Influence of educational level on determinants of folic acid use.

BackgroundCountries worldwide recommend women planning pregnancy to use daily 400 µg of synthetic folic acid in the periconceptional period to prevent birth defects in children. The underlying mechanisms of this preventive effect are not clear, however, epigenetic modulation of growth processes by folic acid is hypothesized. Here, we investigated whether periconceptional maternal folic acid use and markers of global DNA methylation potential (S-adenosylmethionine and S-adenosylhomocysteine blood levels) in mothers and children affect methylation of the insulin-like growth factor 2 gene differentially methylation region (IGF2 DMR) in the child. Moreover, we tested whether the methylation of the IGF2 DMR was independently associated with birth weight.Methodology/Principal Findings IGF2 DMR methylation in 120 children aged 17 months (SD 0.3) of whom 86 mothers had used and 34 had not used folic acid periconceptionally were studied. Methylation was measured of 5 CpG dinucleotides covering the DMR using a mass spectrometry-based method. Children of mother who used folic acid had a 4.5% higher methylation of the IGF2 DMR than children who were not exposed to folic acid (49.5% vs. 47.4%; p = 0.014). IGF2 DMR methylation of the children also was associated with the S-adenosylmethionine blood level of the mother but not of the child (+1.7% methylation per SD S-adenosylmethionine; p = 0.037). Finally, we observed an inverse independent association between IGF2 DMR methylation and birth weight (−1.7% methylation per SD birthweight; p = 0.034).ConclusionsPericonceptional folic acid use is associated with epigenetic changes in IGF2 in the child that may affect intrauterine programming of growth and development with consequences for health and disease throughout life. These results indicate plasticity of IGF2 methylation by periconceptional folic acid use.

Periconceptional folic acid use considerably reduces the risk of neural tube defects. The aim of this study was to measure the effect of the national and the local 'Folic Acid Campaign' on periconceptional folic acid use. Before (1995 survey) and 1 year after the campaign (1996 survey), the awareness and use of folic acid was measured among pregnant women in four regions of the Netherlands. To this end, pregnant women who visited the midwife, general practitioner or obstetrician for the first or second prenatal visit were asked to complete a questionnaire. The results showed that use of folic acid for any period around conception increased from 25.1% in 1995 to 53.5% in 1996. Appropriate use (4 weeks before until 8 weeks after conception) increased from 4.8% in 1995 to 21.0% in 1996. No additional effect of the local Folic Acid Campaign was found (adjusted odds ratio= 1.0; 95% confidence interval = 0.7, 1.4). It was possible to conclude that folic acid use at the recommended time increased considerably as a result of the national and the local Folic Acid Campaign, but the target (use in 46% of women wishing to conceive) was not achieved. New health education programmes are needed to increase further its use at the appropriate times.

Periconceptional supplementation with folic acid has been shown to decrease the occurrence of neural tube defects (anencephaly, encephalocele and spina bifida). Earlier studies , conducted worldwide to assess patient's knowledge regarding periconceptional use of folic acid showed that the overall knowledge about its use among pregnant mothers was low. A cross-sectional study was conducted to assess the level of knowledge regarding periconceptional use of folic acid and to determine factors influencing knowledge about folic acid among pregnant women. In the sample studied, 36.6% of study population had heard about folic acid and among them 33.3% could correctly state the effect of folic acid when used periconceptionally. Among those who had heard about folic acid, 80% believed that it should be taken only after confirmation of pregnancy. Low levels of education was associated with less knowledge regarding folic acid, and the difference was statistically significant (OR 4.86, 95% CI 1.74-13.61). Low socio economic status was also significantly associated with poor knowledge (OR 2.371, 95% CI 1.11- 5.05).The overall knowledge regarding periconceptional use of folic acid among a rural study population was poor. Health education regarding periconceptional use of folic acid among newly married couples may improve knowledge and hence its acceptance in the prevention of neural tube defects. Qualitative assessment regarding knowledge and beliefs also revealed the misconception about role of folic acid and food items containing folic acid among the study population.

To systematically summarise the available evidence concerning the rate of folic acid supplement use pre- and periconceptionally, to identify those characteristics associated with low rates of use and to assess whether folic acid public awareness campaigns are associated with higher folic acid use. Systematic overview. Survey studies. Women of reproductive age, most of whom were currently or recently pregnant. Two investigators searched MEDLINE, Embase and Nutriotiongate databases between 1990 and 2003. Bibliographies of retrieved references were scanned for other relevant publications, and authors were contacted if necessary. Studies were included that evaluated the rate of folic acid supplement use either before conception or in early pregnancy. Rate of preconceptional and/or periconceptional folic acid use, rate of planned pregnancy in each study, as well as significant characteristics differentiating non-users from users of folic acid, including the effect of folic acid awareness campaigns. A total of 52 studies were included. In 34 studies, reported preconceptional folic acid use varied from 0.9% to 50%. In 49 studies, the reported rate of periconceptional supplement use ranged from 0.5% to 52%. Significant predictors of reduced periconceptional folic acid use were a low level of formal education, immigrant status, young maternal age, lack of a partner and an unplanned pregnancy. Four studies examined the effect of mass media campaigns on periconceptional folic acid use; the reported rates increased significantly, by a factor of 1.7 to 7.2, but in no study was the post-campaign rate above 50%. In many countries, fewer than 50% of women take periconceptional folic acid supplements. Consideration should be given to the practical advantages of folic acid fortification of centrally processed foods, such as wheat, corn and rice flour, while further promoting vitamin tablet supplement use and planned pregnancy.

Objective: To evaluate periconception drug use in women undergoing fertility treatment and compare it to women with spontaneous pregnancies. Methods: Retrospective observational cohort study on reproductive-age women. Data on pregnancies, fertility treatments, prescription fillings and demographics were extracted from Clalit Health Services computerized systems. Two quality measures were evaluated: periconception folic acid prescription fillings and use of potentially hazardous drugs in early pregnancy. Results: There were 12,891 fertility treatment cycles in 4868 women; and 4968 women had spontaneous pregnancy. Periconceptional folic acid use was low and similar in both groups (31.3% of fertility cycles versus 29.9% of spontaneous pregnancies, p = 0.07). In the infertility group, 293 prescriptions for potentially hazardous drugs were filled within 45 days after the beginning of a fertility cycle (2.3% of cycles) compared to only 47 (0.9%) in women with spontaneous pregnancy (p < 0.001). Conclusions: The periconception medical care of women who undergo fertility treatment is suboptimal and is not better than in women with spontaneous pregnancies. Folic acid use that can reduce the risk of congenital anomalies is underused; whereas the use of potentially hazardous drugs in early pregnancy is significant. More intensive and targeted counseling regarding drug use before pregnancy is urgently needed.

To understand the periconceptional use of folic acid and its association with selected characteristics in northern China. As part of a population-based case-control study on external structural birth defects, we analysed periconceptional use of folic acid among control mothers. The study was conducted in four counties (Pingding, Xiyang, Taigu and Zezhou) in Shanxi Province of northern China. The subjects in this study were the control mothers, who were interviewed between January 2003 and May 2005. Of the 480 respondent mothers, 49 women (10.2%) reported ever using folic acid supplements, and only 16 women (3.3%) used it periconceptionally. The rates of any use and periconceptional use did not change significantly with study year. Periconceptional use of folic acid was significantly increased among women with more than high school education (odds ratio (OR) = 4.57, P < 0.10), women who were not farmers (OR = 4.72, P < 0.05), women with a history of birth-defect-affected pregnancy (OR = 32.73, P < 0.05) and women who planned their pregnancy (OR = 7.88, P < 0.10). The rate of periconceptional folic acid use was among the lowest of those reported from other countries. More work should be done to improve preconceptional use of folic acid with special attention on less educated women and women farmers.

To investigate the potentially protective of periconceptional folic acid use on the risk of congenital heart defects (CHDs) relative to other non-folate related malformations. We analysed data from a large regional register of birth defects (EUROCAT-Northern Netherlands), over a 10 year period (1996-2005) for a case-control study. The cases were mothers who had delivered infants with isolated or complex heart defects, without any related syndrome or genetic abnormality (n = 611). We used two control groups; one from the EUROCAT database and another from the general population. The registry controls consisted of mothers of children with a known chromosomal or genetic defect, and with infants with other non-folate related congenital malformations (n = 2401). Additional folic acid was taken as a single supplement or as a multivitamin containing folic acid in a dose of >or=400 microg daily. Mothers who had used folate antagonists or who had diabetes, and mothers of children with oral clefts, hypospadias, limb reduction- or neural tube defects, were excluded from both groups. Potentially confounding factors of periconceptional folic acid use in relation to CHD were explored, including baby's birth year, maternal body mass index, education, maternal age at delivery of index baby, smoking behaviour, and alcohol use during pregnancy. Periconceptional folic acid use revealed an odds ratio (OR) of 0.82 (95% CI 0.68-0.98) for all types of CHD relative to other malformations. The estimated relative risk for CHDs of additional folic acid use compared with the general population was comparable [OR 0.74 (95%CI 0.62-0.88)]. Subgroup analysis showed an OR of 0.62 (95% CI 0.47-0.82) for isolated septal defects. The proportions of the potential confounders between mothers of case and control infants did not differ significantly. Our results support the hypothesis that additional periconceptional folic acid use reduces CHD risk in infants. Use of periconceptional folic acid supplements was related to approximately 20% reduction in the prevalence of any CHD. Given the relatively high prevalence of CHD worldwide, our findings are important for public health.

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Periconceptional use of folic acid can prevent birth defects, including at least 50% of neural tube defects. This study used an ongoing surveillance system to explore the association between pregnancy intendedness and women taking periconceptional folic acid. Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) surveys a stratified random sample of women after a live birth. In 1998-1999, 1867 women completed the survey (64.0% response rate); responses were weighted for nonresponse. Women were asked whether they took folic acid most days in the month before becoming pregnant. Overall, 33.2% of women took folic acid most days in the month before becoming pregnant, and 39.9% said that their pregnancy was unintended. Adolescent mothers were less likely to take periconceptional folic acid (9.2%) and more likely to report unintended pregnancy (62.0%) than older women. Overall, women who said that their pregnancy was intended were more likely to report that they had taken periconceptional folic acid (odds ratio: 4.75; 95% confidence interval: 3.16-7.14); after controlling for maternal age and income the odds ratio was 3.70 (95% confidence interval: 2.38-5.56). Women whose pregnancies were intended were more likely to have been taking periconceptional folic acid than women whose pregnancies were unintended. The importance of fertile women's taking daily multivitamins that contain 400 microg (0.4 mg) of folic acid should be stressed among women who are not contemplating pregnancy, especially adolescents and low-income women.

Periconceptional folic acid supplementation has been shown to decrease the occurrence of neural tube defects (NTD’s). In a cross-sectional study, the knowledge attitude and practice regarding the peri-conceptional use of folic acid were assessed among the pregnant women in Benghazi, Libya. 131 women attending antenatal clinics in three main polyclinics were interviewed through three polyclinics. Seventy-three percent of the participants had heard about folic acid, and only 37% could correctly identify the effect of folic acid when used periconceptionally. 27% of the pregnant women did not take folic acid during their present pregnancy. Only 6% of the women who took folic acid were taking it consistently before pregnancy with the aim of preventing NTDs. This study shows that the interviewed pregnant women reveal high positive attitude (88%) toward retaking folic acid supplements in their next pregnancy. The overall knowledge regarding the periconceptional use of folic acid was relatively low when compared to other studies worldwide. Health education regarding the periconceptional use of folic acid among newly married couples is recommended.

This study was designed to investigate whether the risk for neural tube defects (NTDs) was associated with reduced folate carrier gene (RFC1 A80G) polymorphism and/or with the interaction between the RFC1 gene and maternal periconceptional use of folic acid. One hundred four nuclear families with NTDs and 100 non-malformed control families were sampled to investigate the potential interaction between maternal or the offspring's RFC1 (A80G) genotypes and the maternal periconceptional use of folic acid through a population-based case-control study. RFC1 (A80G) genotypes were detected using PCR-restricted fragment length polymorphism (PCR-RFLP). Mother who had the GG genotype and did not take folic acid had an elevated risk for NTDs (OR = 5.43, 95% CI = 1.68-18.28) as compared to the mother who had AA or GA genotype and took maternal periconceptional folic acid. The interactive coefficient was 1.12 between maternal GG genotype and the periconceptional folic acid non-use. The risk for having an infant with NTDs was 8.80 (95% CI = 2.83-28.69) for offspring with the GG genotype, as compared to the offspring with AA or GA genotype among the mothers who did not take folic acid supplements. The interactive coefficient was 1.45 for offspring with the GG genotype and without maternal periconceptional supplementation of folic acid. Our findings suggest that there is a potential gene-environment interaction on the risk of NTDs between maternal or offspring RFC1 GG genotype and maternal periconceptional intake of folic acid. The RFC1 is likely to be an important candidate gene in folate transportation and RFC1 GG genotype (A80G) may be associated with an increased risk for NTDs in this Chinese population.

Objective To assess community pharmacists' attitudes towards, and practice behaviour, relating to the periconceptional use of folic acid to prevent neural tube defects Method A postal questionnaire was sent to a random sample of 150 community pharmacists at the end of 1996. The questionnaire covered knowledge, attitude and behaviour regarding the use of folic acid by women of childbearing age Setting Two regions in the Netherlands (Northern and Western Netherlands) Key findings The response rate was 72 per cent. Pharmacists' attitudes towards promoting the use of folic acid by women who wish to have a child are positive. Most pharmacists reported distributing folic acid brochures in their pharmacy and many stated that they displayed posters to promote the use of folic acid. Nearly 30 per cent of pharmacists reported using an additional label on the packaging of oral contraceptives with the standard text: “If you stop using the pill because you wish to have a child, please ask your pharmacist for information about the use of folic acid before you become pregnant”. Perceived attitudes of local general practitioners seemed to influence the willingness of pharmacists to promote the use of folic acid. The results indicate a tendency for some pharmacists to be more reactive than proactive in their advice-giving on the use of folic acid Conclusion Compared with the findings of a similar survey two years ago, it appears that more pharmacists are actively promoting the periconceptional use of folic acid. However, further improvements could still be achieved and pharmacists could become more proactive in their information and advice-giving

To investigate the role of language proficiency as determinant of folic acid knowledge and use in a multi-ethnic pregnancy cohort. Prospective cohort study. Pregnant women from Amsterdam attending obstetric care for their first antenatal visit. Number approached: 12,373 women, response rate: 67% (8266 women aged 14-49 years). Ethnicity was based on the country of birth: the Netherlands, Surinam, Antilles, Turkey, Morocco, Ghana, other non-Western and other Western countries. Knowledge about and use of folic acid supplements in pregnancy as elicited in a multilingual questionnaire, as well as determinants of these in ethnic groups separately. Both periconceptional folic acid use and knowledge were significantly lower among Ghanaian, Moroccan, Turkish, and other non-Western women than among women born in the Netherlands or other Western countries. Language proficiency in Dutch was a major determinant of knowledge in all the ethnic groups with a mother tongue other than Dutch [adjusted odds ratios (OR): Western 3.2, non-Western (all countries combined) 7.5], while educational attainment was of secondary importance. Knowledge in turn was the strongest determinant of use (adjusted OR: Western 17.4, non-Western 27.0). Periconceptional folic acid supplement use among women born in non-Dutch-speaking non-Western countries is low, reflecting a lack of knowledge that is determined by the inability to speak and understand the language of the country of residence. Measures to tackle this problem include the provision of linguistically appropriate information via ethnic health advisors, and language courses integrating health education for immigrants.

BackgroundArsenic induces neural tube defects in several animal models, but its potential to cause neural tube defects in humans is unknown. Our objective was to investigate the associations between maternal arsenic exposure, periconceptional folic acid supplementation, and risk of posterior neural tube defect (myelomeningocele) among a highly exposed population in rural Bangladesh.MethodsWe performed a case–control study that recruited physician-confirmed cases from community health clinics served by Dhaka Community Hospital in Bangladesh, as well as local health facilities that treat children with myelomeningocele. Controls were selected from pregnancy registries in the same areas. Maternal arsenic exposure was estimated from drinking water samples taken from wells used during the first trimester of pregnancy. Periconceptional folic acid use was ascertained by self-report, and maternal folate status was further assessed by plasma folate levels measured at the time of the study visit.ResultsFifty-seven cases of myelomeningocele were identified along with 55 controls. A significant interaction was observed between drinking water inorganic arsenic and periconceptional folic acid use. As drinking water inorganic arsenic concentrations increased from 1 to 25 μg/L, the estimated protective effect of folic acid use declined (OR 0.22 to 1.03), and was not protective at higher concentrations of arsenic. No main effect of arsenic exposure on myelomeningocele risk was identified.ConclusionsOur study found a significant interaction between drinking water inorganic arsenic concentration from wells used during the first trimester of pregnancy and reported intake of periconceptional folic acid supplements. Results suggest that environmental arsenic exposure reduces the effectiveness of folic acid supplementation in preventing myelomeningocele.

The New Zealand Ministry of Health advises that all women planning a pregnancy take a folic acid supplement to reduce the risk of having a neural tube defect (NTD)-affected pregnancy. There is little information available to determine if women are following this advice. The purpose of this study was to determine periconceptional folic acid use among women in the postnatal ward of Queen Mary Maternity Hospital in Dunedin. A questionnaire was administered to women in the postnatal ward between 14 November and 22 December 2004. One hundred and six women were interviewed during the study period. Forty women (39%) used folic acid supplements before conception. Sixty-seven women (64%) planned their pregnancy. The proportion of women (P<0.001) who planned their pregnancy (53%) and used folic acid before conception was higher than those who did not (11%). The proportion of women 30 years of age (55%) who took folic acid supplements before conception was higher than women aged 17 to <25 years (10%). Despite a lack of a public health campaign in New Zealand, a high proportion of participants, especially those who planned their pregnancy, took folic acid during the periconceptional period. A comprehensive public health campaign is needed to increase folic acid use. Fortification may be required to reach those women who do not plan their pregnancies.