Ninth Annual Maternal and Child Health Epidemiology Conference / December 10-12, 2003

Folic Acid and Pregnancy - Data from the PRAMS Project 1996-2000

KIM HAUSER:  Good afternoon, and I will apologize up front if I’m not very familiar with the slides because this happened--like, five minutes before the session started, I found out I was going to be doing this.  Miss Marshall had asked that Kurt Miller be acknowledged for his input into this presentation.  Just some background information on neural tube defects.  I think we’re familiar with this in that we know that there are approximately 4,000 babies born each year in the United States with neural tube defects.  I think we’re starting to see some declines in that because of fortification and some, not much, change in the use of multivitamins.  With this presentation, I was going through and looking at it, this is something that it bears out is a little bit of change that’s happened in Florida with multivitamin use.  As we know, folic acid needs to be taken at least one month prior to pregnancy and during the early months of pregnancy.  And of course, it is in quite a few foods and enriched in cereal products.  The standard recommendation is 400 micrograms of folic acid.  This is for all women of childbearing age.  Women who have had a previous NTD-affected pregnancy, of course, need to take approximately four milligrams.  This is, once again, standard recommendations.  A little bit about the Florida PRAMS data. 

What you’re going to be seeing today are looking at data from 1996 and then comparing it to 2000.  Now, I will kind of add a little aside here is back when Florida initiated its folic acid campaign in 1999, the PRAMS data was used to assess where we were with folic acid knowledge and use in the state of Florida.  In fact, I believe about in 1999, a presentation was done at a PRAMS conference showing where we had kind of used this as a jumping-off point for our folic acid campaign.  The data from 2000 will be approximately two years after our campaign started; so hopefully, you’ll be able to see some changes in this.  In 1996, there was 1986 PRAMS respondents and 2006 and 2001.  And if you don’t know this, Florida is the fourth most populous state in the United States, and we do have the fourth-highest number of live births, which is just about 205,000 a year.  So we’re starting to go back up in our number of live births. 

Some background on PRAMS.  They do a mail survey questionnaire with a telephone follow-up.  It is a stratified selection, and here’s some results.  First of all, our PRAMS has a very good response rate.  I’ve been told it’s close to 80 percent response rate.  So what you’re looking at it is from these new mothers, and it’s a good--I think the data really is accurate.  Overall, 61 percent of new mothers did not take a multivitamin before pregnancy.  I think this is pretty, you know, standard.  We do see about a third of women reporting that they do take multivitamins.  You can see that the women who were on Medicaid reported not taking it at a much higher rate than women who were on Medicaid.  Eight percent of new mothers were aware that folic acid prevented neural tube defects.  I think you’ll find that that’s quite similar to some of the new Gallup Poll results reported by the March of Dimes.  So this is consistent with that data.  And more women heard--about 70 percent--about folic acid from their health care providers than from other sources. 

And I think once again, this is something I view as positive because originally, this was a very low-reported source of hearing about folic acid.  The questions on the survey, “Have you heard or read that taking the vitamin folic acid can help prevent some birth defects?”  This is no awareness of folic acid.  And if you look, what’s really striking is that there was a huge disparity among the Hispanic population in 1996 compared to the Whites, and that is now the knowledge.  I’m going to do this in reverse, even though the slides says “No awareness.”  But you can see the knowledge now is comparable to that of the non-Hispanic White, which I think shows we have--in Florida, there has been a lot of efforts focused on getting the folic acid message out to the Hispanic population.  And some of this is due in part from data from our birth defects registry, where we show that Hispanic women, particularly those of Mexican origin, had a much higher rate of neural tube defect-affected pregnancies than other Hispanic women.  So I think this is positive.  Unfortunately, the same for non-Hispanic Blacks.  Even though the knowledge is improving, we’ve still got a gap there.

Once again, looking at improvements, changes in knowledge, you can see that once again, awareness has increased, and even among the Medicaid population versus non-Medicaid, because once again, I think this is showing a good effort by our health departments in getting the message out to these women.  I think it also shows that there’s a lot of information coming to them.  Another component of this questionnaire is “Have you heard about folic acid from any of the following sources,” and there’s a pick list.  The next slide breaks this down by non-Hispanic White, non-Hispanic Black, and Hispanic.  Now, it looks like that there’s a variety of responses that you can pick, so these are not going to sum to 100 percent.  But if you look across this, what I find is striking is the radio/TV component in the Hispanic population, 62 percent saying they heard about folic acid from that media.  I don’t know how much of that is due in part to some of the efforts that have gone on in the Miami area, and this may have actually been before that process started.  But there has been quite a bit done trying to focus on getting the message out.  Also, pretty much across the board, 71 percent from physicians, 65 percent from physicians.  Magazines seem to be much higher for non-Hispanic Whites as a source of knowledge.  So this gives you kind of a good breakdown about where women are hearing about it, and particularly by their racial and ethnic group. 

One of the other questions on the survey is “In the month before you got pregnant with your new baby, how many times a week did you take a multivitamin?”  And as you can see, as I was looking at this, I think this may show some differences between women who are planning their pregnancy versus women who are not planning their pregnancy, particularly if you look under the younger age groups, the 20 to 24 year olds.  About between 75 and 80 percent did not take a multivitamin, whereas as you got into the older age groups, and particularly the 35-plus age groups, you see that they are taking them before they’re pregnant.  This shows that there’s still a lot of work to be done, particularly with the younger women.  The conclusions:  women of childbearing age who are least likely to take a multivitamin containing folic acid are those under the age of 20, those with a lower level of education, lower incomes, Hispanic women, and women on Medicaid.  And I think these are pretty consistent with other studies that have been done.  Another thing, too, particularly with Hispanic women I know, they do not view pregnancy as a condition needing to go to a physician.  They see it’s just part of a natural occurrence in their life.  So they’re not as--maybe as tuned in as going to see a physician and seeking prenatal care or well-woman care and knowing that they do need to take folic acid. 

Meeting the needs of women and children of childbearing age, I think doctors making patients more aware of folic acid; I think this is very important.  And some of the things that I have done, we have found that physicians are aware of the recommendations, but they don’t typically communicate it to their patients.  So we’re still working on that.  There’s a lot of things that physicians do during a visit, to--they have to tell their patients, and folic acid is one of those things that may not always make it into the conversation.  But there are a lot of other ways that at the health care provider’s office that this information can be communicated to these women, more media attention about benefits of folic acid, also raising awareness about using certain medications that might reduce the effects of folic acid, and encouraging women to take multivitamins.  And Miss Marshall can be reached at helen_marshall@doh.state.fl.us and the PRAMS data for Florida is available on the DOH website.  So thank you.