title: Promotion of folate for the prevention of neural tube defects: who benefits? Women's interest in GP-initiated pre-conception counselling in The Netherlands. Consequences of surveying folate awareness. Maternal knowledge, attitude and practice regarding folic acid intake during the periconceptional period. Folate intakes and awareness of folate to prevent neural tube defects: a survey of women living in Vancouver, Canada. Prevention of neural tube defects: effect of an intervention aimed at implementing the official recommendations The increasing knowledge of the role of periconceptional folate in Victorian women of child‐bearing age: follow‐up of a randomised community intervention trial Knowledge and Clinical Practice Regarding Folic Acid Among Obstetrician‐Gynecologists Addressing preconception risks identified at the time of a negative pregnancy test. A randomized trial. The impact of a preconceptional health promotion program on intendedness of pregnancy. Randomized trial of a physician-based intervention to increase the use of folic acid supplements among women. Current practice and future interest of GPs and prospective parents in pre-conception care in The Netherlands. A survey of preconceptional folic acid use in a group of Canadian women. Pregnancy intendedness and the use of periconceptional folic acid. [Socioeconomic inequalities in the provision and uptake of prenatal care]. A randomized community intervention trial to increase awareness and knowledge of the role of periconceptional folate in women of child-bearing age. Neural tube defects: knowledge and preconceptional prevention practices in minority young women.
abstract: Since the publication of r and omised trials showing firm evidence of prevention of neural tube defects with periconceptional folic acid , there have been population health promotion programmes to encourage women to take folic acid supplements , and the introduction of voluntary fortification of some foods with folic acid in Australia . In order to evaluate these two strategies , we collected data by self-administered question naire from a r and om sample of recently pregnant women in Western Australia between September 1997 and March 2000 .  Response to health promotion was measured in three ways : ( 1 ) knowledge of the association between periconceptional folate and prevention of spina bifida ( the ' correct message ' ) ; ( 2 ) use of periconceptional vitamin supplements of folic acid daily in the periconceptional period ; and ( 3 ) daily folate intake from fortified foods in the 6 months before pregnancy . We examined the relationship of maternal demographic and behavioural characteristics with these three measures . Overall , 62.3 % of women were aware of the correct message before pregnancy , 28.5 % reported taking 200 microg or more of folic acid from supplements daily in the periconceptional period and 56.6 % of women obtained 100 microg or more of folic acid from fortified foods . Women who first became aware of the correct message during pregnancy or who were unaware of the correct message before or during pregnancy were more likely than women aware before pregnancy to be younger , having their first pregnancy , be single or in a de facto relationship , have no tertiary education , and be a public patient . Similar associations were seen for women taking either no folic acid or < 200 microg of folic acid in supplements daily in the periconceptional period . There were no significant associations between these demographic variables and amount of folate obtained from fortified foods . Women who were unaware of the correct message and did not take folic acid supplements were more likely to have smoked , not to have engaged in exercise , and not to have planned their pregnancy , whereas there was no association with these behavioural characteristics and intake of folate from fortified foods . These results indicate that health promotion strategies have not reached all segments of the target population equally , but there is no such disparity with folate-fortified foods , and they suggest that m and atory fortification of a staple food is likely to reach all women regardless of demographic and behavioural characteristics , and hence provide improved opportunity for prevention of neural tube defects in Australia BACKGROUND Pre-conception counselling has the potential to reduce pregnancy complications and congenital disorders . The timing of counselling , before conception , is crucial to maximize the benefit . As many couples are unaware of their risk status and the fact that the first period of pregnancy is crucial , they do not seek information before pregnancy occurs . To reach couples with timely information , it seems that a health care worker needs to take the initiative . In The Netherl and s , the GP is in an ideal position to offer pre-conception counselling . OBJECTIVE The aim of this study was to determine the interest of women aged 18 - 40 in pre-conception counselling  if this is offered to them by their own GP . METHOD A cohort of women ( n = 1206 ) received a personal letter from their own GP with an offer of pre-conception counselling . The women were requested to fill in a reply form , indicating if they were interested , might be interested ( if they decided to become pregnant ) or were not interested in an invitation for pre-conception counselling . When interested , they were asked to give an indication as to when they were planning a pregnancy . Women who were not interested were requested to give a reason . RESULTS Almost 70 % of the women returned the reply form . Up to the age of 29 years , at least 80 % of the respondents were interested or might be interested should they decide to have children . Most women , especially the younger women , do not know exactly when they wish to become pregnant . Regardless of age , > 70 % of the respondents were interested . Only 11 % of the respondents indicated specifically that they were not interested in advice . CONCLUSION Women are interested in GP-initiated pre-conception counselling . Further research is needed to assess the effect of programmed and systematic pre-conception counselling , offered by GPs , on pregnancy outcome and the health of the children . A r and omized controlled trial to assess these effects currently is being conducted at the Department of General Practice in Leiden OBJECTIVES To assess women 's concerns when interviewed about the association between  folate and neural tube defects ( NTDs ) and to determine how this is affected by time , being folate aware , having seen folate promotional material or being pregnant . DESIGN As part of a community r and omized trial outcomes evaluation , independent cross-sectional follow-up surveys were carried out in 1997 and 2000 . SETTING AND PARTICIPANTS Six local government areas in the state of Victoria , Australia ; 2431 women aged between 15 and 44 years . MAIN VARIABLES STUDIED Whether or not women knew of the association between folate and NTDs ( i.e. were folate aware ) , whether or not women had been concerned by seeing folate/NTD information and if an interview about folate and NTDs had raised any concerns for them . RESULTS In the 1997 survey , 36 % of women said that the interview had raised concerns and this decreased to 26 % in 2000 . Women who were folate aware were significantly less likely to have raised concerns than women who were not folate aware ( OR(adj ) = 0.38 , 95 % CI 0.24 - 0.60 ) . In general , women who had seen promotional material were less likely to feel concern about the interview than those who had not , although this varied with whether or not the promotional material had raised concerns . These effects were greater in women who were pregnant . CONCLUSIONS Women had increased concerns having seen folate promotional material and after being interviewed about it . These results are consistent with the proposition that an initial emotional response to sensitive health information is part of an adaptive response appropriate to the process of health-related behaviour change OBJECTIVE To study the knowledge , attitude and practice of pregnant women regarding  periconceptional folic acid ( FA ) intake . DESIGN Question naire-based prospect i ve study . SETTING Antenatal clinic of a District General Hospital . SUBJECTS Three-hundred pregnant women in an antenatal clinic . RESULTS Nearly all ( 298/300 ) had heard of FA . A majority ( 275/300 , 91 % ) knew that FA could prevent neural tube defects , and married women those with higher education those of Social Classes 1 - 3 and women over 30 years of age were more likely to be thus aware . Knowledge about the correct timing of FA intake was seen in 76 % and was more likely in those with higher education married women and women age over 30 years Intake of FA  in the periconceptional period was seen in 134/300 ( 44.6 % ) women and was most likely in the married , Social Classes 1 - 3 , women with higher education ( all P<0.001 ) , non-smokers women with a planned pregnancy and women aged 30 years and over CONCLUSIONS The knowledge of the correct timing of FA intake was present in only 76 % . Less than half ( 44.6 % ) had taken FA in the periconceptional period , and this was far more common in the more ' privileged ' classes . Low socio-economic status , age less than 30 years , lower educational status and unplanned pregnancy were high risk factors for not taking FA . The challenge to the medical profession for targeting this group can not be over-emphasised OBJECTIVE To estimate folate intake and knowledge in women of childbearing age , in relation to risk of neural tube defects . SUBJECTS/ SETTING One hundred forty-eight women ( aged 18 to 45 years ) in the Vancouver area of British Columbia , Canada . DESIGN Using an interviewer-administered survey , we examined women for folate knowledge and the relation of folate knowledge to intake in a r and om sample . Contribution of folate from food , fortified grain products , and supplements was assessed by vali date d semiquantitative food frequency question naire . STATISTICAL ANALYSIS PERFORMED Descriptive statistics , t tests , Chi;(2 ) , Pearson correlation analysis . RESULTS Mean daily folate intake from food , fortified foods , and supplementation was 812+/-710 Dietary Folate Equivalents (DFE)/day . Fortification of bread and grain products contributed 104+/-68 microg synthetic folic acid (SFA)/day ( equal to 174+/-114 DFE ) , and supplements contributed 205+/-388 microg SFA/day . Although 86 % of women met the Estimated Average Requirement ( 320 DFE/day ) for folate , only 26 % met the recommendation ( 400 microg SFA/day ) for women capable of becoming pregnant . Most ( 95 % ) of the women had heard of folate , but only 25 % knew that it could prevent birth defects . One-fourth of the women had good or very good knowledge of folate-rich foods . However , folate knowledge was not related to its intake . The most common sources of folate information were magazines/newspapers , doctors , and television/radio . Lack of awareness of the importance of folate was the most common reason given for choosing not to use folic acid supplements before pregnancy . However , 78 % of the women indicated that , with knowledge of the benefits of folate , they would use supplemental folic acid daily to reduce the risk of birth defects . APPLICATIONS/ CONCLUSIONS Educational strategies are required to increase folate awareness among women and to promote the benefits of periconceptional folic acid supplementation . Targeting physicians to educate women on the importance of folate could be a potentially successful route . Summary .¶ Objectives : The periconceptional intake of 0.4 mg folic acid is recommended in many countries to prevent neural tube defects . This paper describes the poor implementation of corresponding guidelines in Germany , the effectiveness of an intervention-based on providing adequate information and the problems associated with the implementation.¶ Methods : Two cross sectional studies investigated knowledge , attitude , and behaviour of r and omly sample d gynaecologists ( n = 24/27 ) , pharmacists ( n = 21/21 ) , and women in childbed ( n = 131/118 ) before and after the information campaign.¶ Results : Before the intervention , 3.8 % of the women implemented  folic-acid-prophylaxis  compared with 9.3 % afterwards ( p = n.s . ) . The awareness of the prophylaxis before pregnancy correlated with socio-economic status and rose from 28 % ( before ) to 42 % after intervention ( p<0.05 ) . Before the intervention , 38 % of the gynaecologists and 38 % of the pharmacists recommended the prophylaxis compared with 74 % ( p<0.05 ) and 43 % ( p = n.s . ) afterwards.¶ Conclusions : The effect of the intervention was small . To improve the situation , fortification of specially selected and labelled food should be considered . An accompanying nation-wide information campaign should focus on women with lower socio-economic status Objectives : To determine the changes since 1996 in knowledge of folate for the prevention of neural tube defects ( NTDs ) among women of child‐bearing age and measure the residual effect of an earlier consumer‐directed information campaign Objective To assess obstetrician-gynecologists ' knowledge of and clinical practice concerning folate . Methods We mailed surveys on nutrition during pregnancy to the 230 ACOG Fellows who are members of the Collaborative Ambulatory Research Network and to a r and om sample of 800 Fellows who are not members of the Network . Our results focus on questions concerning folate . Results We analyzed 488 surveys ( a 47.4 % response rate ) . Approximately two thirds of respondents screen their pregnant patients for folate  intake . Fewer ( 53 % ) screen their nonpregnant patients of childbearing age . Those who screened their patients for folate intake were more likely to counsel pregnant patients about diet . They also were more likely to believe that nutritional counseling would improve pregnancy outcomes ( 70.0 % versus 56.5 % ) and overall patient health ( 77.5 % versus 66.5 % ) . Most Fellows were aware that macrocytic anemia was a manifestation of folate deficiency ( 90.4 % ) and that folic acid supplementation during preconception and the early prenatal period helps protect against neural tube defects ( 96.5 % ) . They were aware that alcoholics ( 91.4 % ) , smokers ( 61.3 % ) , and lactating women ( 53.5 % ) are at increased risk of folate deficiency . They were less aware of other consequences of low folate intake , such as increased serum homocysteine ( 20.3 % ) . Respondents who screen their pregnant patients for folate intake correctly answered more of the knowledge questions about folate than physicians who do not screen . Conclusion Obstetrician-gynecologists are generally aware of the link between folate intake and neural tube defects , but are less aware of other aspects of folate metabolism BACKGROUND A preconception care program has the potential to assist women who want to become pregnant by advising these women about risk factors , healthy lifestyles , and assessing readiness for pregnancy . We conducted a r and omized controlled trial to determine whether comprehensive preconception risk assessment at the time of a negative pregnancy test followed by referral to primary care services is effective in initiating treatment for women with preconception risk factors . METHODS One hundred seventy women were offered preconception risk assessment following a negative pregnancy test . Women were assigned r and omly either to a usual care group or an intervention group . Women in the latter group were informed about the risks identified and received an appointment with a primary care clinician who was also informed . Women in the usual care group and their clinicians received no feedback . All charts were review ed and the women were contacted by telephone to determine if interventions to reduce risk were offered by clinicians during the year following the assessment . RESULTS An average of 8.96 risks were identified per woman . The proportion of women having risks in each of 12 risk categories studied ranged from 19 % to 71 % . One hundred women ( 59 % ) made at least one visit during the subsequent year , thus allowing the opportunity for preconception care . The proportion of these women who had a risk addressed ranged from 18 % for psychosocial risks to 48 % for those with fetal exposures ( smoking , alcohol , and drug use ) . There was no difference between groups in the percentage of risks addressed . CONCLUSIONS The notification of women and their clinicians of identified preconception risks did not improve intervention rates . A more organized intervention system including office-based protocol s is needed The objective for this study was to determine whether a brief preconceptional health promotion program for low-income women attending family planning clinics impacts on intendedness of pregnancy . In this prospect i ve study , we examined data on 1378 women presenting for prenatal care at three local health departments . Each of the departments offers a st and ardized preconceptional health promotion program in its family planning clinics . Comparisons were undertaken for 456 women who had been exposed to the family planning preconception program , 309 women who had attended the family planning clinics but had not been exposed to the program , and 613 women who were unknown to the health department before beginning prenatal care . Women exposed to information on preconceptional health during routine family planning visits , the experimental group , had a 51.8 % ( p = 0.064 ) greater likelihood of identifying their pregnancies at intended than a group known to the local health departments ' family planning programs but unexposed to the intervention . Furthermore , the experimental group had a 64.2 % ( p = 0.0009 ) greater likelihood of intendedness than a comparison group not known to the health departments before the initiation of prenatal care . Our study indicates that an introductory program of preconceptional health promotion which is targeted to women not planning a pregnancy in the immediate future is associated with a higher rate of intendedness in subsequent pregnancies . Expansion of similar preconceptional programs in family planning clinics may prove a useful approach for promoting intendedness of pregnancy in low-income women OBJECTIVE Fewer than one third of American women take folic acid daily , although many women report that they would take folic acid if their physicians advised them to do so . This study determined the impact of a physician intervention during routine gynecologic visits on folic acid supplementation . STUDY DESIGN Patients were assigned r and omly to receive brief folic acid counseling , a reminder phone call , and 30 folic acid tablets ( n = 162 women ; intervention group ) or to receive counseling about other preventive health behaviors and a folic acid informational pamphlet ( n = 160 women ; control group ) . Self-reported folic acid use was compared at baseline and at 2 months . RESULTS Of the 279 patients who completed the study , weekly folic acid intake increased in the intervention group by 68 % , compared with 20 % in the control group ( P = .008 ) . No significant differences were found in daily intake . The women who were most influenced by the intervention were black and lower income and not planning pregnancies . CONCLUSION With little effort expended to encourage folic acid use , gynecologists could potentially reduce the risk of folate-preventable birth defects among their patients by as much as 11 % BACKGROUND Evidence for the effectiveness of pre-conception care is growing . GPs are among the possible providers of pre-conception care . OBJECTIVES Our first aim was to investigate current pre-conception care activities of GPs and to determine whether prospect i ve parents would visit the GP in the existing health care system . A further aim was to determine the interest of GPs and prospect i ve parents in the introduction of pre-conception care clinics . METHODS A survey was conducted among 200 GPs and 303 recently married couples ( 606 individuals ) . RESULTS Of the eligible GPs , 52 % ( n = 102 ) participated , as did 70 % ( n = 381 ) of the eligible individuals who are planning a pregnancy . In the current situation , only a few individuals visit their GP pre-conceptionally , and many GPs do not discuss family history or consanguinity with prospect i ve parents . In general , the GPs and prospect i ve parents had a positive attitude towards the introduction of pre-conception care clinics . CONCLUSION Since most GPs and prospect i ve parents favoured the introduction of pre-conception care , future research should focus on the most appropriate way of implementation BACKGROUND R and omized controlled trials have demonstrated that periconceptional folic acid supplementation has a dramatic effect in reducing neural tube defects , one of the most serious congenital anomalies . Unfortunately , supplementation tends to be suboptimal in disadvantaged population s. OBJECTIVE The primary objective was to determine patient factors associated with a lack of use of periconceptional folic acid among Canadian women in a multi-ethnic , urban setting . Our secondary objective was to assess patient knowledge about folic acid tablet supplementation and its link to reduced birth defects . METHODS We undertook a cross-sectional study to survey postpartum Toronto women on their use and knowledge of periconceptional folic acid . RESULTS Of the 383 women surveyed , only 28 % took folic acid or a multivitamin containing folic acid during the periconceptional period . Multivariate analysis revealed that the use of periconceptional folic acid  was more common among women of Jewish descent ( adjusted relative risk [ RR ] 0.3 ; 95 % confidence interval [ CI ] , 0.04 - 0.9 ) and those who had 1 or no children ( adjusted RR 0.6 ; 95 % CI , 0.4 - 0.8 ) . Not taking folic acid was associated with unplanned pregnancy ( adjusted RR 1.5 ; 95 % CI , 1.4 - 1.6 ) and a lack of knowledge about when folic acid should be taken ( adjusted RR 1.8 ; 95 % CI , 1.6 - 1.8 ) . CONCLUSION Ethnic background is an independent predictor of periconceptional folic acid use OBJECTIVE 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 .  METHODS Oregon Pregnancy Risk Assessment Monitoring System ( PRAMS ) surveys a stratified r and om 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 . RESULTS 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 ) . CONCLUSIONS 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 OBJECTIVE To describe socioeconomic inequalities in the provision and uptake of prenatal care among women in Barcelona ( Spain ) between 1994 and 2003 . METHODS Cross-sectional study of women in Barcelona who delivered a child without birth defects . Information was obtained from hospital medical records and a personal interview with women included in the Barcelona Birth Defects Registry , containing a r and om sample of 2 % of all pregnant women in the city ( n = 2299 ) . DEPENDENT VARIABLES number of obstetric visits , the trimester of the first visit , the number of obstetric ultrasound scans , the fifth-month diagnostic ultrasound scan , invasive procedures , prenatal folic acid intake , pregnancy planning , smoking and smoking cessation . The independent variables were maternal age and social class . Logistic regression models were filted for each dependent variable . RESULTS In social classes with manual occupations , there was a higher proportion of pregnant women who attended less than six obstetric visits and who attended the first obstetric visit after the first trimester . Moreover , these women were less likely to have undergone an invasive procedure , to have taken folic acid supplements , to have planned the pregnancy , to be non-smokers and to stop smoking . In the more privileged classes , there was a higher proportion of women who attended more than 12 obstetric visits and who underwent more than three ultrasound scans . CONCLUSIONS Socioeconomic inequalities were found in the provision and uptake of prenatal care in Barcelona . Uptake was greater in the more advantaged social classes but excessive medicalization was found in all classes . Rationalizing the use of healthcare re sources and reducing excessive medicalization would reduce inequalities in prenatal care in Barcelona OBJECTIVES : To determine the effect of a consumer-directed information campaign to increase knowledge of folate for the prevention of neural tube defects among women of child-bearing age , and to measure women 's recall of sources of information and knowledge about folate . DESIGN : A community r and omized trial . SETTING : Three matched pairs of geographically distinct Local Government Areas in the state of Victoria , Australia . INTERVENTION : Printed information recommending folate intake to decrease the risk of neural tube defects was disseminated to women of child-bearing age in three of the Local Government Areas selected r and omly . MAIN OUTCOME MEASURE : The proportion of women aware of the association between folate and spina bifida . RESULTS : Of 1197 women interviewed prior to the intervention , 12.4 % ( adjusted for the cluster and population sampling unit ) were aware of folate and neural tube defects . After the intervention , there was not only a significant background increase of 3.4 % ( P=0.02 ) in folate awareness since the pre-intervention survey ( n=603 ) , but also a significant additional increase of 4.0 % ( P=0.04 ) owing to the intervention itself ( n=603 ) . Only 70 % of women who were aware of folate knew the correct timing . CONCLUSIONS : The provision of printed educational material can increase folate awareness among women of child-bearing age . A comprehensive , long-term and ongoing health promotion campaign including such material , together with initiatives by relevant health service providers and the food industry , could best address the current low levels of folate awareness among women of child-bearing age OBJECTIVE To assess 1 ) knowledge of neural tube defect ( NTD ) prevention by folic acid , 2 ) frequency of intake of multivitamins and folate- and folic acid-fortified food , and 3 ) factors associated with knowledge and prevention practice s among sexually active minority adolescent and young adult women . METHODS Young minority women were enrolled in a folic acid program at 3 urban Houston , Texas , reproductive health clinics and assessed for NTD knowledge and preventive practice s. A 3-month supply of multivitamins was also dispensed at enrollment . A 3-month program follow-up survey of a r and omly selected sample at 2 sites was conducted . RESULTS Of 387 women ( mean age : 18 + /- 1.9 years ) , 72 % were black and 28 % were Hispanic . At enrollment , clinics were a major source of information of NTD prevention ( 44 % ) ; 52 % had heard of folic acid , 45 % had heard of NTDs , and 50 % had heard of birth defects prevention by multivitamins . Significantly more Hispanic than black young women had heard of NTDs ( 59 % vs 39 % ) . Pregnancy history , regular birth control use , and education level for age were independently associated with knowledge . In young women with low education level for age , regular birth control use was significantly associated with knowledge . At enrollment , daily multivitamin intake was very low ( 9 % ) and folate-rich foods were consumed in inadequate amounts . Adequate folate diet was not associated with knowledge . The program follow-up survey indicated that 88 % to 92 % had knowledge of NTDs and folic acid , and 67 % reported taking a daily multivitamin . CONCLUSIONS Publicly funded clinics may be the only source of information on NTD prevention for many minority young women . Preliminary evidence suggests that a promotion program improves knowledge , and dispensing of multivitamins increases multivitamin use . However , clinicians in such programs need to reinforce daily adherence to multivitamins in young women
target: There were factors that are particularly associated with lower rates of use of folic acid supplements .
  One of the most important of these is the link with unintended pregnancy , followed by age , socio-economic and ethnic group .
  Integrated campaigns can increase the use of folic acid supplements to some extent .
  Research trials indicated that : ( i ) printed re sources and the mass media used in isolation are not effective in the longer term ; and ( ii ) health-care-based initiatives can be effective and are more likely to be successful if they include making supplements easily available .
  Campaigns and interventions have the potential to exacerbate socio-economic inequalities in folic acid use .
  However , even high- quality campaigns that increase use result in under half of women in the target group taking supplements
background: OBJECTIVE To provide a basis for making recommendations on the potential to improve use of folic acid supplements in the UK , particularly among low-income and young women .