Knowledge and Use of Folic Acid by Women of Childbearing Age -- United States, 1995

Each year in the United States approximately 2500 infants are born with spina bifida and anencephaly (1), and an estimated 1500 fetuses affected by these birth defects are aborted. Recent studies indicate that the B vitamin folic acid can reduce the risk for spina bifida and anencephaly by at least 50% when consumed daily before conception and during early pregnancy. In September 1992, the Public Health Service (PHS) recommended that all women of childbearing age who are capable of becoming pregnant consume 0.4 mg of folic acid daily (1). Folic acid can be obtained from multivitamins or other supplements containing folic acid and some breakfast cereals. This report summarizes the results of a survey conducted during January-February 1995 regarding knowledge and practices of women of childbearing age in the United States about consumption of folic acid from supplements and breakfast cereals.

During January-February 1995, The Gallup Organization conducted for the March of Dimes Birth Defects Foundation a proportionate, stratified random-digit-dialed telephone survey of a national sample of 2010 women aged 18-45 years. The response rate was 50%. Respondents were asked, "Have you ever heard or read anything about folic acid?" Respondents also were asked, "From what you know, is there anything a woman can do to reduce her risk of having a baby with birth defects?" and "To the best of your knowledge, can consuming vitamins during pregnancy reduce the risk of birth defects?" For this analysis, estimates were statistically weighted to reflect the total population of women aged 18-45 years in the continental United States residing in households with telephones. The margin of error for estimates based on the total sample size within 95% confidence intervals is 2%.

Overall, 52% of women reported ever hearing of or reading about folic acid. Of these, 9% answered that folic acid helps to prevent birth defects and 6% that folic acid helps reduce the risk for spina bifida; 45% were unable to recall what they had heard or read. Fifteen percent of respondents reported having knowledge of the PHS recommendation regarding the use of folic acid; 4% reported that the recommendation was for prevention of birth defects and 1%, for prevention of spina bifida.

A total of 88% of respondents reported that a woman can help reduce the risk for having an infant with birth defects. The most common responses about how to reduce risk were avoiding alcohol and drugs (73%), and not smoking (63%); 1% reported that folic acid could reduce risk. Overall, 56% reported that consumption of vitamins during pregnancy can reduce the risk for having an infant with birth defects, and 78% reported that women should take multivitamins before pregnancy. The most frequently mentioned supplements respondents believed to be especially important to women of childbearing age and to pregnant women were iron (27%), calcium (26%), multivitamins (20%), vitamin C (14%), and folic acid (6%).

Overall, 25% of nonpregnant women of childbearing age reported taking a daily vitamin supplement containing folic acid. Of women who had been pregnant during the 2 years preceding the survey, 20% reported taking the vitamins before pregnancy. Among women who did not take vitamin or mineral supplements daily, the most frequently cited reasons for not taking them were "Don't feel I need them," (22%); "Forget to take them," (18%); and "Get balanced nutrition from foods," (12%).

Overall, 77% of women surveyed reported eating at least one serving of breakfast cereal each week; 14% reported eating at least seven servings per week. The average number of servings per week was three. Most cereals eaten contained 0.1 mg folic acid per serving, and few (6%) respondents who included cereals in their diets reported eating a cereal that contains 0.4 mg folic acid per serving.

Reported by: RB Johnston, Jr, MD, DA Staples, March of Dimes Birth Defects Foundation, White Plains, New York. Birth Defects and Genetic Diseases Br, Div of Birth Defects and Developmental Disabilities, National Center for Environmental Health, CDC.

Editorial Note

Editorial Note: A convenient method for a woman to achieve the PHS recommendation for the use of folic acid to reduce the risk for spina bifida and anencephaly is to take daily a vitamin supplement that contains 0.4 mg folic acid or eat a breakfast cereal containing 0.4 mg folic acid per serving. The findings in this report indicate that only 25% of nonpregnant women in the United States regularly consumed a vitamin supplement containing 0.4 mg folic acid, and only a small proportion ate a breakfast cereal containing 0.4 mg folic acid per serving. A previous report indicated that among women in South Carolina who had given birth during October 1992-September 1994, only 12% had used folic acid-containing vitamin supplements during the periconceptional period (2). In addition to consumption of folic acid-containing supplements or breakfast cereals, women can increase their consumption of folates by choosing foods consistent with the U.S. Dietary Guidelines for Americans and the U.S. dietary pyramid (e.g., orange juice and green leafy vegetables) (1).

An important limitation of this telephone survey was the low response rate (50%). In particular, knowledge and behavior patterns of nonparticipants may have been different from those of participants. Because participating women were more highly educated than the total U.S. population, the prevalence of use of vitamin supplements may have been higher among these women than U.S. women in general because vitamin usage increases with education (3). Additional surveys of a more representative sample of women of childbearing age in the United States will be necessary to obtain more precise estimates of the use of vitamin supplements among such women. Nonetheless, the findings in this report and the South Carolina study (2) suggest the need to increase knowledge of the importance of consuming folic acid among women of childbearing age and to heighten awareness among women about the potential benefits of taking folic acid on a daily basis.

Strategies for educating women about folic acid include reporting the issues in the news media, widely distributing informational materials (e.g., in physicians' offices, clinics, schools, and health clubs), and encouraging health-care providers to emphasize consistently the importance of daily consumption of folic acid when speaking to women of childbearing age. The most effective and efficient methods for increasing knowledge of the benefits of increased folic acid consumption and for changing behavior to increase use should be determined by additional research and demonstration projects. In addition, because folic acid consumption also could be increased by the addition of folic acid to staple foods, the Food and Drug Administration has proposed requiring the addition of folic acid to a variety of enriched cereal grain products (4).

The March of Dimes Birth Defects Foundation is using data from this survey as an integral part of its new "Think Ahead" public education campaign to promote preparation for pregnancy. Additional information about folic acid consumption patterns among women is available from R.B. Johnston, Jr., M.D., March of Dimes Birth Defects Foundation, 1275 Mamarneck Ave., White Plains, NY 10605.

References

1. CDC. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR 1991;41(no. RR-14):1-7.

2. CDC. Prevention program for reducing risk for neural tube defects -- South Carolina, 1992-1994. MMWR 1995;44:141-3,149-50.

3. Block G, Cox C, Madans J, et al. Vitamin supplement use by demographic characteristics. Am J Epidemiol 1988;127:297-309.

4. FDA. Proposed rule. Food standards: amendment of the standards of identity for enriched grain products to require addition of folic acid. Federal Register 1993;58:53305-12.

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