Assessment of compliance with periconceptual Folic acid supplements amongst pregnant women at a metropolitan Hospital
*Corresponding author: Kassam Mahomed, Senior Staff Specialist, Women’s and Children’s Services, Ipswich Hospital and University of Queensland, Chelmsford Avenue, Ipswich, Australia 4305; E-mail: firstname.lastname@example.org
Neural tube defects result from a failure of the neural tube to close during embryonic development. Neural tube closure begins on day 18 and is complete by day 28 afterfertilisation [1,2], therefore often before a woman even realises she is pregnant. There is clear evidence that women with a higher intake of folic acid (FA) in the peri-conceptual period (one month before and 3 months after conception) have a 70% decreased risk of NTD . As dietary intake cannot achieve the recommended levels of PFS for maximal NTD risk reduction, it is recommended that a supplement of 400 mcg folic acid should be taken during the peri conceptual period.
This paper will focus on use and adherence with current PFAS guidelines amongst pregnant women attending for antenatal care in Ipswich, Queensland.
This was a prospective cross-sectional survey of women attending for their first booking in visit with the midwife at Ipswich Hospital, Ipswich, Queensland. Women were requested to participate if they spoke good English and were 20 weeks or less pregnant. The study questionnaire was designed to ascertain women’s adherence with PFS guidelines.
Data entry and quantitative data analysis were performed using SPSS Statistics Version 19.0 . Bivariate analysis was performed using Pearson’s chi-squared test and a Fisher’s exact test was applied where variables contained <6 outcomes per category. Logistic regression was performed to generate adjusted and unadjusted Odds Ratios, 95% Confidence Intervals
The study was approved by the Darling Downs – West Moreton Health Service District Human Research Ethics Committee (Project Number 38-10) and University of Queensland Medical Research Ethics Committee (Project Number 2010001326).
Over a period of 9 months 410 women were eligible; 8 women declined and 2 were excluded due to ineligibility noted after completion of the survey, Figure 1.
In total 11.8% (47/397; 95%CI, 8.7-14.9%) of women achieved adequate adherence with the recommendations, by taking a supplement containing at least 400µg FA throughout the periconceptual period, Figure 1. The number of women with inadequate adherence, who took a FA supplement for any time during the month prior to conception and the first trimester, the periconceptual period, was 69.0% (274/397). No adherence with the recommendation was present in 19.1% (76/397).
Periconceptual Folic Acid Use
When asked “Have you increased your FA intake before or during pregnancy?” 77.5% (310/400) women replied that they had taken a supplement containing FA. Of these women 31 also increased their dietary FA intake. The common themes identified for not using a supplement containing FA are presented in Table 1.
|Lack of awareness of the importance of folic acid supplementation||“Didn’t know I had to”||45|
|Dietary intake already adequate||“My diet is good so don’t require multivitamin supplements. I’m not sick with this pregnancy.”||14|
|Chosen not to/ I don’t need it||“I didn’t with any of my other pregnancies and everything was fine. They turned out OK”||7|
|Not sure||“No particular reason”||6|
|Not bothered||“Cause I’m lazy, I forget”||4|
|Doctor didn’t recommend||“My doctor didn’t mention this pregnancy – did with last one”||4|
|Iron levels were checked and they were fine||“Checked iron levels prior to pregnancy and nothing wrong”||3|
|Difficulty with nausea and vomiting||“They made me sick”||3|
|“I have been vomiting a lot”|
|Didn’t see the doctor||“I haven’t gone to the GP this time to check for folic acid”||2|
|Couldn’t afford||“I couldn’t afford it, thought about it and decided not to.”||2|
|Caution regarding medications in pregnancy||“You need to be careful about what pills you take when you are pregnant”||1|
The most common reasons cited were lack of awareness of the need for FA supplementation (49.5%, 45/91), dietary intake was already adequate (15.4%, 14/91) and a decision not to take FA or that the woman didn’t require it (7.7%, 7/91). Additionally, the GP was mentioned by non-users of PFS as either not recommending PFS or reassuring women that they had sufficient iron levels (7.7%, 7/91).
Periconceptual Timing of Folic Acid Supplements: Supplements containing FA were used by 86.0% (344/400) of women. This includes 34 women who stated that they did not deliberately increase FA intake before or during pregnancy, but unwittingly did use a supplement containing FA. Only 19.5% (78/400) of women began a supplement containing FA at least one month prior to their last menstrual period (Figure 2).
The majority of women, 46.8% (187/400), began a supplement containing FA between 4-8 weeks of gestation. Of the women who took a FA supplement 91.9% (316/344) were still taking it at or beyond the end of the first trimester.
Full adherence with the recommendations to use a supplement containing FA during the periconceptual period was achieved by 16.0% (64/400) of women. Those women who started a supplement containing FA at any time during the periconceptual period were considered to have partial adherence, accounting for 65.0% (260/400) of women. No adherence with FA supplement intake within the periconceptual period was evident in 19.0% of women (76/400).
Frequency of Folic Acid Use: Of the women that achieved full or partial adherence during the periconceptual period 78.4% (254/324) reported they took it daily, 16.7% (54/324) reported they took it four to six times per week and 4.9% (16/324) took it one to three times per week. Ten women who achieved full adherence for periconceptual timing reported they did not take the supplement daily, thus reducing full adherence with the recommendations to take a supplement containing FA every day during the periconceptual period to 13.5% (54/400).
Dose of Folic Acid Supplementation: During the periconceptual period 11.6% (43/344) of women who used a supplement containing FA, used a product containing an insufficient dose of FA (<400µg). Seven women were unable to identify the supplement they used and therefore dosage of FA could not be confirmed. Of the supplements used by women in the periconceptual period FGF, Fefol, Ferro-F-tabs, Cenovis Women’s Multi Vitamins and Minerals, Blackmores B Plus C and ForelifeNatalCare do not meet the recommended 400µg dose for FA supplementation.
With only one in 10 women meeting recommended PFAS guidelines, NTD prevention in Queensland is clearly suboptimal. Recent Australian studies have shown PFAS adherence rates of 64% in South Australia  and 55% in New South Wales . However, these studies were limited by large recall bias of up to 12 months and 3 years post-partum respectively. Additionally, the sample size of these studies was small and computer assisted telephone interviewing methodology was utilized with limitations of sampling bias, response bias, validity and reliability. An interviewer-assisted questionnaire of women in antenatal clinics in South Australia reported 30% PFAS [6,7]. This is likely a more accurate reflection of PFAS adherenceas the study had greater response rates and methodological reliability and validity. With such clear benefits of PFAS in NTD prevention it is vital to increase PFAS in Queensland and Australia wide.
Preconception use of a FA supplement appears to be a major barrier in PFAS adherence. This study demonstrated that only 19.5% of women began supplements at least one month prior to conception. However, 70% of women first realised they were pregnant at K5-8 and during this same period 47% of women began a FA supplement. Similar results have been seen in Victoria  and New South Wales  with 23% of women consuming a FA supplement prior to conception, whilst 56% and 65% respectively, took a FA supplement after conception. Most NTD will have arisen by day 28 of conception, hence, often before a woman even realises she is pregnant and begins a FA supplement, underlining the importance of improving pre-conception FA supplementation.
Over half of pregnancies in this study were unplanned. This is analogous with 40% unplanned pregnancy rates in other Australian studies [10,11]. Unplanned pregnancy was significantly related to PFS non-adherence in univariate analysis in the current study, but not in the adjusted model. Similarly, planned pregnancy has been significantly associated with adequate PFAS use in Australia [9,12]. In the Netherlands, with a 78% planned pregnancy rate and considerable public health education, PFAS adherence rates of 51% have been achieved, the highest worldwide . This level of unplanned pregnancy in Australia is unacceptable and renewed focus into family planning in Australia needs to occur to maximise women’s preconception care and pregnancy outcomes.
One in 10 women who took FA in the periconceptual period used a product containing an insufficient FA dose. In a South Australian study, similarly 8% of women used a product containing <400mcg FA . This study supports another  that calls for manufacturers and the Therapeutic Goods Administration to ensure all preconception and pregnancy supplements contain at least 400mcg of FA, and extend this recommendation to all multivitamins used by WRA. GPs and pharmacists need also be cognizant of the recommended dosage when providing advice.
Strengths of this study include interviewer-assisted methodology to maximize survey completion and validity of response, minimal recall bias as women were interviewed within the first trimester, high response rates, use of a visual identification chart to correctly identify FA supplement content and assessment of all aspects of PFAS adherence: periconceptual timing, dosage and frequency of use.
To further clarify contributors to PFAS non-adherence and identify methods to improve PFAS adherence, future research directions could investigate barriers and enablers of pregnancy planning and accessing preconception care, including focus groups to ascertain women’s view.
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