Periconceptional folic acid supplementation in Southern Brazil: Why are not we doing it right?

Several countries, as Brazil, have public policies for periconceptional folic acid supplementation (FAS) in order to prevent unfavorable outcomes. Our aim was to evaluate the FAS situation in a public reference hospital from Southern Brazil. This study included all mothers who had children born at the Hospital Materno Infantil Presidente Vargas, RS, Brazil, in a 1-year period. Data collection was conducted through interviews with application of a clinical protocol and analysis of the patients' records. FAS was defined as the use of folic acid in any period of the periconceptional period, irrespective of the duration and amount. We also classified those mothers who correctly followed the national recommendation proposed by the Health Ministry of Brazil. The sample consisted of 765 mothers evaluated soon after childbirth. Their ages ranged from 12 to 45 years (mean 25.2 years). The overall level of FAS was 51.5%, and the use according to the national recommendation occurred in only 1.6%. Factors associated with non-FAS consisted of lower maternal age (p = .009) and maternal schooling (p = .023), higher number of pregnancies (p = .003), fewer prenatal visits (p = .050) and later prenatal care onset (p = .037). Periconceptional FAS in our midst seems to be very far from the ideal goal. Susceptible groups appeared to be mothers who were younger, less educated, multiparous, and had inadequate prenatal care. We believe that efforts of education and awareness should be especially targeted for these groups. These recommendations should also be strengthened among those who prescribe the FAS.

High burden of neural tube defects in Tigray, Northern Ethiopia: Hospital-based study.

INTRODUCTION: Neural tube defects are the major causes of fetal loss and considerable disabilities in infants. Currently, there is no significant research on the incidence of Neural tube defects in the Tigray region of Ethiopia. OBJECTIVE: To determine the incidence and clinical pattern of the Neural Tube Defects. METHODS: A hospital-based cross-sectional study was conducted from October 2016 to June 2017. All pregnancy outcomes were examined for any externally visible birth defects and neurological integrity by trained midwives under the supervision of senior obstetrics and gynecology and a neurosurgeon. Data were collected using a survey tool to collect maternal and newborn demographic data and a checklist developed to capture newborns with Neural Tube Defects. Data were analyzed using SPSS version 20. The prevalence of NTDs was calculated per 10,000 births. RESULT: Out of the 14,903 births during the study period, a total of 195 infants were born afflicted with Neural Tube Defects. The burden of infants with anencephaly and spina bifida was 66.4 and 64.4 per 10, 000 births, respectively. The overall incidence rate of NTDs in this study was 131 per 10, 000 births of which 23% were liveborn and 77% were stillborn. The highest burden of Neural Tube Defects was observed in Adigrat Hospital from Eastern Zone of Tigray (174 per 10,000 births) and Lemlem Karl Hospital from Southern Zone of Tigray (304 per 10,000 births) compared to Kahsay Abera Hospital from Western Zone (72.8 per 10,000 births) and Sihul Hospital from North Western Zone of Tigray (69.8 per 10,000 births). CONCLUSION AND RECOMMENDATION: Assuming that the non folic acid preventable rate should be 5 per 10,000 births, our prevalence rate is 131 per 10,000 births, and then we have a rate or an epidemic that is 26 times what it should be. This just emphasizes the urgency to implement effective programs to get all women of reproductive age to have adequate folic acid to prevent all of folic acid-preventable spina bifida and anencephaly, which would prevent 96% (125/130) of spina bifida and anencephaly in the Tigray Provence.

Components of Successful Staple Food Fortification Programs: Lessons From Latin America.

BACKGROUND: There are few effectiveness evaluations of food fortification programs, and little is known about what makes programs successful. OBJECTIVE: We examined 3 food fortification programs in Latin America to identify common features that might explain their success and to draw lessons for program design and implementation everywhere: The vitamin A fortification of sugar in Guatemala with impact on vitamin A status of the population, the fortification of a basket of foods with iron and other micronutrients in Costa Rica with impact on iron status and anemia in women and children, and the fortification of wheat flour with folic acid in Chile, which reduced the incidence of neural tube defects. METHODS: We identified pertinent literature about these preselected programs and asked regional experts for any additional information. We also conducted structured interviews of key informants to provide historical and contextual information. RESULTS: Institutional research capacity and champions of fortification are features of successful programs in Latin America. We also found that private/public partnerships (industry, government, academia, and civil society) might be key for sustainability. To achieve impact, program managers need to use fortification vehicles that are consumed by the nutritionally vulnerable and to add bioavailable fortificants at adequate content levels in order to fill dietary gaps and reduce micronutrient deficiencies. Adequate monitoring and quality control are essential. CONCLUSIONS: For future programs, we recommend that the evaluation be specified up-front, including a baseline/end line and data collection along the program impact pathway to inform needed improvements and to strengthen causal inferences.

Race and ethnicity and preconception folic acid supplement use among pregnant women in Georgia, PRAMS 2009 to 2011.

BACKGROUND: The United States Public Health Service recommends that all women of reproductive age consume 400 µg of folic acid daily to prevent major neural tube defects. Hispanics have the highest prevalence of neural tube defects compared with other race/ethnic groups. We studied prevalence of preconception folic acid supplement use, and its association with race/ethnicity among pregnant women in Georgia. METHODS: Using state-wide population-based data from 2009 to 2011 Georgia Pregnancy Risk Assessment Monitoring System, we examined the prevalence of preconception folic acid supplement use among pregnant women aged 18 to 45 years. We conducted multivariable logistic regression and estimated adjusted odds ratios and 95% confidence intervals to examine the association between race/ethnicity and supplemental folic acid use among study participants. RESULTS: Overall, 25% of all participants reported taking folic acid supplements daily before conception. Only 21% of Hispanic women reported preconception folic acid supplement use. Hispanic women were twice as likely to not take folic acid supplements (adjusted odds ratio = 2.15; 95% confidence interval, 1.35-3.40) compared with non-Hispanic whites, after controlling for maternal age, parity, pregnancy intention, knowledge that folic acid prevents birth defects, and preconception smoking and exercise. CONCLUSION: Hispanics are a growing population in the United States with an expected 14 million women of child-bearing age by 2020, and the prevalence of preconception folic acid supplement use is low in this group with a high risk of neural tube defects. Promotion of voluntarily fortified corn masa flour can lower neural tube defects in Hispanics. Mandatory corn masa fortification will be a more effective public health policy.Birth Defects Research 109:38-48, 2017. © 2016 Wiley Periodicals, Inc.

Population red blood cell folate concentrations for prevention of neural tube defects: Bayesian model.

OBJECTIVE: To determine an optimal population red blood cell (RBC) folate concentration for the prevention of neural tube birth defects. DESIGN: Bayesian model. SETTING: Data from two population based studies in China. PARTICIPANTS: 247,831 participants in a prospective community intervention project in China (1993-95) to prevent neural tube defects with 400 µg/day folic acid supplementation and 1194 participants in a population based randomized trial (2003-05) to evaluate the effect of folic acid supplementation on blood folate concentration among Chinese women of reproductive age. INTERVENTION: Folic acid supplementation (400 µg/day). MAIN OUTCOME MEASURES: Estimated RBC folate concentration at time of neural tube closure (day 28 of gestation) and risk of neural tube defects. RESULTS: Risk of neural tube defects was high at the lowest estimated RBC folate concentrations (for example, 25.4 (95% uncertainty interval 20.8 to 31.2) neural tube defects per 10,000 births at 500 nmol/L) and decreased as estimated RBC folate concentration increased. Risk of neural tube defects was substantially attenuated at estimated RBC folate concentrations above about 1000 nmol/L (for example, 6 neural tube defects per 10,000 births at 1180 (1050 to 1340) nmol/L). The modeled dose-response relation was consistent with the existing literature. In addition, neural tube defect risk estimates developed using the proposed model and population level RBC information were consistent with the prevalence of neural tube defects in the US population before and after food fortification with folic acid. CONCLUSIONS: A threshold for "optimal" population RBC folate concentration for the prevention of neural tube defects could be defined (for example, approximately 1000 nmol/L). Population based RBC folate concentrations, as a biomarker for risk of neural tube defects, can be used to facilitate evaluation of prevention programs as well as to identify subpopulations at elevated risk for a neural tube defect affected pregnancy due to folate insufficiency.

Folic acid supplementation and neural tube defect recurrence prevention.

BACKGROUND: It is well established that women who have had a pregnancy affected by a neural tube defect (NTD) have an elevated risk of a subsequent NTD-affected pregnancy and that a high dose (4 mg/day) of folic acid taken around the time of conception prevents most recurrences of NTDs. METHODS: We reviewed the literature to identify studies that quantify the reduction in risk if women with a prior-NTD affected pregnancy consistently take folic acid before and during a subsequent pregnancy and the effectiveness of NTD recurrence prevention programs in increasing the percentage of women who consistently consume folic acid supplements. RESULTS: A meta-analysis of randomized trials of folic acid for the prevention of recurrent NTDs indicates a 69% reduction in recurrence risk if analyzed on an intention-to-treat basis and an 87% reduction among those women who took supplements prior to the beginning of pregnancy. Observational studies report reductions in recurrence risk of 85% to 100% among women taking folic acid prior to subsequent pregnancies. The percentage of women who take folic acid prior to a subsequent pregnancy has been reported to vary from 33% to 85%, varying with the demographic background and the intensity of folic acid counseling efforts. CONCLUSIONS: Targeted folic acid information and counseling provided to women with an NTD-affected pregnancy has been demonstrated to substantially reduce the risk of recurrent NTDs and is feasible to implement on a public health basis.

Communicating (birth defects) prevention information to a hmong population in Wisconsin: a study of cultural relevance.

Compelling research from the early 1990s indicated a strong correlation between the consumption of the B-vitamin folic acid and the prevention of a serious birth defect (neural tube defect) in infants. This article examines numerous challenges the author faced when attempting to produce a culturally relevant folic acid brochure for Hmong women of childbearing age in LaCrosse, Wisconsin, part of a broad folic acid education program. An immediate challenge arose from the traditional Hmong belief that birth defects can be either a curse or a gift, "preassigned" in a former life and therefore not preventable. Other challenges that were addressed included language, acculturation and nutrition, literacy, attitudes toward Western health care practices, and attitudes toward taking medications, including a daily multivitamin. In order for public health communicators to reach increasingly diverse ethnic and cultural identities with important health messages, it is essential that project planning start from the target group's cultural context. It is hoped that the lessons learned through this project can be applied to other communications efforts with other cultural groups.

[Folic acid supplementation--voluntary enrichment of different foodstuffs or mandatory fortification of a single staple food?]. / Folsäure--Freiwilliger Zusatz bei diversen Lebensmitteln oder obligate Anreicherung eines Grundnahrungsmittels?

Regular, customary nutrition is not sufficient to cover the recommended daily intake of 400 microg of folic acid as it has been defined by several scientific committees. The provision of various foodstuffs enriched with folic acid would therefore seem to be justified. Whether such products would have a prophylactic effect against different homocysteine-associated diseases of the second part of life is not (yet) proven but certainly a well founded hypothesis. It has been shown that for the prevention of neural tube defects and other embryonic malformations, as well as malignancies of early childhood a pharmaceutical supply of 0,4-0,8 mg before and during the first 12 weeks of pregnancy is required. Mandatory general fortification of all grain products would be an attractive alternative to meet this goal. This measure has been successful in many countries, mainly on the North American continent. The controversy surrounding possible mandatory folic acid fortification of flour in our country is discussed.

Folate intake and the primary prevention of non-neural birth defects.

OBJECTIVES: To investigate whether maternal periconceptional folate intake is associated with a reduction in selected non-neural birth defects in Western Australia (WA). METHODS: Case-control study of folate intake in women whose infants had orofacial clefts (62); congenital heart defects (151); urinary tract defects (117); limb reduction defects (26); or other major birth defects (119); and 578 control women. RESULTS: Neither folic acid supplements nor dietary folate intake in women not using supplements was significantly associated with a reduction in risk in any of the case groups. In contrast to neural tube defects, WA population data for orofacial clefts, heart defects, limb reduction defects and urinary tract defects showed no fall in prevalence since the introduction of folate promotion and voluntary food fortification. CONCLUSIONS: This study provides no evidence of folate being an important factor in the prevention of birth defects other than neural tube defects.

[The primary prophylaxis of neural tube defects in the Podkarpacian region]. / Profilaktyka pierwotna wad cewy nerwowej w regionie podkarpackim.

The paper presents results of investigations carried out in years 2002/ 2003 on prevalence of primary prophylaxis of neural tube defects among children 0 to 3 years old. Subjects were 222 healthy mothers residing in the Podkarpacian region. The results indicate that primary prophylaxis of neural tube defects is propagated quite poorly in this region. A dominant role in its spreading play physicians and at the same time, other sources of knowledge are marginal. There is a strong need for intensification of activities of this kind.

Method of weighted proportion of reproductive-aged women taking folic acid supplements to predict a neural tube defect rate decline.

BACKGROUND: Neural tube defect (NTD) rates can be lowered by increased consumption of folic acid (FA) by women before and during early pregnancy. The crude proportion of reproductive-aged women taking FA supplements has been used to predict a decline of the NTD rate in the general population. In this study we examine the potential error in using the crude proportion to predict NTD risk reduction, and offer an alternative method. METHODS: The crude proportion measures the number of women taking FA. It ignores the substantial variability by maternal age in the probability of giving birth. Age-specific fertility rates (ASFRs) reflect the probability that a woman in a specific age group will give birth in a given year. In this study, we show how to calculate a proportion weighted by ASFRs to predict a decline in the NTD rate, and to assess the effectiveness of FA consumption in preventing NTDs. RESULTS: Our results show that a crude proportion of 50% of women (15-49 years old) taking FA is associated with a range of 24-77% in weighted proportions. Assuming a 40% risk reduction from taking 400 microg of FA daily, the expected NTD rate decline could vary from 9.6% to 30.6%, depending on the age distribution of women taking FA. CONCLUSIONS: The ASFR-weighted proportion estimates the proportion of babies born to women taking FA, as opposed to the crude proportion of women taking FA. We recommend using the ASFR-weighted proportion to predict an NTD rate decline and measure the success of FA education campaigns. We found that when women in high-fertility age groups increased their FA consumption, the decline in the NTD rate was greater than when women in low-fertility age groups did so. Our findings suggest that the more efficient approach to NTD prevention is to focus on women with a higher probability of giving birth. For example, by focusing on <50% of women of childbearing age (20-34 years), as much as 76% of the maximum NTD rate reduction can be achieved.

Puerto Rican primary physicians' knowledge about folic acid supplementation for the prevention of neural tube defects.

BACKGROUND: We conducted a study of a group of primary physicians in Puerto Rico to evaluate their knowledge about folic acid supplementation to prevent neural tube defects. METHOD: The study design was transverse-correlational. A total of 66 primary physicians in two hospitals (public and private) participated in the study. The sample was nonrandom and opportunistic, and only those physicians present in the hospitals at the moment of distribution of the questionnaires participated. A self-administered and anonymous questionnaire was used. Descriptive statistics and cross-tabular analysis were used to describe the results of this study. Inferential statistics were also used, including Chi square and t-tests to establish the associations/differences between physician knowledge and the independent variables. RESULTS: Of the participants, 87.9% demonstrated an inadequate knowledge about folic acid supplementation for the prevention of neural tube defects as part of preconception care and only 12.1% demonstrated adequate knowledge. Older physicians had greater knowledge about folic acid. Also, women demonstrated greater knowledge about folic acid than did men. Most of the physicians who always recommend supplementation to their patients demonstrated a greater knowledge about folic acid, and all participants with adequate knowledge came from the public hospital. CONCLUSIONS: Despite a concerted effort by the Health Department of Puerto Rico to provide education in the importance of folic acid supplementation to reduce the incidence of neural tube defects, primary physicians in two Puerto Rican hospitals generally have not availed themselves of this training and showed a lack of knowledge on this important clinical issue.

Potential prevention of neural tube defects by assessment of women of childbearing age through monitoring of folate.

BACKGROUND: Three quarters of neural tube defects (NTD) can be prevented by sufficient dietary folate supplementation. Despite this knowledge, most women do not supplement their diet effectively. Red cell folate concentrations correlate with the risk of NTD, and levels of less than 900 nM are associated with an increased risk of these serious congenital anomalies. OBJECTIVE: Laboratory tests to assess anemia include testing for folate. This study was conducted to estimate the potential benefits of informing women of reproductive age who are unaware of their low folate levels, uncovered in their anemia tests. METHODS: The number of Ontario women of reproductive age who undergo folate tests and are at an increased risk of NTD was calculated. In addition, the authors calculated the number of NTD cases that could have been prevented if these women were informed of the possible consequences of their low folate levels should they become pregnant. RESULTS: In 1998, red cell folate concentrations were measured in 23,109 women of childbearing age (15-45 y). Approximately half of the women [n = 11,392 (49.3%)] had folate levels below 900 nM and thus were at an increased risk of giving birth to a child with NTD should they have become pregnant. Their overall mean relative risk (RR) of NTD was 1.95, or 1:512 births. If they would have been informed of this risk and subsequently increased their consumption of folate before becoming pregnant, 22.3 cases of NTD per year could have possibly been prevented at no extra cost, since the folic acid results were a part of investigational blood tests performed for another reason (anemia). CONCLUSIONS: Women of reproductive age who are being evaluated for the cause of anemia and have low red cell folate results constitute a high-risk group for NTD in their children. These women should be informed of the increased risk and of methods of dietary folate supplementation.

Modelling the potential impact of population-wide periconceptional folate/multivitamin supplementation on multiple births.

OBJECTIVE: To develop a model of the impact of population-wide periconceptional folate supplementation on neural tube defects and twin births. DESIGN: A hypothetical cohort of 100,000 pregnancies > or =20 weeks, plus terminations of pregnancy after prenatal diagnosis before 20 weeks. METHODS: Application of pooled data on the relative risks for neural tube defects and twins following periconceptional folate from meta-analysis of the randomised trials. MAIN OUTCOME MEASURES: 1. Pregnancies with a neural tube defect (i.e. terminations of pregnancy, perinatal deaths, and surviving infants); 2. twin births (i.e. preterm births, perinatal deaths, postneonatal deaths, birth defects, cerebral palsy); 3. numbers needed to treat. RESULTS: The change in neural tube defects would be 75 fewer terminations (95% CI -47, -90), 30 fewer perinatal deaths (95% CI 18, -35), and 13 fewer surviving infants with a neural tube defect (95% CI -8, -16). The change in twinning would be an additional 572 twin confinements (95% CI -100, +1587), among whom there would be 63 very preterm twin confinements (95% CI -11, +174), 54 perinatal and postneonatal deaths (95% CI -9, +149), 48 surviving twins with a birth defect (95% CI -8, +133), and nine with cerebral palsy (95% CI -2, +26). The numbers needed to treat for the prevention of one pregnancy with a neural tube defect is 847, for the birth of one additional set of twins is 175, for the birth of one additional set of very preterm twins is 1587, and for the birth of an additional twin with any of the following outcomes (perinatal death, postneonatal death, survival with a birth defect, or survival with cerebral palsy) is 901. CONCLUSIONS: Monitoring rates of neural tube defects and twinning is essential as supplementation or fortification with folate is implemented.

Response of red blood cell folate to intervention: implications for folate recommendations for the prevention of neural tube defects.

Committees worldwide have set almost identical folate recommendations for the prevention of the first occurrence of neural tube defects (NTDs). We evaluate these recommendations by reviewing the results of intervention studies that examined the response of red blood cell folate to altered folate intake. Three options are suggested to achieve the extra 400 microg folic acid/d being recommended by the official committees: increased intake of folate-rich foods, dietary folic acid supplementation, and folic acid fortification of food. A significant increase in foods naturally rich in folates was shown to be a relatively ineffective means of increasing red blood cell folate status in women compared with equivalent intakes of folic acid-fortified food, presumably because the synthetic form of the vitamin is more stable and more bioavailable. Although folic acid supplements are highly effective in optimizing folate status, supplementation is not an effective strategy for the primary prevention of NTDs because of poor compliance. Thus, food fortification is seen by many as the only option likely to succeed. Mandatory folic acid fortification of grain products was introduced recently in the United States at a level projected to provide an additional mean intake of 100 microg folic acid/d, but some feel that this policy does not go far enough. A recent clinical trial predicted that the additional intake of folic acid in the United States will reduce NTDs by >20%, whereas 200 microg/d would be highly protective and is the dose also shown to be optimal in lowering plasma homocysteine, with possible benefits in preventing cardiovascular disease. Thus, an amount lower than the current target of an extra 400 microg/d may be sufficient to increase red blood cell folate to concentrations associated with the lowest risk of NTDs, but further investigation is warranted to establish the optimal amount.

The prevention of neural tube defects.

The prevention of neural tube defects is a complex problem. The genetic associations may ultimately allow the prepregnancy identification of women at high risk of a neural tube defect. Education of both the public and healthcare providers has been shown to increase awareness, but the majority of women do not take folic acid before and in the early part of pregnancy. Food fortification will be effective in increasing the folate levels of the population and will have a benefit even at low doses of fortification.