Introduction
Neural tube defects (NTDs) are among the most common and serious birth defects of the brain and spinal cord that occur when the neural tube fails to close completely within 28 days of conception, resulting in stillbirths, child deaths or lifelong disability(Reference Butterworth and Bendich1–Reference Greene and Copp4). The global prevalence of NTD is 0·3 to 1·99 per 1000 births. However, the prevalence of NTD varies from region to region, ranging from 9 cases per 10 000 births in Europe to 21·9 cases in the Eastern Mediterranean region(Reference Ibrahim, Ahlia and Tsang Becky5). In Ethiopia, NTDs are a serious, preventable public health issue, and the burden of NTDs in the eastern part of Ethiopia was 105·7 per 10·000 which is the second highest rate in the country and the proportion of NTDs increased linearly year to year(Reference Berhane and Belachew6), as women lack knowledge about preconception of folic acid. The countries such as United States, Canada, Costa Rica, South Africa, and Chile have effectively implemented food fortification with folic acid to reduce the risk of NTDs. This resulted in a significant reduction in NTDs, as low as 5 to 6 per 10 000 pregnancies(Reference Crider, Bailey and Berry7,Reference Rahman, Hamdani and Awan8) . Alternative of fortification of cereal with folic acid, preconception of folic acid supplement (FAS) can reduce the risk of NTDs by 50–70 %(Reference Reynolds9–Reference Berry, Li and Erickson11). In Ethiopia, folate deficiency in reproductive-aged women is widespread, prevalent and a public health problem(12,Reference Haidar, Melaku and Pobocik13) and the highest prevalence of folate deficiency was found in Harari (81 %), Tigray region (54 %), Dire Dawa (53 %) and the entire country are 46 %(Reference Haidar, Melaku and Pobocik13). This prevalence supports that there is a high prevalence of NTDs and others related to adverse pregnancy and birth outcomes. Educational interventions implemented in parts of China and the United States showed significant improvements on knowledge of folate(Reference Lin, Yang and Li14,Reference Flores, Isenburg and Hillard15) . However, such interventions have not been implemented throughout worldwide. In many developing countries including Ethiopia the level of knowledge on folic acid, and NTDs, is low(Reference Samar, Arif and Samar16). A study found in Ethiopia reported that more than 90 % of mothers, including mothers of newborns affected by NTDs, had no knowledge of folic acid use. In addition to this, 100 % of the mothers surveyed were unaware of the association between NTD and folic acid(Reference Welderufael, Berihu and Berhe17).
As Ethiopia makes progress towards achieving the Sustainable Development Goals (SDGs), the government is implementing various strategies to reduce maternal and neonatal mortality and morbidity. The prevalence of NTDs is a high and low level of knowledge of preconception of folic acid, it is crucial to assess the current level of knowledge and identify related factors affecting preconception of folic acid among women reproductive age (WRA). Therefore, the aim of the present study was to add and provide insight to better understand the level of knowledge about FAS as well as to evaluate factors associated with the likelihood of FAS among WRA in eastern Ethiopia with a high prevalence of NTDs. The present study could help to improve certain strategies aimed at increasing knowledge of FAS to reduce NTDs and provides the whole picture of the situation in the study area. The present study is also helpful for policymakers for interventional work using the existing healthcare system and approach to the community on preconception care to improve maternal and infant health in the country.
Methods and materials
Study design and population
This was a community-based cross-sectional study conducted in Dire Dawa city administration, the eastern part of Ethiopia. Randomly selected reproductive age group women (15–49 years) who lived in Dire Dawa city administration for 6 months and above and gives consent to participate were eligible for enrolment into the study in the study. However, women who are non-Ethiopian, who are mentally/physically challenged to provide consent were excluded from the study. This study was conducted according to the guidelines laid down in the Declaration of Helsinki(18).
Sample size determination
The required sample size was determined using a single population proportion formula and calculated by Open Epi Info version 3.5.3 statistical software package with the following assumptions: The prevalence of women's awareness of folic acid supplementation from the previous study, 15·9 and 20 %(Reference Goshu, Liyeh and Ayele19,Reference Kassa and Yohannes20) , respectively, a significant level at 95 % confidence interval (CI) and 4 % marginal errors with an additional 5 % added to account for non-response and the final sample size becomes 441.
Sampling procedure
Then, the calculated sample size was assigned for each randomly selected kebele based on proportional allocation. To reach the study unit, a systematic random sampling method was used in all randomly selected kebeles. When there was no eligible participant in the selected house, the nearby house was asked. In the case of more than one eligible woman encountered in the selected household, a lottery method was used to determine which woman would be interviewed. After taking informed consent, the participants were interviewed.
Data collection tools
An interviewer-administered semi-structured questionnaire was used to collect the necessary data. The questionnaire included socio-demographic characteristics (age, marital status, educational status, occupation, husband's educational status, reproductive and maternal health-related history). An English version of the questionnaire was developed and translated into the local language, then translated back to English to evaluate the consistency of the thought of the questions.
To maintain the quality of the research, the questionnaire was adapted from different literature pretested with a convenient sample of the study population (n 41), and some questions were modified based on the feedback from the pilot testing. Data collectors, and supervisors, were trained for 3 d. The data collection procedure was overseen by the supervisor and the principal investigator. The data collection team holds daily meetings and provides daily feedback.
The knowledge level of the study participants was determined using a dichotomous scale. Participants were asked a list of nine knowledge questions. One point is scored if a participant answers one or more of the correct answers to some of the questions with more than one correct answer. Then, for those who answered, a correct answer was marked as ‘yes’ and for those who answered, an incorrect answer was marked as ‘no’. Knowledge was then measured by calculating the mean of the nine items and whether participants scored ≥4 on the correct questions, which were categorised as good knowledge, and whether participants scored ≤3 on the correct questions, which were categorised as poor knowledge(Reference Goshu, Liyeh and Ayele19,Reference Kassa and Yohannes20) .
Statistical analysis
Categorical variables are presented as frequency and percentage and continuous variables are expressed as mean ± standard deviation (sd). χ 2 test was used for significant difference between knowledge of participants and other predictors. Generilized linear models with multiple logistic regressions were conducted to see the effect of predictors on knowledge of participants. The Akaike Information Criterion (AIC) was used for model selection, and the smallest AIC value represented a better fitting model. Important assumptions were checked using the standard procedures. The goodness of fit of the final model was examined by the Hosmer–Lemeshow test (P > 0·05). Multicollinearity was assessed using standard error (se) and the accepted maximum value was 2. Outcomes presented as odds ratios (ORs) with 95 % CIs. A two-sided P-value of <0·05 was considered statistically significant. SPSS version 25 statistical software was used for analysis.
Results
A total of 441 women were participated in the study. The mean age of women was 30·7 years old with standard deviation (30·7 ± 5·9 years). A total 56·5 % (n 249) of participants were housewives. Approximately, 23·8 % of the sample had completed at least secondary education (Table 1).
Socio-demographic characteristics of study population (n 441)
Of all studied women, only 35·1 % (n 155) had a good knowledge and majority (>50 %) still had a poor knowledge on preconception of folic acid supplement. The majority 53·6 % (n 236) of participants heard about the preconception of FAS, of these, the majority of 47 % (n 111) commonly cited healthcare providers were the source of information. Only, fewer women 8·4 % (n 37) understood that it was required for preventing birth defects; 3·8 % of the subjects were aware that the right time of initiation of FAS is 3 months before pregnancy. These findings are summarised in Table 2.
Frequency distribution of participants according to knowledge of folic acid (FA) and neural tube defects (NTDs) (n 441)
FAS, Folic acid supplement.
Few of 8·2 % (n 36) and majority 83 % (n 366) of participants were pregnant and had <5 gravidity, respectively. Majority 390 (88·4 %) of the participants were followed antenatal care (ANC) services. History of NTDs was presented for 1·7 % of the participant's women. The result portrays that 10·1 %, and 20·8 % of women had history of preterm, and spontaneous abortion, respectively (Table 3).
Reproductive and maternal health-related history of participants (n 441)
ANC, antenatal care; IFAS, iron folic acid; NTDs, neural tube defects.
There was a statistically significant difference between educational status, occupational status and monthly average income of the study participants with awareness of preconception of folic acid for the prevention of NTDs (P < 0·001; P < 0·001; P < 0·001, respectively). In addition, there was a statistically significant difference between having history of NTDs and spontaneous abortion with taking of FAS (P = 0·04; P = 0·032, respectively) (Table 4).
Relation between socio-demographic characteristics and knowledge about folic acid (n 441)
* Pearson correlation significant at P < 0·05.
Factors association of knowledge with preconception of folic acid
On multivariable logistic regression analysis, independent determinants of knowledge were: women who were attended secondary education (OR 2·7; 95 % CI 1·1, 6·0, P = 0·017), governmental employee (OR 3·5; 95 % CI 2·3, 17·8, P < 0·001), current pregnancy status (OR 3·0; 95 % CI 2·1, 4·2, P = 0·043), history of visit ANC during pregnancy (OR 2·9; 95 % CI 1·07, 7·8, P = 0·03) and history of taking FAS (OR 4·5; 95 % CI 2·9, 7·1, P < 0·001) (Table 5).
Multivariate analysis of study participants (n 441)
AOR, adjusted odds ratio; ANC, antenatal care; CI, confidence interval; FAS, folic acid supplement.
Maximum standard error = 1·569, Hosmer–Lemeshow test P = 0·829, Max standard error = 0·89.
* Significant at P-value < 0·05.
Discussion
Ethiopia is one of the developing countries where the incidence of NTDs is highly prevalent(Reference Berhane and Belachew6) and where one-third of women were affected by folate deficiency(Reference Haidar, Melaku and Pobocik13). It is important and crucial that WRA is having a knowledge of taking folic acid before pregnancy and during postpartum period for at least 4 weeks which helps protect against the occurrence of NTDs and other congenital abnormalities. This understanding is also important while planning folic acid intervention programmes and essential for understanding the effect of folic acid intervention on NTD.
Knowledge of preconception of folic acid in the present study was (35·15 %) and comparatively much lower than those of many studies conducted in developed countries like Canada (81 %)(21), the Netherlands (57·3 %)(Reference Temel, Erdem and Voorham22,Reference Bitzer, von Stenglin and Bannemerschult23) , Taipei (90 %)(Reference Jou, Hsu and Liu24) and Western Australia (89 %)(Reference Oddy, Miller and Payne25). It is important to note, however, that these countries have targeted women of childbearing age through national health awareness programmes that have been implemented since the mid-1990s. In other countries with minimal or no national awareness campaigns conducted thus far, like Ethiopia is lower than developed countries.
Although lower in this study than in developing countries like Egypt (71·6 %)(Reference Hassan, Youness and Zahran26), Saudi Arabia (88·4 %)(Reference Al-Akhfash, Abdulla and Osman27), Nigeria (64·6 %)(Reference Anzaku28), Qatar (53·7 %) and the United Arab Emirates (46·6 %). This difference may be due to the difference in study population where previous studies were conducted in pregnant women, while the present study was conducted in women childbearing age (15–49 years). Additionally, the lowest level of awareness in the present study may be due to low media coverage in Ethiopia. Furthermore, the fundamental facts for the poor knowledge of FAS among WRA could be a result of the absence of policy on preconception care service in the healthcare system and this care gives a large room for improvement in the preconception of folate knowledge. The other one might be the failures of healthcare providers to prescribe FAS at protective time.
However, the finding of the present study is much larger than the study conducted in Adet town of Amhara region (15·9 %)(Reference Goshu, Liyeh and Ayele19) in Manna District, Oromia region, Southwest Ethiopia (6·7 %)(Reference Teshome, Kebede and Girma29) in Tanzania (6·9 %)(Reference Mwandelile, Mpembeni and Abade30) and in Pakistan (6·7 %)(Reference Rehan, Mahmood and Mazhar31). This difference might be due to the fact that women's knowledge with regard to preconception of folic acid supplementation is the study time difference and geographical area between our study and previous studies.
Our finding reveals that in which women's education was a strong predictor of knowledge of preconception of FAS. This association lends support to the findings of previous studies among Ethiopian women(Reference Goshu, Liyeh and Ayele19), and Norwegian and Italian women(Reference De Santis, Quattrocchi and Mappa32,Reference Nilsen, Vollset and Gjessing33) and in different studies around the world(Reference Alsammani, Kunna and Adam34–Reference Hisam, Rahman and Mashhadi38). The possible association can be explained by the fact that when people are educated they are exposed to various sources of information and can easily understand the information. This finding gives highlights the contribution of women's education to access simple information about their health issues including prevention approaches of NTDs through preconception of folic acid supplementation and/or fortified foods or, at the very least, better diet and lifestyles. Given the association between women's education and having a knowledge on preventatives, this strategy may work if delivered in the appropriate way for different parts of society to enhance risk reduction and ensure all WRA received some level of protection.
In addition, our study found that women who had an occupation were more likely to have a good awareness of preconception of FAS compared to women who are housewives. The finding of the study agrees with a study conducted in Korean women of childbearing age(Reference Kim, Yon and Kim39) and in Saudi Arabia(Reference Kim, Kim and Hwang40). This might be due to exposure to different people and the environment might give a chance to know about the benefits of FAS.
Our study revealed that there is associated with currently pregnant and had a history of ANC attendance. The findings of the study are in line with a study conducted in Korea(Reference Kim, Kim and Hwang40), in Sudan(Reference Alsammani, Kunna and Adam34), in Ethiopia, Hawassa(Reference Kassa and Yohannes20) and in Manna District, Oromia region, Southwest Ethiopia(Reference Teshome, Kebede and Girma29). The similarity might be due to the fact that contact with healthcare providers and attending to ANC increases the exposure to health-related information including awareness of folic acid. As the number of contacts with healthcare providers increases, so does access to information, which in turn increases health-seeking behaviour and service utilisation.
Our findings give insight that the need of educational interventions to increase the knowledge of preconception of FAS and NTDs as well uptake among WRA in the country. Different previous studies have shown that educational interventions are an effective approach to increase not only in knowledge and awareness of the use of folic acid, but also on uptake. The United States based studies have shown that educational interventions play a great role to increase folic acid awareness from 78 to 98 % and knowledge of the role of folic acid in the prevention of birth defects from 82 to 92 %(Reference deRosset, Mullenix and Flores41). Additionally, awareness campaigns have been shown to increase usage from 6 to 41 % in the UK(Reference Rofail, Colligs and Abetz42) and from 8 to 35 % in the US (1992–2007) which suggests that educational interventions may be well received.
However, women with unplanned pregnancies may not benefit from this approach. Therefore, the government must use folic acid-fortified foods in addition to educational programmes. This approach itself presents an important opportunity to reduce the risk of NTD in high-risk populations including in eastern Ethiopia(Reference Berhane and Belachew6). Therefore, combining both approaches will help reduce risk and ensure that all pregnancies are protected to some level of protection.
The current study has some strengths: it was conducted in a community-based study, so the findings represent and reflect the general population or the true population. On the other hand, the present study used the maximum sample size considered. But it has not been ended without limitation; our study is purely quantitative and incapable of investigating the myriad contextual and social factors that may limit women's knowledge of folic acid supplement prejudices. Therefore, it is very worthwhile to suggest the future qualitative research to follow up on these findings. Also, the present study was that it is conducted in one region, relatively a big city. So the finding of the present study may not be generalised to other regions of the country, especially rural areas and small towns. Recall bias can occur in response to some questions, such as those related to obstetrical and gynaecological factors, that are asked for history taking prior to conception. Despite those limitations, the present study provides some insight into the knowledge of women for usage of folic acid for prevention of NTDs.
Conclusion
The findings of this study concluded that women's knowledge on preconception of folic acid supplementation was very low and only one-third of women had good knowledge. Educational, occupational status, current pregnancy status, visit ANC during pregnancy and history of taking FAS were the identified predictive factors. The poor level of knowledge evident in our study, demands that the medical community should broadcast the benefit of folic acid supplementation for prevention of NTDs. The study revealed that there is a real unmet need to provide women of childbearing age with appropriate counselling and education regarding the benefits and timely use of folic acid supplementation. So, the government and stakeholders should advocate the benefit of preconception of folic acid through different media including health extension workers and the existing health care system in order to prevent the incidence of NTDs. Furthermore, we recommended other studies in the study area and look forward to staple food fortification.
Acknowledgements
The authors would like to thank all of the study participants, data collectors and supervisors who participated in the study.
B. B. and A. B. wrote the manuscript; Z. T. prepared the figures. All authors reviewed the manuscript.
There is no fund granted for this work.
The authors declare no conflicts of interest in this work.
All necessary data for this work are available within the manuscript. Additional data can be obtained from the corresponding author on a reasonable request.
All methods of this study were carried out in accordance with the Declaration of Helsinki-Ethical principle for medical research involving human subjects. Before beginning data collection, the ethics review committee of the Department of Public Health, Dire Dawa University granted ethical clearance with the reference number IRB/PGY/738/21. Written informed consent to participate was obtained from participants and legally authorised representatives ‘of minors below 16 years of age and illiterates’ after the purpose of the study was explained and their privacy and confidentiality were maintained. All personal identifiers were excluded, and data were kept confidential and used for the proposed study only.
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