Level of folic acid awareness for the prevention of neural tube defects and associated factors among pregnant women in Adama, South East Ethiopia

Abstract Background: Neural tube defects are congenital anomalies of the brain, spinal cord, and their surrounding structures. Folic acid intake before and during the early weeks of pregnancy could reduce neural tube and other birth defects. Folic acid usage in the protective period of pregnancy against the neural tube defects is related to high level of awareness. This study aimed at evaluating the level of folic acid awareness for the prevention of neural tube defects and associated factors among pregnant women in Adama, South East Ethiopia. Method: A descriptive cross-sectional study design was used. 398 consented pregnant women attending antenatal care in Adama were the participants of the study. The women were selected by using a systematic random sampling method. A structured pre-tested interviewer-administered questionnaire was used to collect the data. The questionnaire was concerned with participants’ demographic information, and their awareness about folic acid, roles of folic acid, and the recommended time of intake. Data were analyzed using SPSS version 20 statical software. Simple and multiple binary logistic regression analyses were conducted. 95% confidence interval and p-value were used to evaluate the association between dependent and independent variables. Results: Of the interviewed women, 20.9% reported having heard or read something about folic acid supplements. But only 1.01% and 6.03% were aware of the recommended time of intake and the role of folic acid in preventing neural tube defects and other congenital anomalies respectively. The healthcare providers were the primary source of information about folic acid, which account 78.3%. Folic acid awareness was associated with age, educational status, household monthly income, week of pregnancy at the first antenatal visit, any complication during current pregnancy, and use of folic acid during current pregnancy. Conclusions: Most of the pregnant women were not aware of folic acid, its importance and the recommended time of intake for preventing neural tube defects. Further effort is required from policymakers, healthcare providers, the media, and community to increase women's awareness about folic acid.

structures [1,2]. NTDs are a source of high morbidity, distress, and severe physical, psychological, and social handicaps [3]. The impact of having a baby with spina bifida or losing a baby born with anencephaly is profound -emotionally, spiritually, and financially [4]. Most individuals who survive with NTDs have a multiple system handicaps and a limited life expectancy [5]. Stigmatization and discrimination may pose lifelong problems [6]. Anencephaly which accounts for about one-third of cases is incompatible with life while spina bifida, about two-thirds of NTDs, are associated with varying degrees of physical and mental disabilities even after treatment. Some of these are loss of bladder and bowel function, paralysis of the lower limbs, and hydrocephalus [7,8]. The implications of this negative trend are the enormous physical, emotional, psychological, and financial burdens on the patients, the affected families, the caregivers, the healthcare system, and the community as a whole [2,7].
Maternal folate status is involved in the pathogenesis of NTDs. Although the exact mechanism is not clear, a nutritional or genetic defect in homocysteine metabolism via methionine synthase appears likely [9]. In folate deficiency, homocysteine accumulates in the serum resulting in negative effects for health including increased risk of having a baby with NTD, increased risk of cardiovascular disease, and late pregnancy complications such as pre-eclampsia [10]. The deficiency of folic acid during pregnancy is also associated with the defects of the upper lip and mouth, urinary tract and limb morphology by disturbances in the nucleic acid synthesis and chromosomal breaks [8].
Different studies explore that in order to encourage folic acid supplement use in pregnancy to prevent NTDs; it is vital to promote the awareness of women of childbearing age regarding the importance of folic acid in preventing NTDs and other congenital anomalies [2,16]. In doing so, it is necessary to evaluate the level of awareness and predicting factors among pregnant women. Data reported from Turkey, India, Honduras, Nigeria, Australia, Lebanon, Europe, USA, United Arab Emirate, Taiwan and Iran range from 27.5% to 96.2% [1,7,9,12,13,[17][18][19][20][21][22][23]. Several factors seem to affect folic acid awareness for NTD prevention among women, such as age, educational status, household monthly income, and use of folic acid supplement [7,20,23,24]. In Ethiopia, there is no any official recommendation about preconceptional folic acid intake for NTD prevention. It is left to the judgment of the healthcare providers.
There is scant research on levels of folic acid awareness for prevention of NTDs and predicting factors among pregnant women in Ethiopia, particularly in Adama. The aim of this study was to assess the level of folic acid awareness and associated factors among pregnant women in Adama, South East Ethiopia.

Study setting and period
The study was conducted from August to November 2014 in two government health facilities, i.e.
Adama Health Center and Adama Hospital Medical College located in Adama. These two heath facilities are commonly visited by pregnant women for antenatal care (ANC). Adama is a city located at 8.54°N 39.27°E at an elevation of 1712 meters, 99 km southeast of Addis Ababa. Based on the 2007 census conducted by the Central Statistical Agency of Ethiopia, this city has a total population of 220,212, of whom 111,340 were women. It was reported that the four largest ethnic groups in Adama were Oromo, Amhara, Gurage, and Silte. There are government hospitals and health centers in Adama that provides ANC follow up and other obstetric care free of charge [25].

Study design and population
An institution based descriptive cross-sectional study design was used. The study was conducted among women attending ANC. All pregnant women who visited Adama Health Center and Adama Hospital Medical College for ANC were included in the study.

Data collection tools and study variables
An original, structured, pre-tested questionnaire was prepared in English and translated into Amharic (local language) to the guardians then translated back to English. The Amharic version of the questionnaire was used to collect the data. The trained data collector administered the questionnaires to the subjects and conducted a face-to-face interviews with them to extract the required information. The questionnaire was concerned about sociodemographic variables, obstetric history, and awareness about folic acid and sources of information about folic acid supplements. The questions were aimed at women's awareness of folic acid in prevention of NTDs and other congenital anomalies and not about its role in anemia prevention. The assessment also included awareness about natural sources of folic acid, the importance of folic acid supplement, recommended time of intake for preventing NTDs, intake of folic acid supplements at some point during the current pregnancy, and previous history of a child with a birth defect. Women were grouped as aware if they report having heard and/or read about folic acid supplements. The household monthly income of the women was described using Ethiopian Birr (ETB).
The dependent variable was level of folic acid awareness for prevention of NTDs and the independent variables were age, educational status, marital status, household monthly income, occupation, number of pregnancies, number of antenatal visit, week of pregnancy at first ANC visit, gestational age at time of interview, history of unsuccessful pregnancy, history of a baby with a birth defect, presence of any complication during current pregnancy such as preeclampsia, any diagnosed chronic illness such as diabetes mellitus, hypertension, epilepsy, and use of folic acid during current pregnancy.

Data analysis
The data were entered to Epi Info version 7.2.1.0 and exported to SPSS version 20 statistical software.
Data was double entered to check the consistency. Data were cleaned and edited before analysis. A simple and multiple binary logistic regression analyses were conducted using SPSS version 20 statistical software. Descriptive statistics were used to give a clear picture of the dependent and the independent variables. The data were analyzed and a 95% confidence interval, chi-square test, and P-value were used to check for the association between dependent and independent variables. A p-value of less than 0.05 was considered as statistically significant.

Socio-demographic and obstetric characteristics of women
A total 407 women were requested to participate in the study, but 9 of them were not voluntary and the final sample size becomes 398. The participation rate was 97.8%. More than half of the women (54.8%) were at the age of 25 years and above(minimum was 16 years) and 96% of the women were married. About 37.7% of the women attended elementary and 33.4% attended high school. More than half of the women (51.5%) had a monthly income between 1001 to 3000ETB. 57.8% of the women were housewives (Table 1).
Among the interviewed women, 49% had 2-4 pregnancy and 46.5% were primigravida. About 21.6% of the women came for their first ANC visit while 62.8% came for their 2 nd to 4 th visit. Gestational age at the first ANC visit was less than or equal to 12 weeks in 39.7% and greater than or equal to 25 weeks in 4.3% of the women. Most of the interviewed women (67.6%) were in their third trimester.
About 15.8% of the women had a previous history of unsuccessful pregnancy and 1% had a history of a baby with a birth defect. 6.3% of the women had complications during current pregnancy and 5.3% had a diagnosed chronic illness (Table 2).

Folic acid awareness of women and associated factors
Of the interviewed women, 20.9% (83/398) reported having heard or read something about folic acid supplements. Of those women, 91.6% (76/83) described folic acid in their own words. Folic acid was described by 5.3% (4/76) of the women as a supplement to prevent birth defects, including NTDs.
About 62.7% (52/83) of the participant mentioned pregnant women as a group of people who needs to take folic acid supplements. Only about 6.1% (4/66) of the women stated one month before pregnancy and 3 months after pregnancy as recommended time of intake. When the women were asked about the importance of folic acid supplement intake, 37.9% (25/66) of them said it helps women to have a healthy baby, and 16.7% (11/66) of the women said it prevents NTDs. About 48.2% of women (192/398) reported they could identify natural folate-rich food and 24.4% correctly identified any of the correct natural sources of folic acid. The healthcare providers were a primary source of information about the folic acid supplement which accounts about 78.3% (65/83). Table 3 shows the detail of folic acid awareness among women.
In the current study, folic acid awareness was significantly associated with age (OR=1.96, CI=1.177- In the present study, 20.9% of the women had heard or read about folic acid supplement which was close to 27.5% of heard or read about folic acid in Turkey [1]  Since media could address a wider range of people, it is necessary to emphasize more about health education programs on radio and television and health related articles in journals and magazines.
In our study, older age women were more likely to be aware of folic acid than younger women. This

Conclusions
Most of the pregnant women were not aware of folic acid supplements; its importance and the recommended time of intake to prevent birth defects. Even though there are a lot of different types of media in Ethiopia, they have a few contributions on teaching women about folic acid and its importance in the prevention of birth defects. In order to improve folic acid supplement usage at the protective time for prevention of NTDs and other birth defects, further effort is required from policy maker, healthcare provider, media and community to start a folic acid awareness campaign. The study was conducted after ethical clearance letters obtained from the University of Gondar, College of Medicine and Health Science, School of Medicine ethical committee. Informed verbal consent was taken from the study participant. The objective of this research was explained to the study participant's after that, those willing to participate were included. The study participants were free in answering the questionnaire or withdraw from the study at any time. The verbal consent was obtained over the written consent because most of Ethiopian consider signing on any paper as taking responsibility and fear of being cheated after signing on any document which is not their own business. So we use verbal consent to facilitate the data collection. The ethical committee has approved it.

Availability of the data
The datasets generated and analyzed in the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that there is no competing interest.

Funding
This research has been funded by the University of Gondar, College of Medicine and Health Science.
The university gives a grant in order to conduct the study but have no any role in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication.