females was higher than in males in 1997–1999 but decreased to a similar level as that in males in 2000. Maternal age exceeding 35 years was associated with a higher incidence of congenital anomalies. Among the 23 types of congenital anomalies recorded, neural tube defects were the most common; the incidence declined from 39.3 cases per 10,000 births in 1997 to 6.1 cases per 10,000 births in 2011.

Conclusion

The incidence of congenital anomalies has decreased in Henan Province over the past 15 years due to significant reductions in rural areas and among girls. This decrease was partly related to a reduction in neural tube defects that was likely the result of a folic acid intervention in the province.

Consumer preferences for micronutrient strategies in China. A comparison between folic acid supplementation and folate biofortification

OBJECTIVE

Despite public health efforts, folate deficiency is still largely prevalent in poor, rural populations and continues to cause a large burden of disease. The present paper determines and compares consumer preferences for two folate strategies: folic acid supplementation v. folate biofortification, i.e. the enhancement of the folate content in staple crops.

DESIGN

Experimental auctions with non-repeated information rounds are applied to rice in order to obtain willingness-to-pay for folate products. Thereby, GM or non-GM folate-biofortified rice (FBR) is auctioned together with rice that is supplemented with free folic acid pills (FAR).

SETTING

Shanxi Province (China) as a high-risk region of folate deficiency.

SUBJECTS

One hundred and twenty-six women of childbearing age, divided into a school (n 60) and market sample (n 66).

RESULTS

Despite differences according to the targeted sample, a general preference for folate biofortification is observed, regardless of the applied breeding technology. Premiums vary between 33·9 % (GM FBR), 36·5 % (non-GM FBR) and 19·0 % (FAR). Zero bidding behaviour as well as the product choice question, respectively, support and validate these findings. The targeted sample, the timing of the auction, the intention to consume GM food and the responsibility for rice purchases are considered key determinants of product choice. A novel ex-post negative valuation procedure shows low consistency in zero bidding.

CONCLUSIONS

While the low attractiveness of FAR provides an additional argument for the limited effectiveness of past folic acid supplementation programmes, the positive reactions towards GM FBR further support its potential as a possible complementary micronutrient intervention.

Preconceptional folic acid-containing supplement use in the National Birth Defects Prevention Study

BACKGROUND

Despite public health campaigns encouraging women to take a daily folic acid supplement, the proportion of reproductive age women, in the United States, who comply with this recommendation is less than optimal. The objective of this analysis was to identify predictors of preconceptional folic acid-containing supplement use to define subgroups of women who may benefit from targeted folic acid campaigns.

METHODS

This study included 6570 mothers of live born infants from the control population of National Birth Defects Prevention Study (1997-2005). Logistic regression analyses were used to identify predictors of preconceptional folic acid supplementation. A classification and regression tree (CART) analysis was used to define subgroups of women with different patterns of preconceptional folic acid supplementation.

RESULTS

Race/ethnicity, education, age at delivery, nativity, employment, income, number of dependents, smoking, and birth control use were significantly associated with preconceptional folic acid-containing supplement use. Based on a CART analysis, education, race/ethnicity, and age were the most distinguishing factors between women with different preconceptional supplementation patterns. Non-white women with <4 years of a college education were the least likely to use folic acid-containing supplements (11%). However, even in the most compliant subgroup (women with ≥4 years of college), only 60% of women supplemented with folic acid.

CONCLUSION

These results demonstrate the need for continued efforts to increase folic acid supplementation among all reproductive aged women. However, the success of such efforts may be improved if maternal characteristics such as education, race/ethnicity, and age, are considered in the development of future interventions.

Geographic and urban-rural disparities in the total prevalence of neural tube defects and their subtypes during 2006-2008 in China: a study using the hospital-based birth defects surveillance system

BACKGROUND

Previous reports on the prevalence of neural tube defects (NTDs) in China did not include cases of NTDs that were less than 28 weeks of gestational age (GA) and hence did not accurately reflect the total prevalence of NTDs or the geographic and urban-rural disparities in their prevalence. This article includes cases of NTDs that were less than 28 weeks of GA.

METHODS

Data used in this study were collected from 2006 to 2008 using a nationwide hospital-based registry, the Chinese Birth Defects Monitoring Network. The total prevalence ratio (PR) of NTDs and their subtypes, the ratios of PR (PRR), and 95% confidence intervals (CI) were used to analyse geographic disparities at both the regional (north, south) and provincial levels and to analyse disparities between rural and urban areas.

RESULTS

Overall, the total PR of NTDs was 14.0 per 10,000 births. The PRR of NTDs of rural women between the north and south region was 2.26 (95% CI: 2.04-2.52), which was much higher than that of urban women (PRR: 1.56, 95% CI: 1.41-1.72). The three subtypes of NTDs had different geographic distribution at the level of province. The urban-rural PRR of NTDs was 2.14 (95% CI: 1.94-2.34) in the north but only 1.47 (95% CI: 1.31-1.66) in the south.

CONCLUSIONS

There is a high total prevalence of NTDs, which remains one of the major public health concerns in China. Eliminating the geographic and urban-rural disparities in the disease burden is a priority for future intervention.