Neural tube defects (NTDs), including spina bifida, encephalocele and anencephaly, are among the most frequent congenital malformations worldwide.1 They occur in approximately 1–2.5 per 1000 live births2 and result from failure of the embryonic neural tube to fuse at around day 28 of gestation.3 They are associated with physical, neurological and developmental impairment causing life-long disabilities.
In the United Arab Emirates (UAE), NTDs are one of the leading (14.5%) anomalies involving a single system among infants with major malformations.4 The incidence of NTDs in UAE is around 1.2 per 1000 births.5
Folic acid and folate, the naturally occurring state of folic acid, are both forms of the water-soluble vitamin B. Folates are essential for the synthesis of thymidylate and purines, precursors required for de novo DNA synthesis and cell division.6 The demand for folic acid is greatest during the rapid fetal development stage during the first month and, in particular, for the development of the neural tube. Folate deficiency remains one the most common vitamin deficiencies in women7 and there is ample evidence that periconception folic acid supplementation can significantly reduce the risk of NTDs.6,8–10
Furthermore, there is evidence that the use of folic acid reduces the risk of cardiac and craniofacial structural abnormalities. As the embryonic neural tube fuses at around day 28 of gestation, before most women realize they are pregnant, folic acid supplements should be taken prior to conception and through to the end of the first trimester.11
Measuring folic acid awareness and intake rates among women of child-bearing age is essential for understanding the effect of folic acid intervention on NTDs.12
The aim of this study was to ascertain the awareness and knowledge of the benefits and use of folic acid supplements among Emirati women.
This was a cross-sectional study carried out among women of child-bearing age residing in the Al Ain District, Abu Dhabi, United Arab Emirates. Data were collected from October 2011 until March 2012 and a convenience sample was invited to participate in this study. Women were recruited from the Family Development Institute, Tawam hospital, and Al Khabisi primary health clinic. All females included in this study were between the ages of 16 and 45 years. No UAE national females were excluded and all women who participated in the study were asked to fill out a 20-item questionnaire. The questionnaire requested details of their age, level of education, internet use, marital status, employment and knowledge and attitude towards the use, benefits and time of administration of folic acid. A pilot sample was selected prior to commencing the study to detect any shortfalls in the questionnaire. This study was approved by the Ethical Committee of the Faculty of Medicine and Health Sciences, United Arab Emirates.
All collected data were subjected to statistical analysis using SPSS (SPSS Inc., Chicago, IL, USA) and a P-value of < 0.05 was considered to be significant. Categorical data were reported as percentages and a chi-squared test was used to analyse the differences between categorical variables. Univariable and multivariable logistic regression analyses were performed to ascertain the factors influencing unawareness.
A total of 251 questionnaires were distributed and the number of respondents was 205, which was a response rate of 81.7%. The median age of respondents was 23 years (range 16–45 years). A total of 77 women (37.6%) were housewives, 113 (55.1%) women were either married or previously been married and 72.5% of these women had children. Of the 205 respondents, 67 women (32.7%) had a higher education level and 173 women (84.4%) were internet users.
Only 85 women (41.5%) revealed that they knew the importance and benefits of periconception folic acid and 23 women (11.2%) thought that folic acid should be taken before pregnancy (Figure 1).
There was significantly greater knowledge among women with a higher education level (p = 0.001) and those > 31 years old (p = 0.003) regarding the importance of folic acid and the time of administration than among women of a lower education level and those < 31 years of age. Women who were married or had previously been married had significantly greater knowledge about the importance of preconception folic acid (P < 0.001) when compared with single women. Internet users showed no difference in their knowledge of the use and benefits of folic acid supplements compared with non-internet users.
The aim of our study was to investigate the awareness of UAE women regarding the importance of folic acid in preventing fetal NTDs and the time of administration. We limited our study to Emirati women as they have easy and free access to all levels of health care facilities. Unfortunately, our study showed that nearly half of the respondents were not aware of the importance of folic acid in the prevention of NTDs, and only 12% thought that it should be taken before pregnancy. These results are very alarming. In 2003, Abdulrazzaq et al.13 investigated the awareness of folic acid among women in the postpartum period who delivered their baby in the Al Ain District, UAE. Interestingly, their findings were very similar to those of the present study, with only 46.4% of the women being aware of the benefits of folic acid and only 12.2% having used folic acid before pregnancy. This is very alarming as it reveals that the awareness among UAE women of a cheap, available and effective supplement such as folic acid has not changed in the last decade. Unfortunately, the situation is similar in the whole region as well as worldwide. Benner et al.7 reported that only one-quarter of the surveyed Qatari women were aware of the importance of folate, and only 14% were aware that it has a role in preventing birth defects. Kari et al.14 stated that the awareness of the importance of folic acid in preventing fetal anomalies was as low as 12% among Saudi female college students, and De Santis et al.11 found that only half of the Italian women included in their study took folic acid before they became pregnant, even when they were trying to conceive. Similar figures were reported from Ireland15 and even more worrying results have been reported from developing countries.9 Rabiu et al.9 interviewed 200 Nigerian women and none of them had used folic acid preconception.9
Our study supports other reports observing that age and increased level of education significantly improve women's awareness of the importance of folic acid and time of administration.16
There is an abundance of evidence that supports the knowledge that folic acid is effective for reducing neural tube anomalies and associated neonatal mortality.17,18 However, it seems that further efforts are required to increase knowledge and awareness of the importance of preconception folic acid among women. Increased knowledge ensures that women are informed of the benefits of folic acid and are able to make informed decisions about folic acid consumption.19 Women who are aware of folic acid benefits and plan to conceive are more likely to take folic acid in the periconception period.20 Health care providers play a pivotal role in changing women's attitudes towards folic acid and its intake;12 unfortunately, health care providers seem to lack proper and efficient training in preconception care, education and counseling.2 Morgan et al.21 reported that only 19% of the 1000 obstetricians included in their study discussed folic acid with their non-pregnant patients during well-woman care visits.21
The required folic acid dose will vary according to each woman's degree of risk. While all women of child-bearing age should take 0.4 mg (400 µg) of folic acid daily when planning a pregnancy, women with a previous affected child, high BMI, diabetes mellitus or epilepsy should be advised to take a higher dose of 5 mg (5000 µg) of folic acid daily. It seems that younger women, those with a lower level of education and those with a lower income require more attention and education regarding the benefits of preconception folic acid.22
Mandatory folic acid fortification may be required to achieve the desired effects. Many countries have introduced folic acid fortification with significant reduction in the incidence of NTDs.10 Nevertheless, there are some concerns regarding its cost-effectiveness and possible association with colon cancer, masking of irreversible pernicious anaemia of B12 deficiency, increased insulin resistance and obesity in offspring.23,24 However, further research is required to confirm these suggested risks.
The awareness and knowledge of the benefits and use of folic acid supplements among Emirati women remains low. Further efforts are required to educate and encourage women of child-bearing age to take preconception folic acid supplements. Young women and those with low education required more attention to educate them of the benefits of folic acid.