Preconceptional folic acid utilization in Israel: Five years after the guidelines
Introduction
Conclusive evidence that perceptional folic acid (FA) is essential in the prevention of neural tube defects (NTDs) has been available since 1991 (MRC, 1991). In 1999, Berry et al. provided irrefutable evidence that confirmed the efficacy of a 400 μg daily dose.
Terminations of pregnancy as a result of improved prenatal diagnostics have led to a decreased incidence of NTDs at birth. In order to ascertain the “true” incidence of NTDs the Ministry of Health's (MOH) Department of Community Genetics established an “NTD” registry in Israel in 1999. Reports from ultrasound clinics, genetic laboratories and units, and pathology departments are cross-referenced with the national birth registry, stillbirth and abortion (spontaneous and induced) records.
The rate of NTDs in 1999–2000 was 1.2 per 1000 in the Jewish population and 2.2 per 1000 live births in the Arab population. Live-born, stillborn infants and electively terminated pregnancies were included in the analyses. The incidence of spina bifida (reflected within NTDs) was 0.49/1000 Jews and 0.98/1000 Arab live births (Zlotogora et al., 2006).
A baseline national survey conducted in June 2000 (n = 1719) revealed FA awareness, knowledge and preconceptional utilization at 54.6%, 17.6% and 5.2%, respectively. Survey results endorsed the need for a national FA policy.
In August 2000, guidelines were issued recommending a daily 400 μg FA supplement for all women in their childbearing years with emphasis on the 3 months preceding conception and throughout the first trimester (MOH, 2000). National guidelines for a 4 mg preconceptional FA supplement to prevent NTD recurrence have been in effect since 1994 (MOH, 1994).
A national FA campaign was launched concurrently with the issue of the 2000 guidelines. A detailed description of the original campaign was reported earlier (Amitai et al., 2004).
In 2002, the first post campaign survey was conducted (n = 1661). Folic acid awareness, knowledge and preconceptional utilization were 85%, 77.7% and 30.5% (Jewish 35%, Arabs 21%), respectively (Amitai et al., 2004).
Data from the NTD registry (2002–2004) reported a concurrent decline in open NTDs (Jews 33%, Arabs 23%) and spina bifida (Jews 45%, Arabs 35%; Zlotogora et al., 2006).
As a result of the 2002 survey, we began targeting specific populations at risk for NTDs. Southern district Bedouin have a high fertility rate (7–8) and the highest incidence of NTDs (3/1000) (Friedlander, 2002, Zlotogora et al., 2002). Programs targeting this population were developed in conjunction with Ben Gurion University. Bedouin women were trained as health educators and employed in various outreach programs.
Ultra orthodox Jews in the Tel Aviv district were targeted due to their high fertility rate (7.0) (Friedlander, 2002) and religious objections to terminations of pregnancy despite congenital defects. Programs were developed in conjunction with the approval of local rabbis. A nurse functioned as the FA liaison with local existing women's groups; providing lectures and handouts and weekly rounds at the postpartum convalescent facility.
An annual national FA awareness week was established in January 2005. The week is highlighted by intensive radio advertisements and the distribution of FA pamphlets to all women in their childbearing years by sick fund and drugstore pharmacists. During each of these weeks a total of 125,000 pamphlets were distributed (live births in Israel per annum are 143,000).
The focus of this report is the March 2005, third national FA survey.
Section snippets
Methods
Pregnant and women up to 2 months postpartum who presented to the MCHCs (Maternal Child Health Clinics) for either prenatal, postpartum or infant care were the target population.
A total of 2256 Hebrew and Arabic multiple-choice questionnaires were distributed via district health offices to 515 MCHCs throughout the country. Nurses conducted structured interviews on the first 3–5 eligible women who presented at the MCHC during the survey period.
Awareness, knowledge of FA, timing knowledge and
Results
A total of 1860/2256 (82.4%) questionnaires were returned. Demographic data are presented in the Table 1.
Religion was classified as Jewish, Moslem Arab (excluding Bedouin), Bedouin, Christian Arab, Druze and other. Religion was delineated by 1830 respondents (1123 Jewish and 707 Arab women).
Moslem Bedouin women had significantly more children and less years of schooling than Druze, Christian and non-Bedouin Moslem women. Christian women had significantly more years of schooling than Moslem and
Discussion
Five years into the national FA campaign; preconceptional utilization has increased from 5.2% (2000) to 34% (2005), awareness has exceeded 90%, more than 80% know that FA is essential in the prevention of birth defects and more than 70% know that in order to be effective FA must be taken preconceptionally as well as during the pregnancy.
Education is significantly correlated with FA utilization. To achieve client empowerment, it is necessary to provide the knowledge that can influence attitudes
Acknowledgments
We would like to thank the Tipat Halav (MCHCs) nurses throughout the country who have been instrumental in spreading the FA message and interviewing the study women. A special thank you to the following nurse supervisors for their role in organizing the distribution of the survey questionnaire: Shula Altman, Yael Arbelli, Bracha Avraham, Chana Ben-Ari, Sara Binyamin, Yardena Ben-Chamu, Gila Benztik, Zahava Dror, Naomi Eidelstein, Sara Hadar, Tzipi Kachal, Dorit Mizrachi, Yehudit Pasternak,
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Lower rates of neural tube defects in Israel following folic acid supplementation policy
2020, Preventive MedicineCitation Excerpt :McStay et al., 2017) Large studies have since shown only one in three women in the United Kingdom (Bestwick et al., 2014) and in the United States (Centers for Disease Control and Prevention, 1999) reported taking FA supplements. In Israel, a nationwide campaign raised preconceptional FA intake from 5% in 2000 to 34% in 2005; utilization in Arab women (26%) was lower than in Jewish women (39%), and was also decreased in women with lower levels of education (Amitai et al., 2008). A 2005 international study of over 13 million births found no significant change in NTD rate following supplementation recommendations, attributed to insufficient implementation of this policy (Botto et al., 2005).
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