Pre-conceptional folic acid supplementation in uninsured pregnant Hispanic women.

To the Editor: Neural tube defects (NTDs) are among the most commonly occurring preventable birth defects. Preconceptional consumption of synthetic folic acid, in addition to the usual diet, will prevent 60 to 70% of NTDs. (1) Hispanic infants are 1.5 to 3 times more likely to be born with a NTD. (2) Studies have demonstrated that Hispanic women were significantly less likely to be both aware of folic acid's role in preventing birth defects or taking folic acid supplementation. (3) These studies did not address the income status of the population studied. The objective of this study was to determine the knowledge and practices of pre- and postconceptional folic acid supplementation in a sample of pregnant and uninsured Hispanic women in North Carolina.

Participants were recruited at a prenatal clinic in a low-income neighborhood where the majority of patients are uninsured Hispanics. Upon verbal informed consent, a questionnaire was administered orally in English or Spanish by the author through a fluent interpreter. The primary outcome of interest in the questionnaire was the level of perinatal folic acid consumption, with the secondary outcome of interest being the level and source of folic acid knowledge. Student's t test and analysis of variance (ANOVA) were used to compare continuous data, and the chi-square statistic was used to compare categorical data.

Forty uninsured Hispanic women were interviewed, with patient demographics summarized in Table 1. The demographics of our convenience sample are similar to the demographics of patients attending our prenatal clinic (data not shown). Results from questions pertaining to folic acid usage and knowledge are summarized in Table 2.

To our knowledge, this is the first description of perinatal knowledge and behavior in an uninsured pregnant Hispanic sample. The demographics of the sample examined is typical of the population of migrant workers in North Carolina, featuring young (mean age 24) mothers with an average of 8 years of education, who have had a relatively short length (mean 3.7 years) of residency in the US. This is in contrast to the more established Hispanic populations previously sampled in studies from Texas and California.

Our findings suggest that despite the wealth of national and state-based educational campaigns, an increase in public awareness has not translated to behavioral change in this small sample of uninsured Hispanics. Only 3 of 40 uninsured Hispanic women attending a low-income prenatal clinic consumed either preconceptional supplemental folic acid or a multivitamin. This disparity is consistent with a recent study demonstrating that low-income, no insurance, and Hispanic race were all significant risk factors for failure to use preconceptional folic acid supplementation. (4)

In our study, 47% of women surveyed were aware of the purpose of folic acid. Public health educational strategies appear to contribute toward the knowledge level of this population. The most common sources of folic acid knowledge were described as television ads (50%) and prenatal clinic visits (38%).

The majority of women sampled in our study initiated folic acid supplementation upon presentation to prenatal care, which was at an average of 14 weeks gestation. Since neural tube defects occur at less than 4 weeks of gestation, and as a significant proportion of pregnancies in the US are unplanned, primary care physicians have an obligation to educate patients regarding preconceptional supplementation. Evidently, education and encouragement by the physician plays a very large role in the modification of behavior in smoking cessation and exercise. Application of this to the realm of preconceptional supplementation may translate to improved compliance with USDA recommendations.

Furthermore, an increase in fortification dosage, and fortification of grain products used by Hispanics, should be considered. Evidently, healthcare providers and public health educational efforts also need to be improved, such that the preconceptional importance of folic acid consumption can be conveyed effectively to the Hispanic population.

Acknowledgments

The authors thank Joan Robie, Belice Cabrera, and Dr. Mary Lou Moore for assistance with questionnaire development and implementation of study protocol. Much appreciation goes to the Hispanic women who participated in this survey and offered not only answers to questions, but also windows into their lives.

Daniel T. Leung, MD, MSc

Joseph M. Ernest, MD

Department of Obstetrics and Gynecology 

Wake Forest University School of Medicine 

Winston Salem, NC

References

1. Werler MM, Shapiro S, Mitchell AA. Periconceptional folic acid exposure and risk of occurrent neural tube defects. JAMA 1993;269:1257-1261.

2. Hendricks KA, Simpson JS, Larsen RD. Neural tube defects along the Texas-Mexico border, 1993-1995. Am J Epidemiol 1999;149:1119-1127.

3. Canfield MA, Anderson JL, Waller DK, et al. Folic acid awareness and use among women with a history of a neural tube defect pregnancy-Texas, 2000-2001. MMWR Recomm Rep 2002;51:16-19.

4. Rosenberg KD, Gelow JM, Sandoval AP. Pregnancy intendedness and the use of periconceptional folic acid. Pediatrics 2003;111:1142-1145.

Financial support: DTL was supported by the David E. Rogers Fellowship of the New York Academy of Medicine.

Presented in part at the Society of Teachers of Family Medicine Resident/Student Research Forum. San Francisco, CA, April, 2002.

*Current affiliation is the Department of Internal Medicine, University of Washington Hospitals, Seattle, WA.

Table 1. WIC: The special supplemental nutrition program for women,
infants, and children

Demographic variable                     %

Maternal Age (years)
  <20                                    18
  20-24                                  25
  25-29                                  23
  >30                                    10
Gravidity
  1                                      43
  2                                      33
  >2                                     25
Education (years)
  <8                                     23
  8-9                                    52
  >10                                    26
Marriage status
  Married                                38
  Single                                 43
  Other                                   5
Gestational age (weeks)
  <20                                    18
  20-29                                  40
  30-35                                  30
  >35                                    13
First visit to clinic (weeks gestation)
  <13                                    48
  13-26                                  48
  >26                                     5
No. of prior clinic visits
  0                                      18
  1-4                                    23
  5-9                                    53
  >9                                      8
Length of US residency
  <1 year                                20
  1-1.9 years                            23
  2-4 years                              23
  5-9 years                              25
  >9 years                               10
Country of origin
  Mexico                                 90
  Others                                 10
Primary language
  Spanish                                93
  English                                 8
Employment
  Unemployed                             70
  <20 hr/wk                               3
  20-39 hr/wk                            10
  [greater than or equal to]40 hr/wk     18
Enrolled in WIC
  Yes                                    70
  No                                     30
Enrolled in Baby Love
  Yes                                    68
  No                                     33

Table 2. Pre-conceptional supplement usage, usage during pregnancy, and
knowledge base of folic acid in a population of 40 uninsured Hispanic
women attending a prenatal clinic

Variable                                         (%)

Pre-conceptional use of folic acid/multivitamin   3/40 (7.5)
Current use of folic acid/multi-vitamin
  First prenatal clinic visit                     4/7 (57)
  >1 prenatal clinic visit                       33/33 (100)
"What is the purpose of folic acid?"
  Don't know                                     21/40 (53)
  Prevent birth defects                           7/40 (18)
  Prevent brain/neural tube defect               12/40 (30)
Source of folic acid knowledge
  Television                                      8/16 (50)
  Prenatal clinic/clinic literature               6/16 (38)
  Others                                          2/16 (13)