Folic acid consumption before and during pregnancy

Taking a folic acid pill a day - a simple measure to prevent severe birth defects - is under-promoted in the media, under-recommended by health care providers and underused by women of childbearing age, according to a new review of studies.

Less than one-fourth of women who are aware of the importance of folic acid take supplements daily in accordance with public health guidelines, said Corina Mihaela Chivu, lead author of the systematic review, which appears in the March/April issue of the American Journal of Health Promotion.

Chivu and co-authors reviewed 31 studies conducted between 1992 and 2005 designed to increase awareness, knowledge and consumption of folic acid before and during pregnancy. The studies used television, Internet, brochures, counseling, posters, newspapers and magazines to provide information about folic acid to women. The data encompassed some 23,000 women ages 15 to 49, Chivu said.

Overall, researchers found that receiving information increased awareness and knowledge: 60 percent of women were aware of the role of folic acid before the interventions while 72 percent were afterward. However, knowledge did not necessarily translate to action: 14 percent took folic acid before the intervention; only 23 percent started taking it afterward.

What will help the message sink in?

The role of the mass media and health professionals is crucial, said Chivu, a physician who was with the National Institute for Research and Development in Health, in Bucharest, Romania when the review took place.

“For the last six months in the U.S., no advertisement about folic acid in pregnancy has appeared on TV,” Chivu said. “Instead, ads promoting expensive and ineffective drugs appear daily.”

Chivu, now with the Centre for Public Health Research at Brunel University in London, was surprised to learn that “interventions within national campaigns didn't persuade health professionals about the importance of counseling women on folic acid.”

A study in the Netherlands showed 25 percent of health professionals never advised women about folic acid, she added.

Similarly, a March of Dimes Gallup Survey in 2007 revealed that of those aware of folic acid, only one-third had heard about it from a health provider. However, this represents an increase from 1995, when only 13 percent heard about the supplement from a health provider. Another 31 percent read about folic acid in magazines and 23 percent received the news from radio or television.

Folic acid, a form of vitamin B, occurs in green plants, fresh fruit, liver and yeast. U.S. Public Health Service guidelines call for women of childbearing age to take 400 micrograms of folic acid daily. Health officials say women should take folic acid for two months before pregnancy and during the first three months of pregnancy.

Taking folic acid can help prevent specific neural tube defects, according to the March of Dimes. The neural tube is an embryonic structure that develops into the brain and spinal cord. Spina bifida, one of the two most common neural tube defects, is a condition in which there is exposure of part of the spinal cord and its coverings. The other is anencephaly, in which a large portion of the child's brain is missing.

The U.S. Food and Drug Administration and the Department of Health and Human Services have promoted fortification of enriched cereal grain products with folic acid. This “has apparently been successful in reducing neural tube defects in the United States, as well as in Canada,” the authors say, adding that results might justify a decision to fortify flour in other countries.

Folic-acid fortification is a step forward, Chivy said. However, “fortification is not a surrogate for supplementation,” she added.

In 2007, a study from Centers for Disease Control and Prevention found an 8 percent to 16-percent decline in folate levels in U.S. women of childbearing age. It based the finding on blood-draw surveys conducted between 1999 and 2004. Health officials speculated that popular, low-carbohydrate diets might be causing the decline.

“Women who plan a pregnancy should eat foods rich in folate or fortified products, but at the same time take the pills with folic acid,” Chivu said.

The review's findings are consistent with the experiences of health advocates. More women have heard about the importance of taking folic acid supplements; however, “we're not where we should be” in terms of consumption, said Joann Petrini, director of the perinatal data center for the March of Dimes. The organization has encouraged women to take supplements and she said the new review offers more data undergirding this message.

“The leading reason [women did not take the supplement] was that they forgot,” Petrini said. “Some said they didn't need them—they are not planning a pregnancy—but we know that half of pregnancies are unplanned…half. That reinforces the idea that you may not be thinking about it, but it may happen.”

American Journal of Health Promotion: Call (248) 682-0707 or visit http://www.healthpromotionjournal.com

Chivu CM, et al. A systematic review of interventions to increase awareness, knowledge and folic acid consumption before and during pregnancy. Am J Health Promo 22(4), 2008.