Determinants of folic acid use in early pregnancy in a multi-ethnic urban population in The Netherlands: The Generation R study
Introduction
From the early nineties recommendations have been launched that women planning pregnancy should use a folic acid supplement of 0.4 mg/day from at least 1 month before until 3 months after conception. (Centers for Disease Control, 1992) These recommendations were largely based on two randomized trials showing that folic acid supplementation reduces the risk of neural tube defects (NTDs) by 72% and 100%. (Czeizel and Dudas, 1992, MRC Vitamin Study Research Group, 1991).
Although folate is an essential micronutrient for cellular growth, the underlying mechanisms by which folate prevents NTDs are not clear. (Ashworth and Antipatis, 2001) However, it is known that pregnant women with folate deficiency are at increased risk for reproductive complications including NTDs. (Lumley et al., 2000) Despite campaigns to promote folic acid intake and evidence that this B vitamin also has beneficial effects against other reproductive failures, the number of women who take folic acid supplements in the recommended period remains low. (Meijer and de Walle, 2005) A strategy to improve intake is mandatory food fortification, which has not yet been introduced in any European country. (Botto, 2006, Health Council of the Netherlands, 2000, Meijer and de Walle, 2005, World Health Organization, 1998) Therefore, currently the most effective strategy in Europe, is to use a daily folic acid supplement.
The Dutch mass media campaign in 1995 together with continuing media attention in the following years to promote intake, resulted in an increase from approximately 19% to 36% adequate folic acid use in the Netherlands. In particular, adequate folic acid supplementation appeared to be insufficient in low educated women. (de Walle et al., 2002) It has furthermore been suggested that language proficiency is an important determinant for folic acid knowledge and, subsequently, folic acid intake. (van Eijsden et al., 2006) In order to develop more targeted strategies to improve adequate preconception folic acid use in the future, knowledge about other sociodemographic and lifestyle determinants might be important.
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Methods
This study was embedded in the Generation R Study Rotterdam, the Netherlands, a population-based prospective cohort study from pregnancy onwards. The study was designed to identify determinants of growth and development from fetal life until young adulthood. (Jaddoe, 2007, Jaddoe, 2006) In total 8880 women enrolled in the study between 2002 and 2006. (Jaddoe et al., 2006) The Medical Ethics Committee of the Erasmus Medical Center approved the study protocol.
Pregnant women were asked by
Results
The response rate of the questionnaire on general characteristics and folic acid supplementation was 78%. Baseline characteristics are shown in Table 1. Thirty-seven percent of these 6940 women started folic acid supplement use preconceptionally (adequate), 35% from pregnancy recognition onwards (subadequate), and 28% did not use folic acid at all (total of 63% inadequate use).
Women who used inadequate folic acid were younger, more often single and lower educated (Table 2). All non-Dutch groups
Discussion
In this multi-ethnic pregnancy cohort between 2002 and 2006, adequate preconception use of folic acid was as low as 37%. Thus, over the past years this percentage has not significantly changed. (de Walle et al., 2002) The most important factors for inadequate folic acid use appear to be unplanned pregnancy, low socioeconomic status (SES), and non-Dutch ethnicity. Other identified determinants are younger age, single marital status, multiparity, previous spontaneous abortion, smoking and alcohol
Conclusions
Adequate preconception use of folic acid is still low. Unplanned pregnancy, low socioeconomic status and non-Dutch ethnicity are the main determinants of inadequate folic acid use. There is a relation between folic acid use and adverse lifestyle factors. To change not only awareness but also attitude towards adequate preconception folic acid use, a change in total lifestyle is necessary. Preconception health educational programmes should be developed and applied to improve the intake of folic
Conflict of interest statement
There are no conflicts of interest.
Acknowledgments
The Generation R Study is conducted by the Erasmus Medical Center in close collaboration with the School of Law and Faculty of Social Sciences of the Erasmus University Rotterdam, the Municipal Health Service Rotterdam area, Rotterdam, the Rotterdam Homecare Foundation, Rotterdam and the Stichting Trombosedienst and Artsenlaboratorium Rijnmond (STAR), Rotterdam. We gratefully acknowledge the contribution of general practitioners, hospitals, midwives and pharmacies in Rotterdam.
This phase of the
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