Women and Birth
Volume 23, Issue 2 , Pages 67-73, June 2010

A survey of folic acid use in primigravid women

  • Diane C. Wilton

      Affiliations

    • Practice Development Midwife-Delivery Suite, Al Wasl Hospital, Dubai, United Arab Emirates
    • Corresponding Author InformationCorresponding author. P.O. Box 214139, Jumeira Post Office, Dubai, United Arab Emirates. Tel.: +971 501 058 072.
    • ,
  • Maralyn J. Foureur

      Affiliations

    • Centre for Midwifery, Child and Family Health, University of Technology, Sydney, NSW, Australia

Received 22 October 2008; received in revised form 5 July 2009; accepted 13 September 2009.

Article Outline

Summary 

A convenience sample of 320 consecutive primigravid women attending the antenatal clinic of a large Sydney tertiary referral hospital were invited to take part in a survey of folic acid use in pregnancy. The aim of the survey was to determine the number of primigravid women who commenced taking folic acid supplementation at least 1 month prior to conception. In addition the survey sought information on women's source of knowledge about the need for folic acid in pregnancy and whether their pregnancy was planned or unplanned. 295 women qualified to be included in the survey. While 88.1% of women took folic acid at some time prior to and/or during the first trimester, only 23.4% were found to have taken folic acid at least 1 month prior to conception. Of women with a planned birth only 34.5% commenced folic acid prior to conception. This survey adds further weight to the decision of the Australian Government to mandate for fortification of bread-making flour with folic acid, due to commence in September 2009. However, even with folic acid fortified food, health professionals need to continue to advise women to take supplements prior to conception and for at least 12 weeks into their pregnancy to prevent neural tube defects.

Keywords: Folic acid, Folate, Pregnancy, Fortification of food, Neural tube defects

 

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Introduction 

The effectiveness of folic acid supplements in the prevention of neural tube defects is well documented.1, 2 For optimal prevention it is recommended that folic acid supplements be commenced at least 1 month prior to conception as neural tube development begins early in the embryological stage2, 3, 4 – even before a woman may know that she is pregnant and certainly before her first visit to a health professional for confirmation of pregnancy. The long-term economic and psychological costs of a diagnosis of neural tube defect in a fetus are difficult to assess. For those babies who survive it entails life long medical costs and social repercussions. In Australia, prenatal diagnosis of a fetus with a neural tube defect allows for the option of termination of pregnancy, however, since this is a distressful experience for women it would be preferable to concentrate on measures to prevent neural tube defects.5 The New South Wales Department of Health recommends that “all women planning a pregnancy or likely to become pregnant” should be provided with advice regarding the importance of folate and they should be offered a folic acid supplementation of 0.5mg daily from 1 month prior to conception until at least the 12th week of pregnancy.4 Food Standards Australia and New Zealand recommend at least 0.4mg of folic acid additional to dietary folate.6, 7

In order to address the issue of the unplanned pregnancy or a lack of awareness of the need for folate, universal fortification of food products with folic acid has been implemented in over 40 countries in the world including the United States of America where a 30% reduction in neural tube defects has been reported since fortification commenced.8, 9 The fortification of food with folate is not without its critics calling this process “mass medication of the population”.10 Perceived risks of certain cancers such as colon11 and breast, and the masking of pernicious anaemia have been reported.12 These risks, however, have been outweighed by the benefits since it is thought that a deficiency in micronutrients, including folic acid, can put people at a higher risk of disease.5

On June 22, 2007 the Australian and New Zealand Food Regulation Ministerial Council issued a Joint Communiqué13 which approved mandatory fortification of food with folic acid to be implemented in 2009. In New Zealand bread is to be fortified and in Australia bread-making flour is to be fortified. This was gazetted and became law in Australia in September 2007.14, 15 Industry has a 2-year time limit in which to commence implementation of the fortification of flour. This means that by September 2009 all bread-making flour in Australia will be fortified with folic acid. By implementing this measure it is estimated that 49 cases or 14% of neural tube defects will be prevented each year in Australia.16

It must be noted, however, that the recommended amount of folic acid to be added to flour is 2–3mg/kg of flour which means that bread will contain approximately only 0.12mg of folic acid per 100g or per three slices.14 As mentioned earlier, the daily recommended folic acid intake for women planning pregnancy and within the first trimester of pregnancy is at least 0.4mg. The amount of folic acid consumed would depend upon the amount of bread flour products eaten, or indeed whether they are eaten at all. This has been recognized by the Australian and New Zealand Food Standards Board, however, the Board came to the conclusion that fortifying flour and bread will provide some cover at conception and in the early embryonic stage of pregnancy for those women who have unplanned pregnancies and for those women who do not commence folic acid prior to pregnancy. It will, therefore, still be necessary for women to be encouraged to commence folic acid supplements prior to pregnancy and this continues to be a recommendation from the Australia and New Zealand Food Standards Board.14, 15

There have been several studies in Australia asking women about their periconceptual lifestyle habits and vitamin supplementation, including folic acid usage. Two surveys have been conducted by the Epidemiology and Surveillance Branch of the New South Wales (NSW) Department of Health with a survey carried out in 200116 that was replicated in 2006.17 The surveys sought to quantify the number of women who had taken folic acid 1 month prior to pregnancy and for 3 months into pregnancy. The 2001 survey of 647 women within 12 months after the birth of their baby reported that 47.6% stated they had taken folic acid in this way. The 2006 survey of 263 women found that the proportion of respondents who had taken folic acid had increased to 53.1%. However, both surveys were limited by their time of administration which may have influenced responders to either over or underestimate folic acid use. The results of the two NSW Department of Health surveys are not supported by other studies undertaken in different states in Australia. Bower et al.18 surveyed 578 recently pregnant women in Western Australia (WA) between 1997 and 2000 and found that even though 62.3% of women were aware of the need to commence folic acid prior to a pregnancy, only 28.5% of women had done so. A South Australian (SA) survey of 140 pregnant women (at any gestational age) attending a hospital antenatal clinic who were asked about their folic acid use in the 3 months prior to their pregnancy, found that 31% had commenced folic acid prior to conception.19 Forster et al.20 surveyed 588 women at approximately 38 weeks of pregnancy who were attending a Victorian (VIC) hospital antenatal clinic during 2003 and 2004 and found that 23% of respondents took pre-pregnancy folic acid supplements for at least 4 weeks prior to conception of a pregnancy. While each of these surveys looked at periconceptual folic acid use none distinguished between primigravid and multigravid women nor did they distinguish between planned and unplanned pregnancies. What is clear however is that while the rates may vary, each survey reveals low uptake of folic acid prior to conception. Despite many years of recommendations for preconceptual folic acid it is clear that this important health message is still not being heard.

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Background to study 

While working as a midwife in the antenatal clinic of a large tertiary level Sydney Hospital (Westmead Hospital), one of us (DW) observed that most women had not commenced taking folic acid until at least 4 weeks after conception. As all women required a referral letter from a medical practitioner to book into the hospital, it could be assumed that most women did not commence folic acid until after their first visit with their general practitioner to confirm their pregnancy. It appeared that women were not aware of the need to take folic acid prior to conception and for at least the first 12 weeks of pregnancy. This concern was heightened when DW cared for a woman with a 19 week pregnancy who had chosen to have a termination because the fetus had been diagnosed with anencephaly on an 18 week ultrasound. This woman had not taken folic acid at any time prior to or during her pregnancy.

To determine whether these informal impressions that few women were taking folic acid according to the recommended guideline were accurate and to increase our understanding of the source of health information for pregnant women, a survey was designed to determine the proportion of primigravid women attending the clinic who commenced folic acid supplementation prior to pregnancy. In addition the survey sought to gain insight into the source of information about the need for folic acid pre- and post-conception and to provide some indication where efforts could be made to improve uptake.

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Study design and methods 

A survey was conducted using convenience sampling and a written questionnaire (see Box 1). A convenience sample of 320 primigravid women attending the antenatal clinic at Westmead Hospital were surveyed between September 2005 and March 2006 (permission to identify the hospital was provided by the Director of Clinical Governance of the Western Sydney Area Health Service). Westmead Hospital is a large tertiary referral hospital in the western suburbs of Sydney. The sample size of 320 represented approximately 10% of the number of primigravid women who book into Westmead each year for the birth of their baby. The inclusion criteria for the survey were that the woman should be pregnant with her very first pregnancy, that the survey be conducted only at the booking-in visit and, as the survey was only available in English, all respondents needed to be able to read, understand and write English. Being a primigravid ensured that the information about the need for folic acid was not gained from a previous pregnancy. Conducting the survey during the booking-in visit, that is, early in pregnancy, ensured that the information was relatively current and thus as accurate as possible with reduced potential for recall bias. A midwife conducts the ‘booking-in’ visit for all women intending to give birth at Westmead Hospital. Allocation to an ongoing midwifery or medical model of care is done following this initial visit.

Box 1. Survey questions.

1. How many previous pregnancies have you had?
2. Is this present pregnancy a planned pregnancy?Yes/No
3. Are you taking, or have you taken, folic acid for this pregnancy?Yes/No
If you answered “Yes” please proceed to next questions.
4. When did you commence taking folic acid?
(a) Prior to pregnancy?Yes/No
If “Yes” how many weeks prior to conception did you commence folic acid?
If “No” at what week of pregnancy did you commence taking folic acid?
5. Where did you get the information regarding the need for folic acid in pregnancy?

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Method 

The midwife conducting the ‘booking-in’ visit asked whether or not the woman would like to participate in a survey regarding the use of folic acid for pregnancy. It was explained that taking folic acid in early pregnancy was known to reduce the incidence of certain brain and spinal abnormalities and that it was important for midwives and other health professionals to know whether or not this message was getting out into the community. Once the woman had given verbal consent to her participation she was asked to complete the questionnaire while still with the ‘booking-in’ midwife. This allowed any queries to be dealt with immediately and also aided accuracy. On completion, the questionnaire was handed back to the midwife for collation with other completed questionnaires.

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The survey tool 

The specially developed questionnaire asked three initial questions to elicit whether or not the woman was primigravid, whether or not the pregnancy was planned and whether or not folic acid was being taken or had been taken. If the woman answered “No” to folic acid use she was thanked for her participation and was not required to answer any more questions. Because the inclusion criteria required that the woman be primigravid it was important to establish that this was the case. Whether or not the pregnancy was planned was asked to discern those women who were most likely to have commenced taking folic acid prior to pregnancy. This question also gave information on the percentage of women who were experiencing an unplanned pregnancy. The issue of unplanned pregnancies is important in the light of support for fortification of bread flour in Australia. If a woman indicated that she had taken, or was taking folic acid, she was asked to indicate whether or not folic acid had been commenced prior to pregnancy or after she knew she was pregnant. Details of how many weeks prior to or following pregnancy the folic acid had been commenced were also ascertained. Finally the women were asked how they had known to commence folic acid. This information would allow some insight into how the results of this survey could be used to increase information dissemination and heighten awareness of the need for folic acid to be commenced prior to conception.

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Ethical issues 

National Health and Medical Research Council (NHMRC) guidelines in the “National Statement on Ethical Conduct in Research Involving Humans”21 were adhered to for this project. Ethical approval was not sought as the survey was regarded as a quality assurance activity within Westmead Hospital. The survey was intended to assess adherence to the guideline on folic acid supplementation in pregnancy, therefore was considered to be an audit of practice for which ethical approval is not required. However, in retrospect it is apparent that as new information was being sought about the planning of pregnancy and the women's sources of information about the need for folic acid supplementation, the survey was indeed research. Determining whether a project is research or audit is sometimes a challenge. It is important to seek the advice of the local Human Research Ethics Committee on all projects involving patients or staff to determine whether ethical approval is required. All women were informed they had the right to refuse to participate without affecting their care in any way. The identity of participating women was confidential to the midwife conducting the booking-in consultation. No identifying information was obtained on the survey so that the anonymity of participating women could also be protected.

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Data analysis 

Data from the questionnaires were entered into an Excel database and then analyzed using simple descriptive statistics (frequencies and percentages). Frequencies and percentages were determined for overall folic acid use and whether or not the pregnancy was planned. Further data from respondents who had taken folic acid was obtained for time of commencement of folic acid (prior to or following conception), the number of weeks prior to or following conception the folic acid was commenced and source of information regarding folic acid. To explore whether pregnancy planning influenced whether and when folic acid was taken, responses from the women with planned and unplanned pregnancies were compared.

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Results 

The response rate for the survey was 99.0%. 320 questionnaires were distributed and 317 were returned. Of those returned 295 were eligible for inclusion since 22 women recorded at least one previous pregnancy and thus were excluded.

Almost two thirds of women indicated their pregnancies (67.7%) were planned (Fig. 1). The majority (88.1%) of all respondents took folic acid either before and/or within the first trimester of their pregnancy (Fig. 2). Twenty three percent of all respondents commenced taking folic acid at least 1 month or more prior to pregnancy, 64.7% commenced folic acid after conception and 10.5% did not take folic acid at all (Fig. 3). Of the 64.7% who commenced folic acid after conception 9.4% could not give the week of commencement of folic acid and all others (except for one woman who stated that she had started taking folic acid at 3 weeks gestation) commenced folic acid after 4 weeks of pregnancy, in some cases as late as 11 and 12 weeks of pregnancy.

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Influence of pregnancy planning on commencement of folic acid 

Most women (83.2%) with an unplanned pregnancy commenced folic acid in the first trimester and only 16.8% did not take folic acid at all (Fig. 4). Of the 200 women with a planned pregnancy just over one third (34.5%) commenced taking folic at least 1 month prior to becoming pregnant, 56.0% commenced folic acid after conception, 7.5% did not take folic acid and 2% of women were unsure of whether they had taken folic acid (Fig. 5). Six women reported that they commenced folic acid as late as 12 weeks of pregnancy.

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Source of information 

Of the 260 women who took folic acid, 76.2% cited a medical practitioner, for example, ‘doctor’, ‘GP’, or ‘Gynae’ as the source of their information on the need for folic acid. The remaining 23.9% gained their information from a variety of other sources such as books, family, ‘mother a RN’ (Fig. 6). No respondent identified a ‘midwife’ as a source of information.

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Discussion 

One of the aims of this survey was to determine the prevalence of primigravid women attending Westmead Hospital who commenced folic acid at least 1 month prior to conception. It was concerning to find that only 23.4% of all respondents had done so (Fig. 3). Within the planned pregnancy group, where it could be expected that folic acid would be commenced prior to conception, only 34.5% of respondents had done so (Fig. 5). Both rates are lower than those found in two other NSW surveys undertaken by the NSW Department of Health (47.6%, 53.1%).16, 17 However, both these surveys were of mothers with a baby of less than 12 months of age. The long length of time between the periconceptual period and the administration of the survey could have influenced the ability to recall exactly when folic acid was commenced. Also neither NSW Department of Health surveys distinguished between multigravid and primigravid women and thus did not take into account the possibility of the women having received information regarding folic acid during a previous pregnancy.

The results from the Western Australian,18 South Australian19 and the Victorian20 based surveys are similar to the study reported here. Despite the failure to distinguish between primigravid and multigravid women or those with planned and unplanned pregnancies, similar low rates of periconceptual folic acid uptake were found in all studies (28.5% in WA, 31% in SA, 23% in VIC and 23.4% in the Westmead study).

Overall folic acid use by women either prior to and/or during the first trimester of pregnancy was found by the two NSW Department of Health surveys of 2001 and 2006 to be 75.4% and 82.7% respectively. Forster et al.20 found that 79.5% of all respondents took folic acid at some time before 13 weeks of pregnancy. The Westmead survey found that 88.1% of all women took folic acid either before or within the first 12 weeks of pregnancy. However, that the great majority of women in the Westmead survey commenced folic acid after the 4th week of pregnancy is worrying as by this stage a neural tube defect may already have occurred.

Only the Victorian survey20 asked the main source of folic acid information. Forster et al.20 reported that 57.3% of respondents named doctors as their main source of folic acid information compared with 76% in the study reported here. The assumption is that the information was provided during the medical consultation to confirm pregnancy although it could have been an opportunistic conversation prior to pregnancy. If the information is only provided on confirmation of pregnancy, it is too late.

The WA, SA, VIC and NSW surveys concur, less than a third of women took folic acid prior to pregnancy and more than half the women relied on their doctor for information regarding the need for folic acid. These results therefore reveal the lack of effective public awareness programs in this area.

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Recommendations 

That optimal protection against neural tube defects can only be provided if folic acid is taken prior to pregnancy and into the first trimester of pregnancy needs to become common knowledge within the general community. For this to happen there will need to be more effective public health campaigns. This could utilize popular media which targets women of childbearing age. The Internet, women's magazines, television and radio advertisements could be employed to get the message across. Newspaper articles could be written, posters and leaflets could be distributed in women's health clinics, doctors’ offices, family planning clinics, university campuses and on public transport. Health workers who visit schools for various health awareness programs could bring the message to young women still at school.

Continuing education programs for all health workers are imperative especially for those who have contact with women of childbearing age. Counselling skills in promoting health related behavioural change should be a part of this education. As general practitioners have been shown by this survey to be so important in the dissemination of information regarding folic acid it is essential that their training instill in them the need to advise all women who potentially could have a pregnancy, of the importance of folic acid prior to conception.

This survey has highlighted that many pregnancies remain unplanned and that the majority of primigravid women do not take folic acid prior to pregnancy. Because of this it provides support for the decision by the Australian government to fortify bread flour with folic acid in Australia planned for September 2009. While bread flour fortification will provide some protection against neural tube defects it will not provide optimal protection. For optimal protection women will still have to take folic acid supplements prior to pregnancy and as such all health care providers will need to continue to inform women of this fact.

It is essential that midwives are well informed regarding the mandatory fortification of bread-making flour. It is also essential that midwives know that the amount of folate which will be available from food products using bread-making flour, while offering some preventative measures, will not be equal to the daily recommended dose for the periconceptual period. Because of this it will remain necessary for women to take additional folic acid periconceptually. With the role of the midwife expanding, and midwives moving into different models of care involving more contact with women from early in pregnancy, it is important that midwives are providing up-to-date information.

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Limitations 

The main limitation of this survey is that formal ethics approval was not sought prior to the commencement of data collection. In retrospect the survey should have been regarded as research and formal ethics approval sought. The distinction between quality assurance audit and research is sometimes blurred and the advice of the appropriate ethics committee could have been obtained to clarify the status of the survey in this instance. Generally speaking research is concerned with generating new knowledge, or determining “what is the right thing to do” and audit is concerned with determining “whether the right thing is being done”.22 Both activities involve careful sampling, appropriate questionnaire design, data collection and analysis. One question that may be helpful to ask is “does the project involve anything being done to people that is beyond what can be described as normal clinical management?” If the answer is “yes” then the project is research. In this case, the intention was to generate new knowledge about women's behaviour in relation to folic acid use prior to conception of pregnancy and so can be considered as research.

Another limitation of the survey is that it was conducted in a hospital setting which required all women to be referred by a doctor prior to booking in. There was no opportunity provided for women to be seen by a midwife prior to booking-in and there was no information collected as to the likelihood that a midwife had been consulted prior to or following pregnancy. Because of this the survey provides a reflection of doctors’ advice and provides no information regarding midwives’ advice about periconceptual folate.

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Conclusion 

The results of this survey indicate that the majority of primigravid women are not well enough informed regarding the preventative properties of folic acid against fetal neural tube defects at conception of a pregnancy. While this can be seen as a failure of health professionals to pass on the information to women at the relevant time it also highlights the need for a targeted public health education campaign. It also validates the Federal Government's legislation for mandatory fortification of bread-making flour in Australia. Priority should be given to the primary prevention of neural tube defects thus reducing the financial and emotional burden placed upon individuals and the community once an abnormality is diagnosed. As midwives have an important role in the dissemination of health promotion information, and are increasingly in roles which facilitate this, they are in a prime position to contribute towards this preventative initiative.

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Acknowledgements 

The data for this survey was collected in Clinic 9, in the University Clinics of Westmead Hospital, NSW. We would like to thank all midwives who generously assisted with the collection of the data. Westmead Hospital has provided permission for the inclusion of the name of the hospital in the publication of this paper.

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References 

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PII: S1871-5192(09)00069-9

doi:10.1016/j.wombi.2009.09.001

Women and Birth
Volume 23, Issue 2 , Pages 67-73, June 2010

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