Goals for folic acid preventable birth defects
The progress that has been made
What Florida women know
Women less likely to take a multivitamin
Hispanic women - a higher risk group
Goals have not yet been met
Role of the health care professional in Florida
Opportunities abound
What you can do

Together we can reach the Healthy People 2010 goal of a 50% reduction in neural tube birth defects obtainable with adequate folic acid intake by women.

Goals for folic acid preventable birth defects

Healthy People 2010, a set of health objectives for the nation established by the Centers for Disease Control and Prevention and the Health Resources and Services Administration, includes two goals related to folic acid and birth defects.

• Reduce the occurrence of spina bifida and other neural tube defects by 50% (from 6 new cases per 10,000 births from baseline years 1991-1994 to 3 new cases per 10,000 births).

• Have 80% of non-pregnant women aged 15-44 years consuming at least 400 micrograms of folic acid every day from fortified foods or dietary supplements (up from 21% in the baseline years 1991-1994).

Achieving these goals for Floridians requires a partnership between all interested parties:

• health care professionals
• health care organizations
• governmental agencies
• businesses
• consumers
• volunteer organizations

Everyone has a stake and a role in achieving success!

The progress that has been made

Folic acid education efforts have been extensive. In 1997, the CDC initiated the National Council on Folic Acid (NCFA), comprised of 15 of the country's leading organizations concerned about maternal and infant health. In 1998, the March of Dimes launched a multi-year national folic acid campaign with the goal of increasing awareness of the preventive effects of folic acid consumption. State agencies, organizations, private businesses and universities have banded together to promote folic acid intake. As a result of these efforts, the Florida Folic Acid Coalition came together in 1999 to spearhead folic acid educational activities in Florida.  

Since 1995, the March of Dimes has commissioned The Gallup Organization to conduct a series of national telephone surveys of women ages 18 to 45 years to measure changes in women's awareness and behavior relative to folic acid and other pre-pregnancy issues. The table below summarizes the findings comparing the most recent data (2004) to baseline (1995) (The Gallup Organization 2004).

Source: Folic Acid and the Prevention of Birth Defects - A national survey of pre-pregnancy awareness and behavior among women of childbearing age 1995-2004.   Conducted by The Gallup Organization for March of Dimes, September, 2004

What Florida women know

Consumer Confidence Survey, 2000-2001

In 1999, the University of South Florida (USF) Birth Defects Center contracted with the University of Florida Bureau of Economic and Business Research (UF-BEBR) to gather data from women of childbearing age (18-45) for an assessment of folic acid knowledge (funding provided by the March of Dimes). The UF-BEBR added folic acid questions to its monthly Consumer Confidence telephone survey. These questions appeared on the survey from February 2000 to January 2001. These data along with the 2002 MOD national survey provide an opportunity to compare state and national folic acid awareness and knowledge.

Pregnancy Risk Assessment Monitoring System (PRAMS)

The Pregnancy Risk Assessment Monitoring System (PRAMS), based on a cooperative agreement between the Centers for Disease Control and Prevention (CDC) and the Florida Department of Health (DOH), establishes and maintains state-specific, population-based surveillance of selected maternal behaviors that occur during pregnancy and early infancy.

Since 2000, new mothers have been surveyed concerning their use of multivitamins before pregnancy. The following table compares multivitamin use over time (Florida Department of Health 2005a).

Based on PRAMS surveillance, data have been consistent over a four-year period with a little over one-third of new mothers taking a multivitamin prior to pregnancy.

Behavioral Risk Factor Surveillance System (BRFSS)

The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based telephone surveillance system designed to collect data on individual risk behaviors and preventive health practices related to the leading causes of morbidity and mortality in the U.S.

The following table compares the most recently available data (Florida Department of Health 2005a).

Note: data are for women age 18-44 years.

Most recent data indicate that less than one-half of women surveyed (age 18-44 years) take a multivitamin.

Women less likely to take a multivitamin

According to national survey data (The Gallup Organization 2004) and published research studies (de Jong-van den Berg et al. 2005, Cleves et al. 2004, Rosenberg et al. 2003), certain women may be less likely to take folic acid every day, including:

• Younger (25 years of age or less)
• Hispanic or non-white
• Not married
• Lower education level
• Lower household income
• From the southern U.S.

Practitioners who work with women who have one or more of these characteristics should especially encourage folic acid intake for their patients.

Hispanic women - a higher risk group

Data in Florida and other states indicate that some Hispanic women may be at increased risk for having a baby with a neural tube defect. In Florida, data from the Florida Birth Defects Registry for 1996-2001 indicates that Mexican women living in Florida but not born in the United States had an almost 60% increased risk compared to non-Hispanic women (Florida Birth Defects Registry 2005a), while no other Hispanic sub-group had a significantly increased risk. Practitioners should be aware that Mexican women not born in the U.S. may need special counseling concerning the importance of folic acid intake or other factors that might decrease their risk for having a baby with an NTD.

Goals have not yet been met

Here is where we stand with respect to the Healthy People 2010 goals:

* It is estimated that the observed decline in NTD affected pregnancies has been primarily due to the fortification of cereal grain foods with folic acid (de Jong-van den Berg et al. 2005). 

Role of the health care professional in Florida

The role of Florida's health care providers is crucial in meeting the Healthy People 2010 goals. Health care providers in Florida vary widely in their knowledge about folic acid and in their patterns of recommendation of folic acid to their patients. Here is the breakdown of surveyed Florida health care providers who know the recommended dose of 400 micrograms/day of folic acid for women of childbearing age (Hauser & Lilly 2004):

• 89% of Obstetricians/Gynecologists
• 88% of Nurse Midwives
• 65% of Pediatricians and Family Physicians

When it comes to health care professionals actually making the recommendation of folic acid to women of childbearing age, the rates are somewhat disappointing. The percentage of surveyed Florida health care providers who routinely recommend folic acid to women of childbearing age is as follows (Hauser & Lilly 2004):

• 80% of Obstetricians/Gynecologists and Nurse Midwives
• 51% of Family Physicians
• 42% of Pediatricians

Opportunities abound

According to the March of Dimes 2004 annual national telephone survey, women look to their health care provider for information about folic acid, yet generally are not receiving it. This highlights several opportunities for intervention by health care providers.

• 89% of women between 18 to 45 years of age, who do not currently take a multivitamin on a daily basis, say that they would be very likely or somewhat likely to take a daily multivitamin if advised to do so by their physician or health care provider.

• These women were asked to list what, if anything would make them more likely to do so. Unprompted, 42%, said that they would be more likely to do so if their doctor or health care provider recommended they take it.

• Only one in four, 26%, of women age 18-45 years report that their doctor or other health careprovider has discussed the benefits of folic acid with them.

• Of women aware of folic acid, less than one-third, 29%, cite health care providers as their sources of information about folic acid.

"Our survey shows that many women would be willing to change their behavior and take the vitamin if that advice came from a health care professional...We call on physicians, nurses, midwives, pharmacists, and other health care professionals to use every contact they have with women of childbearing age to urge them to take a multivitamin with folic acid daily." - Dr. Jennifer L. Howse, President of March of Dimes

It is unfortunate that in this era of evidence-based medicine and with the strong scientific evidence supporting an association between folic acid and reduced NTD risk, health care providers are missing such an important opportunity to enhance the health of their patients. Quoting from the report of the Cochrane Database of Systematic Reviews on folic acid and NTDs (Vol.2, 1999):

"periconceptional folate supplementation has a strong protective effect against neural tube defects. Information about folate should be made more widely available throughout the health and education systems."

What you can do

Here's what we know:

•  Approximately 50% of all pregnancies in the U.S. are unplanned, and 80-95% of teenage pregnancies are unplanned.

•  NTD rates in the US decreased, but have only reached the halfway point of the final goal of at least 50% reduction in NTD-affected births.

•  NTD rates in Florida decreased between 1997-2001, but only by 4% and lag behind the national trend.

•  Many women of childbearing age still do not get the recommended amount of folic acid they need every day to reduce their risk of having a baby with a serious birth defect.

•  Folic acid is an inexpensive, easy, and effective way for women to increase their chances of someday having a healthy baby.

•  Health care providers are important and necessary sources of the folic acid message to women. Yet, a substantial number of health care providers in Florida and across the U.S. fail to make the recommendation.

Here's what you can do:

•  Lead where you are - Anyone can spearhead the message of the preventive health benefits of folic acid in their practice.   Use a staff meeting to discuss your office's or organization's responsibility to be a leader in promoting the health benefits of folic acid consumption.

•  Know and follow folic acid recommendations - Follow the U.S. Public Health Service recommendation of suggesting to your female patients of childbearing age and capable of becoming pregnant that they take 400 micrograms of folic acid every day. Many health professional organizations have issued folic acid recommendations; follow them by discussing folic acid with your patients. For more information on health care organizations recommendations click here.

•  Offer a written recommendation/prescription - Provide your patients with a written reminder for taking a multivitamin containing 400 micrograms of folic acid every day.

•  Remind yourself - Include visible reminders such as posters in your office and examination rooms to recommend folic acid to women of childbearing age.

•  Offer informative literature - Have literature on hand to give to your patients to reinforce the important preventive health benefits of folic acid and how they can readily meet the recommendations. Click here for a list of resources.

•  Target and modify your folic acid message to high risk groups - Identify the high risk groups you serve in your practice (such as Hispanic women born in Mexico). Have Spanish literature available. Click here for a list of resources.

• Choose a spokesperson or family to promote folic acid - Identify a local family who has experienced an NTD-affected pregnancy to act as spokespeople for the cause. Click here to view a personal story about birth defects and folic acid.

•  Keep current on folic acid - Become aware of current information on emerging health benefits of folic acid in professional journals as well as what your patients are reading about folic acid in consumer literature. Be prepared to answer questions but be the FIRST one to bring up the subject of folic acid with your patients.

References

Centers for Disease Control and Prevention. (2004) Spina Bifida and Anencephaly Before and After Folic Acid Mandate -- United States. 2004. MMWR 53:362-365

Cleves, M.A., Hobbs, C.A., Collins, H.B., Andrews, N., Smith, L.N., Robbins, J.M. (2004) Folic acid use by women receiving routine gynecologic care. The American College of Obstetricians and Gynecologists. 103(4): 746-753.

de Jong-van den Berg, L.T.W., Hernandez-Diaz, S., Werler, M.M., Louik, C., Mitchell, A.A. (2005) Trends and predictors of folic acid awareness and periconceptional use in pregnant women. American Journal of Obstetrics and Gynecology. 192: 121-128.

Florida Birth Defects Registry, Florida Department of Health, personal communication, April 2005a.

Florida Birth Defects Registry, Florida Department of Health, personal communication, April 2005. Based on the difference in NTD rates between 1997 (4.9 NTDs per 10,000 live births) and the most recent document year of 2001b (4.3 NTDs per 10,000 live births).

Florida Department of Health, personal communication, April 2005a. Based on 2003 Florida PRAMS and BRFSS data.

Florida Department of Health, personal communication, April 2005b.

The Gallup Organization. (2004) Folic Acid and the Prevention of Birth Defects. A national survey of pre-pregnancy awareness and behavior among women of childbearing age, 1995-2004. Princeton, NJ.

Hauser, K.W. & Lilly, C.M. (2004) Florida health care providers' knowledge of folic acid for the prevention of neural tube defects. Southern Medical Journal. 97(5):437-439.

Rosenberg, K.D., Gelow, J.M., Sandoval, A.P. (2003) Pregnancy intendedness and the use of periconceptional folic acid. Pediatrics. 111: 1142-1145.