Determinants of folic acid use in a multi-ethnic population of pregnant women: a cross-sectional study

Are migrants during the periconception period less likely to be supplementing with folic acid: An Australian cohort study

BACKGROUND

Folic acid (FA) supplementation before and in early pregnancy is known to improve outcomes such as reducing neural tube defects; however, little is known about groups in Australia at risk of low FA use.

AIM

To determine whether differences exist in FA supplementation rates between Australian-born women and migrant women, with a secondary aim of examining the sociodemographic characteristics of women who are not supplementing with FA in early pregnancy.

METHODS

A retrospective cohort study from January 2018-July 2022 in a high-migrant population in Western Sydney, Australia. Multivariate logistic regression analysis was conducted adjusting for confounders including place of birth, age, ethnicity, parity, history of diabetes, and type of conception.

FINDINGS

There were 48,045 women who met inclusion criteria; 65% of whom were migrants. We identified that 39.4% of the study population did not report FA supplementation by early pregnancy. Women who were migrants were more likely to report FA usage than those born in Australia (aOR 1.24; 95%CI 1.17-1.31). Women least likely to report use of FA were women < 20 years of age (aOR 0.54; 95%CI 0.44-0.67) and multiparous women (aOR 0.84; 95%CI 0.82-0.86). Women with type 1 or type 2 diabetes were more likely to report FA use (aOR 1.66; 95%CI 1.11-2.48, aOR 1.30; 95%CI 1.05-1.61).

CONCLUSION

A significant proportion of the population did not report FA supplementation before or during early pregnancy. To increase uptake of FA supplementation, clinicians and public health messaging should target at-risk groups.

Prenatal folic acid supplementation and folate status in early pregnancy: ECLIPSES study

This research evaluates the prevalence of inadequate folate status in early pregnancy, the pattern of prenatal folic acid (FA) supplementation and associated factors in Spanish pregnant women from the ECLIPSES study, which included 791 participants prior gestational week 12. A cross-sectional evaluation of erythrocyte folate levels was performed at recruitment and used to calculate the prevalence of folate deficiency (erythrocyte folate < 340 nmol/l) and insufficiency (erythrocyte folate < 906 nmol/l). Sociodemographic and lifestyle data as well as information on prenatal FA supplementation were recorded. Descriptive and multivariate statistical analyses were performed. The prevalence of folate deficiency and insufficiency were 9·6 % and 86·5 %, respectively. Most of women used prenatal FA supplements, but only 6·3 % did so as recommended. Supplementation with FA during the periconceptional period abolished folate deficiency and reduced folate insufficiency. Prenatal FA supplementation with ≥1000 µg/d in periconceptional time and pregnancy planning increased erythrocyte folate levels. The main risk factor for folate insufficiency in early pregnancy was getting prenatal FA supplementation out of the periconceptional time (OR 3·32, 95 % CI 1·02, 15·36), while for folate deficiency they were young age (OR 2·02, 95 % CI 1·05, 3·99), and smoking (OR 2·39, 95 % CI 1·30, 4·37). In addition, social and ethnic differences according to folate status were also identified. As conclusion, periconceptional FA use is crucial for achieving optimal folate levels in early pregnancy. Pregnancy planning should focus on young women, smokers, those with low consumption of folate-rich foods, low socio-economic status or from ethnic minorities.

The role of education and migration background in explaining differences in folic acid supplementation intake in pregnancy: results from a German birth cohort study

OBJECTIVE

Official German recommendations advise women to start taking folic acid supplementation (FAS) before conception and continue during the first pregnancy trimester to lower the risk of birth defects. Women from lower socio-economic background and ethnic minorities tend to be less likely to take FAS in other European countries. As little is known about the determinants of FAS in Germany, we aimed to investigate the association between FAS and formal education and migration background, adjusting for demographic factors.

DESIGN

We used data (2013-2016) on nutrition and socio-economic and migration background from the baseline questionnaire of the BaBi cohort study. We performed multivariate regressions and mediation analyses.

SETTING

Bielefeld, Germany.

PARTICIPANTS

Nine-hundred forty-seven women (pregnant or who had given birth in the past 2 months).

RESULTS

16.7% of the participants (158/947) did not use FAS. Migration-related variables (e.g. language, length of stay) were not associated with FAS in the adjusted models. FAS was lower in women with lower level of formal education and in unplanned pregnancies. Reasons given by women for not taking FAS were unplanned pregnancy and lack of knowledge of FAS.

CONCLUSIONS

Health practitioners may be inclined to see migrant women as an inherently at-risk group for failed intake of FAS. However, it is primarily women who did not plan their pregnancy, and women of lower formal education level, who are at risk. Different public health strategies to counter low supplementation rates should be supported, those addressing the social determinants of health (i.e. education) and those more focused on family planning.

Arabic-speaking pregnant women with a migration background: A vulnerable target group for prenatal counseling on medicines

BACKGROUND

The diversity of the European population increased over the last decades due to migration influences. It is obvious that pregnant women with a migration background also need access to the healthcare system of their host country. Nevertheless, pregnancies among women with a migration background may be even more challenging due to a higher prevalence of adverse pregnancy outcomes, higher risk of vitamin deficiencies or lower intake of folic acid. These issues reinforce the need for effective counseling by healthcare professionals (HCPs).

OBJECTIVES

To explore the experiences of Arabic-speaking pregnant women with a migration background living in Belgium regarding their communication with HCPs, as well as their perceptions towards HCPs and the use of healthcare products during pregnancy.

METHODS

Semi-structured interviews with Arabic-speaking pregnant women were conducted between February-July 2017 using purposive and snowball sampling. An empirically based conceptual framework, grounded in the interview data, was developed prior to content analysis and coding with Nvivo 11.

RESULTS

In total, 17 interviews were conducted. Most women reported that they were suffering from the language barrier, which hindered their communication with HCPs and had undesirable consequences on their treatment and medication use. Communication was largely affected by the presence of interpreters. During pregnancy, a high threshold to use medicines and a preference for natural remedies was observed.

CONCLUSION

Arabic-speaking pregnant women with a migration background living in Belgium are a vulnerable target group for prenatal counseling on medicines. Besides early dectection and willingness to help these women, HCPs should refer them to appropriate and understandable online sources and provide evidence-based information about the use of healthcare products during pregnancy. To facilitate the patient-HCP communication, strategies are further needed to stimulate these women to learn a national language and to increase their social integration.

Paternal characteristics associated with maternal periconceptional use of folic acid supplementation

Background

Maternal predictors of folic acid (FA) supplementation use to reduce offspring risk of neural tube defects are well known, while paternal determinants for maternal FA use are less known. Such knowledge is important to increase women’s compliance to recommended periconceptional FA use.

Methods

In a nation-wide study of 683,785 births registered in the Medical Birth Registry of Norway during 1999–2010, the associations between paternal characteristics (age, education, occupation, country of origin) and maternal FA use were estimated by relative risks (RR) with 95% confidence intervals (CI), using log-binomial regression.

Results

Maternal FA use before and during pregnancy (adequate FA use) was found in 16% of the births. The association between paternal age and adequate FA use was inversely U-shaped; adjusted RRs for adequate FA use were 0.35 (95% CI 0.28–0.43) and 0.72 (95% CI 0.71–0.74) for paternal age < 20 and ≥ 40 years, respectively, comparing age 30–34 years. Compulsory education (1–9 years) among fathers was compared to tertiary education; the RR was 0.69 (95% CI 0.68–0.71) for adequate FA use. The lower risk of adequate FA use for paternal compulsory education was present in all categories of maternal education. Occupation classes other than “Higher professionals” were associated with decreased risk of adequate FA use, compared with the reference “Lower professionals”. RR for adequate FA use was 0.58 (95% CI 0.56–0.60) comparing fathers from “Low/middle-income countries” with fathers born in Norway.

Conclusion

Adequate FA use in the periconceptional period was lower when fathers were younger or older than 30–34 years, had shorter education, had manual or self-employed occupations, or originated from low/middle-income countries. Partners may contribute to increase women’s use of periconceptional FA supplementation.

Use of dietary supplements by pregnant women in Colombia

Background

During pregnancy, the need for certain nutrients increases. This study assessed the prevalence and socio-demographic factors associated with dietary supplement use in a representative sample of pregnant women in Colombia.

Method

Data for this study were obtained from a cross-sectional, nationally representative survey (ENSIN, 2010). A total of 1856 pregnant women, 13–49 years of age, were recruited. The use of prenatal dietary supplements (Vitamins A, C or E) was treated as a binary outcome (used at some time or never sued during pregnancy when prescribed by a doctor) in multinomial analyses. Sociodemographic data and associated factors were assessed by computer-assisted personal interview technology.

Results

Of the sample, 1123 women (68.6%) reported taking prenatal dietary supplements at some stage during their pregnancy. Most users had a high socioeconomic level (79.5%), were in their third trimester of pregnancy (79.5%), were 30–49 years of age (74.0%), and lived in the central region of Colombia (73.8%). The multivariate logistic regression showed that third trimester of pregnancy (OR 6.2;95% CI 4.0 to 9.3), high educational level (OR 2.3; 95% CI 1.5 to 3.4), high socioeconomic level -SISBEN IV or more- (OR 2.0; 95% CI 1.4 to 2.8), residence in the Atlantic region (north) (OR 2.6; 95% CI 1.7 to 3.6), Eastern region (OR 2.0; 95% CI 1.3 to 3.1), central region (OR 2.6; 95% CI 1.7 to 3.9), Pacific region (west) (OR 1.5; 95% CI 1.0 to 2.3), and belonging to the mestizo (others) ethnic group (OR 1.2; 95% CI 1.0 to 2.6), were all associated with a higher probability of dietary supplement intake.

Conclusion

The prevalence of prenatal dietary supplements in pregnant women in Colombia was found to be substantial. The variables significantly associated with their use were educational level, socioeconomic level, trimester of pregnancy, geographic level and ethnic group. These results indicate the necessity of implementing new health policies that guarantee uniform access to nutritional supplements for all population sectors, especially in countries, such as Colombia, who are currently undergoing a process of nutritional transition.

Factors associated with intention of Israeli-born women and immigrant women from the Former Soviet Union to take folic acid before and during pregnancy

AIM

Folic acid supplementation before and during pregnancy decreases rates of neural tube defects. However, many women fail to adhere to folic acid supplementation recommendations. This study explored factors associated with women's intention to take folic acid before and during pregnancy, using the Theory of Planned Behaviour, with an emphasis on differences between Israeli-born women and immigrant women from the Former Soviet Union.

METHODS

In this cross-sectional study, 100 Israeli born-women and 100 women from the Former Soviet Union of childbearing age completed a questionnaire, based on the Theory of Planned Behaviour.

RESULTS

The findings indicated a significant difference in the rates at which Israeli-born and FSU-born women took folic acid before and during pregnancy, as well as a significant difference in their intention to take folic acid supplementation in future pregnancies. The theoretical model explained 88.7% of variance in women's intention to take folic acid, with the most influential variable being behavioural attitudes towards taking folic acid.

CONCLUSION

The study emphasizes the need to increase knowledge and change attitudes and beliefs about folic acid supplementation among women and their significant others, as well as the importance of cultural, language, and economic barriers when treating Former Soviet Union immigrant populations.

Prevalence of Neural Tube Defects and the Impact of Prenatal Diagnosis in Three Districts of Beijing, China

BACKGROUND

The objectives of this study were to explore the prevalence of neural tube defects (NTDs) in three districts of Beijing, and to evaluate the impact of prenatal diagnosis on the prevalence.

METHODS

Data were collected between 2006 and 2012 from the Beijing Birth Defects Surveillance System. P₁₃ and P₂₈ represent the prevalence of NTDs diagnosed from 13 weeks and 28 weeks of gestation, respectively, to 7 days after delivery. Populations were classified as household (permanent) and non-household (non-permanent) because differences exist in access to health care, education, and income, among others.

RESULTS

The P₁₃ of NTDs was 11.7 per 10 000 births in the three districts, which declined from 2006-12. In addition, the prevalence of NTDs in the non-household population was 1.7-fold higher than that among the household population. The P₁₃ of anencephaly, spina bifida, and encephalocele were 5.3, 4.9, 1.6, respectively, per 10 000 births. The P₂₈ of NTDs only represented 29.1% of P₁₃ , and this proportion decreased over the 7-year period.

CONCLUSIONS

The prevalence of NTDs remains high in the three districts of Beijing, and the rate was higher in the non-household than household population. The prevalence of birth defects would be under estimated by almost 70 per cent if the report time was set on 28 weeks' gestation or later compared with report time on 13 weeks of gestation. It is better to set the report time earlier in birth defect surveillance in contemporary China.

Compliance to the recommended use of folic acid supplements for women in Sweden is higher among those under treatment for infertility than among fertile controls and is also related to socioeconomic status and lifestyle

Background: Folate has been discussed in relation to fertility among women, but studies on women under treatment for infertility are lacking.

Objective: The objective of this study was to investigate folic acid supplement use and folate status among women under treatment for infertility (hereafter infertile) and fertile women also in regard to socioeconomic and lifestyle factors.

Design: Lifestyle and dietary habits, and use of dietary supplements were assessed using a questionnaire. Blood samples were obtained for analysis of folate status. 24-hour recall interviews were also performed.

Results: Highly educated, employed and infertile women were most prone to using folic acid supplements. The infertile women had a significantly better folate status than the fertile women. Folate status did not correlate with socioeconomic or lifestyle factors. The infertile women were physically more active, smoked less and were employed. Our questionnaire data had only fair agreement with the data from 24-hour recalls, but the folate status data was clearly correlated to our questionnaire results.

Conclusions: Infertile women were most prone to using folic acid supplements and had better folate status than the controls. High educational and employment status were found to be key factors for high compliance to the recommended use folic acid supplements.

Ethnic differences in folic acid supplement use in a population-based cohort of pregnant women in Norway

Background

Peri-conceptional use of folic acid supplements is recommended to prevent neural tube defects. Correct supplement use seems to be less common among ethnic minorities. We examined ethnic differences in folic acid supplement use before and during pregnancy and possible effect modification by education or planning of pregnancy.

Methods

The participants were 811 healthy pregnant women from a population-based cohort study in Oslo, Norway in 2008–2010. Ethnicity was categorized to five groups (European, Middle Eastern, South Asian, East Asian, African). Data on folic acid supplement use were obtained from hospital records and remaining data by a questionnaire. Logistic regression analyses were adjusted for age, parity, planning of pregnancy, education and Norwegian language skills.

Results

Before pregnancy, 30.1% of European women and 7.1 to 13.6% of women in the other ethnic groups used folic acid supplements (p < 0.001). The adjusted odds ratio (OR) for supplement use was 0.55 (95% confidence interval 0.31; 0.96) for South Asian and 0.42 (95% confidence interval 0.19; 0.94) for Middle Eastern women compared with European women. During pregnancy, supplement use was most common in European women (65.7%) and least common in Middle Eastern (29.4%) and African women (29.0%) (p < 0.001). Compared with European women, all other ethnic groups had lower adjusted odds (OR 0.30 to 0.50, p < 0.05 for all) for supplement use among women with high school or less education, but not among more educated women. Planning of pregnancy did not modify the association between ethnicity and supplement use.

Conclusions

Few women used folic acid supplements before pregnancy. Educational level modified the association between ethnicity and supplement use during pregnancy. Public health campaigns should focus on increasing awareness especially in ethnic minority groups with low educational level.

Knowledge on preconceptional folic acid supplementation and intention to seek for preconception care among men and women in an urban city: a population-based cross-sectional study

Background

To study the knowledge of a large city population on preconception folic acid supplementation and intention to seek for preconception care within an urban perinatal health program.

Methods

Cross-sectional surveys run in Rotterdam, the Netherlands, in 2007 and annually from 2009 to 2014. A random sample of residents aged between 16 and 85 years was taken each year from the municipal population register. Bivariate analysis, interaction analysis, trend analysis and logistic regression were performed.

Results

Knowledge on preconceptional folic acid supplementation significantly improved (+20 %) between 2007 and 2009, and the intention to consult a GP or midwife in the preconception period significantly increased (+53 %) from 2007 to 2012. Logistic regression analyses showed that low socio-economic status was significantly associated with low preconceptional folic acid knowledge, but with higher intention to seek out preconception care. An interaction effect was found between educational level and ethnicity, showing that the higher the educational level the lower the gap of level of knowledge between the different ethnic groups.

Conclusion

Despite campaigns about folic acid supplementation knowledge on this supplement remains low. The intention amongst men and women to seek out preconception care is still insufficient. Structural interventions to increase and maintain awareness on folic acid supplementation, especially among high-risk groups, are needed.

Folic acid supplementation and IVF pregnancy outcome in women with unexplained infertility

Folic acid supplements are commonly used by infertile women which leads to a positive folate status. However, the effect of folic acid supplements on pregnancy outcome in women with unexplained infertility has not been well investigated. This study evaluated folic acid supplement use and folate status in women with unexplained infertility in relation to IVF pregnancy outcome. In addition, use of folic acid supplements and folate status were compared between women with unexplained infertility and fertile, nonpregnant control women. Women with unexplained infertility used significantly more folic acid supplements and had higher median total folic acid intake from supplements compared with fertile control women (both P < 0.001). Women with unexplained infertility also had significantly higher median plasma folate and lower median plasma homocysteine concentrations than fertile women (both P < 0.001), but folic acid supplementation or folate status were not related to pregnancy outcome in women with unexplained infertility. In conclusion, folic acid supplementation or good folate status did not have a positive effect on pregnancy outcome following infertility treatment in women with unexplained infertility. Folate is one of the B vitamins which has been suggested to be related to infertility. Folic acid is an artificial form of folate which is commonly used in dietary supplements. Folic acid supplementation has been shown to increase folate concentrations and decrease concentrations of the amino acid homocysteine in the blood. Folic acid supplementation is commonly used by infertile women, but the effect on pregnancy outcome in women with a diagnosis of unexplained infertility has not been thoroughly investigated. In the present study, folic acid supplement use and folate status (concentrations of folate and homocysteine) in women with unexplained infertility were evaluated in relation to pregnancy outcome. In addition, the use of folic acid supplements and folate status were compared between women with unexplained infertility and fertile control women. Our results showed that women with unexplained infertility used considerably more folic acid supplements and had higher total folic acid intake from supplements compared with fertile control women. Women with unexplained infertility had better blood folate and homocysteine concentrations than fertile women, but folic acid supplementation or folate status were not related to pregnancy outcome following the infertility treatment. In conclusion, high folic acid intake or good folate status did not increase the possibility of a birth of a healthy baby after infertility treatment in women with unexplained infertility.

The role of folic acid in fetal programming of birth phenotypes and early human development: a biopsychosocial perspective

Preterm birth, low birthweight, intrauterine growth retardation and small for gestational age are birth phenotypes that significantly contribute to life-long morbidity and mortality. This review examines the epidemiologic and biologic evidence of folic acid (FA) as a potential population-based intervention to curtail some adverse birth phenotypic expressions, and by extension, their later physical and neurodevelopmental consequences. We outlined a feto-placental adaptation categorization taking into account how prenatal insults may be encoded in fetal development, the adaptive success of the feto-placental response, and subsequent expression in the health of the fetus. Although there are plausible biological pathways that can be implicated, we found that the epidemiological evidence on the role of perinatal FA nutriture and fetal programming of adverse birth phenotypes is still inconclusive. Because biologic and epidemiological considerations alone do not suffice in deciphering the utility of FA in averting adverse birth phenotypes, we proposed a biopsychosocial model that takes into account multi-layered psychosocial contexts for improving subsequent research studies in this area.

An increase in neural tube defect notifications, South Australia, 2009-2010

INTRODUCTION

In South Australia, reporting of live births, stillbirths of at least 20 weeks or 400 g birth weight, termination of pregnancies and congenital anomalies is mandated. We describe the investigation of an increase in notifications of neural tube defects (NTDs) in South Australia in 2009 and 2010 using data from several surveillance systems.

METHODS

NTD trend data from 1966 to 2010 were reviewed. Comparisons of pregnancies affected by an NTD in 2009 and 2010 were made with pregnancies affected by an NTD in the period 2003-2008 and with all pregnancies in 2009 and 2010. Statistical analysis was undertaken using Poisson regression, χ(2) or Fisher's exact tests.

RESULTS

The prevalence of NTD-affected pregnancies was 1.95 per 1000 births (39 cases) in 2010 and 1.91 per 1000 births in 2009 (38 cases), the highest annual rates since 1991. Case series comparisons indicated women with NTD-affected pregnancies in 2009 and 2010 were less likely to be Caucasian compared with women who had NTD-affected pregnancies in the period 2003-2008. Women born in the Middle East and African region (n = 7) were significantly more likely to have NTD-affected pregnancies in the years 2009 and 2010 (relative risk: 3.03; 95% confidence interval: 1.39-6.62) compared with women born in the Oceania region.

DISCUSSION

The increased notifications of NTDs can only be partially explained by the increase in numbers of women from the Middle East and African region, with no other contributory causes revealed. This analysis highlighted areas where prevention efforts should be strengthened and surveillance data improved.