Pregnancy Health: Community-Wide Campaigns to Promote the Use of Folic Acid Supplements

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Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends community-wide education campaigns to promote the use of folic acid supplements among women of childbearing age on the basis of sufficient evidence that these approaches are effective in increasing the number of these women who consume folic acid supplements.

Intervention

If a woman has enough folic acid in her body before she is pregnant, it can reduce the risk of a pregnancy affected by neural tube birth defects (NTD). Community-wide campaigns to promote the use of folic acid supplements are designed to disseminate information to women of childbearing age or intending to become pregnant, regarding the use of supplements containing folic acid. These campaigns involve the dissemination of coordinated educational and motivational messages and materials within the community. Educational content can be delivered through:
  • Mass media messages and articles
  • Community activities and promotions
  • Distribution of small media (posters, flyers, brochures, etc.)

The U.S. Public Health Service recommends that all women of childbearing age consume 400 micrograms (0.4 milligrams) of folic acid each day in order to reduce the risk of a pregnancy affected by a neural tube birth defect (CDC). The U.S. Preventive Services Task Force recommends that women of childbearing age take a daily supplement containing 400-800 micrograms (0.4-0.8 milligrams) of folic acid (USPSTF)

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 24 studies. The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to preventing birth defects.

Summary of Results

The twenty-four studies that qualified for the review assessed several outcomes.
  • Folic acid consumption among women of childbearing age:
    • Median increase of 5.9% (interquartile interval [IQI] 2.5% to 20.5%; 16 studies)
    • Studies with lowest baseline consumption rates generally reported the largest effect size.
  • Prevalence rates of neural tube defects (NTD):
    • Median reduction of 4% (IQI: 33.9% to 8.5%; 8 studies)
    • The two studies that showed the greatest reduction were potentially confounded by ongoing national fortification programs and by additional NTD recurrence prevention programs focused on increasing the use of folic acid before and during pregnancy.
    • Findings from individual studies were inconsistent and the effect measured across studies does not indicate substantial changes in NTD rates.

Summary of Economic Evidence

An economic review of this intervention was not conducted.

Applicability

Findings from this review should be applicable to women of childbearing age in high-income countries.

Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)
  • What is the impact of community-wide interventions in communities with low rates of supplement use?
  • Is there a ceiling limit for these behavior changes?
  • How does program effectiveness vary among different populations such as women with lower SES, younger women (aged 18 24 years), and African American and Hispanic women.

Study Characteristics

  • The overall body of evidence represents women of childbearing age (18 45) with varying levels of education and social economic status.
  • The intervention was delivered in urban, rural, and suburban settings.
  • Studies were conducted in Australia (3 studies), Israel (2 studies), Norway (2 studies), the Netherlands (3 studies), Germany (1 study), the United Kingdom (England and Ireland; 4 studies), Denmark (1 study), France (1 study), Mexico (1 study), and the United States (5 studies); one study used registry information from 17 countries in the European Union (not including the UK).

Analytic Framework

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Summary Evidence Table

Effectiveness Review

Summary Evidence Table — Effectiveness Review

Included Studies

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Amitai Y, Fisher N, Haringman M, Meiraz H, et al. Increased awareness, knowledge and utilization of preconceptional folic acid in Israel following a national campaign. Preventive Medicine 2004;39;731-7.

Amitai Y, Fisher N, Meiraz H, et al. Preconceptional folic acid utilization in Israel: Five years after the guidelines. Preventive Medicine 2008;46;166-9.

Bower C, Blum L, O’Daly K, Higgins C, Loutsky F, Kosky C. Promotion of folate for the prevention of neural tube defects: knowledge and use of periconceptional folic acid supplements in Western Australia, 1992 to 1995. Australian and New Zealand Journal of Public Health 1997;21(7):716-21.

Bower C, Eades S, Payne J, D’Antoine H, Stanley F. Trends in neural tube defects in Western Australia in Indigenous and non-Indigenous populations. Paediatric and Perinatal Epidemiology 2004;18:277-80.

Bower C, Ryan A, Rudy E, Miller M. Trends in neural tube defects in Western Australia. Australian and New Zealand Journal of Public Health 2002;26(2):150-1.

Busby A, et al. Preventing neural tube defects in Europe: a missed opportunity. Reproductive Technology 2005;20;393-402.

Busby A, et al. Preventing neural tube defects in Europe: population based study. BMJ 2005;330;574-5.

Chan A, Pickering J, Haan E, Netting M, Burford A, Johnson A, Keane RJ. “Folate before pregnancy”: the impact on women and health professionals of a population-based health promotion campaign in South Australia. Med J Aust 2001;174(12):631-6.

Daltveit AK, Vollset SE, Lande B, Oien H. Changes in knowledge and attitudes of folate, and use of dietary supplements among women of reproductive age in Norway 1998-2000. Scand J Public Health 2004;32;264-71.

de Walle HEK, de Jong-van den Berg LTW. Insufficient folic acid intake in the Netherlands: what about the future? Teratology 2002;66:40-3.

de Walle HEK, Cornel MC, de Jong-van den Berg LTW. Three Years after the Dutch Folic Acid Campaign: Growing Socioeconomic Differences. Preventive Medicine 2002;35:65-9.

de Walle HEK, de Jong-van den Berg LTW, Cornel MC. Periconceptional folic acid intake in the northern Netherlands. Lancet 1999;353:1187.

de Weerd S, Thomas C, Cikot RJL, Steegers-Theunissen RPM, de Boo TM, Steegers EAP. Preconception Counseling Improves Folate Status of Women Planning Pregnancy. Obstetrics and Gynecology 2002;99(1):45-50.

Egen V, Hasford J. Prevention of neural tube defects: effect of an intervention aimed at implementing the official recommendations. Soz Praventivmed 2003;48(1):24-32.

Flores AL, Prue C, Daniel KL. Broadcast behavior change: a comparison of the effectiveness of paid and unpaid media to increase folic acid awareness, knowledge, and consumption among Hispanic women of childbearing age. Health Promotion Practice 2007;8(2):145-53.

Kadir RA, Sabin C, Whitlow B, Brockbank E, Economides D. Neural tube defects and periconceptional folic acid in England and Wales: retrospective study. BMJ 1999;319:92-3.

Knudsen Vk, Orozova-Bekkevold I, Rasmussen LB, Mikkelsen TB, Michaelsen KF, Olsen SF. Low compliance with recommendations on folic acid use in relation to pregnancy: is there a need for fortification? Public Health Nutrition 2004;7(7):843-50.

Lawrence JM, Watkins ML, Ershoff D, Petitti DB, Chiu V, Postlethwaite D, Erickson JD. Design and evaluation of interventions promoting periconceptional multivitamin use. Am J Prev Med 2003;25(1):17-24.

Martinez de Villareal L, et al. Decline of neural tube defects cases after a folic acid campaign in Nuevo Le n, M xico. Teratology 2002;66(5):249-56.

Mathews F, et al. Folates in the periconceptional period: are women getting enough? British Journal of Obstetrics and Gynaecology 1998;105:954-9.

McDonnell R, Johnson Z, Doyle A, Sayers G. Folic acid knowledge and use among expectant mothers in 1997: a comparison with 1996. Irish Medical Journal 1999;92(3):296-9.

Nilsen RM, Vollset SE, Gjessing, Magnus P, Meltzer HM, Haugen M, Ueland PM. Patterns and predictors of folic acid supplement use among pregnant women: the Norwegian Mother and Child Cohort Study. Am J Clin Nutr 2006;84:1134-41.

O’Rourke KM, Roddy ME. A multivitamin supplementation and education intervention as an effective means of increasing multivitamin use among postpartum women of Mexican origin. Paediatric and Perinatal Epidemiology 2007;21:248-55.

Robbins JM, Cleves MA, Collins B, Andrews N, Smith LN, Hobbs CA. Randomized trial of a physician-based intervention to increase the use of folic acid supplements among women. American Journal of Obstetrics and Gynecology 2005;192:1126-32.

Stevenson RE, Allen WP, Pai GS, Best R, Seaver LH, Dean J, Thompson S. Decline in prevalence of neural tube defects in a high-risk region of the United States. Pediatrics 2000; 106(4);677-83.

Stoll C, Alembik Y, Dott B. Are the recommendations on the prevention of neural tube defects working? European Journal of Medical Genetics 2006;49:461-5.

Van der Pal-de Bruin KM, van der Heijden PGM, Buitendijk SE, den Ouden AL. Periconceptional folic acid use and the prevalence of neural tube defects in The Netherlands. European Journal of Obstetrics & Gynecology and Reproductive Biology 2003;108:33-3.

Ward M, Hutton J, McDonnell R, Bachir N, Scallan E, Oleary M, Hoey J, Doyle A, Delany V, Sayers G. Folic acid supplements to prevent neural tube defects: trends in East of Ireland 1996-2002. Irish Medical Journal 2004;97(9):274-6.

Zlotogora J, Amitai Y, Leventhal A. Surveillance of neural tube defects in Israel: the effect of the recommendation for periconceptional folic acid. Isr Med Assoc J 2006;8:601-4.

Search Strategies

The CPSTF finding is based on evidence from a systematic review (search period through March 2008). The following databases were searched for English-language papers that evaluated tobacco control interventions:
  • EMBASE
  • Medline
  • Social Science Citation Index

Search strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software. Reference lists also were reviewed to look for additional studies.

Search Terms

vitamin B12, vitamin B12 deficiency, folic acid, neural tube defects, abnormalities, neoplasms, cardiovascular diseases, Alzheimer disease, food, fortified, dietary supplements, twins/pregnancy, multiple, knowledge, attitudes, practice, health education/health promotion, preconception care, folic acid deficiency

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.
  • Consideration should be given to accessibility as not all women will have money to purchase daily supplements.

Crosswalks

Healthy People 2030

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.