Knowledge of periconceptional folic acid use among pregnant women at Ain Shams University Hospital, Cairo, Egypt

طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 561 Knowledge of periconceptional folic acid use among pregnant women at Ain Shams University Hospital, Cairo, Egypt W. Al-Darzi,1 F. Al-Mudares,1 A. Farah,1 A. Ali 1 and D. Marzouk 2 1Faculty of Medicine; 2Department of Public Health, Ain Shams University, Cairo, Egypt (Correspondence to W. Al-Darzi: waleed.aldarzi@gmail.com). Received: 03/01/13; accepted: 23/06/13 ABSTRACT Egypt has a high incidence of neural tube defects. Folic acid supplementation in the periconceptional period is known to lower the risk of such defects. This cross-sectional study aimed to measure the level of knowledge about periconceptional folic acid use among pregnant women attending for antenatal care at Ain Shams University Hospital, Cairo, Egypt in 2012. Questionnaires were filled through personal interviews with 660 pregnant women. Of the respondents, 62.4% had heard of folic acid and 39.2% knew about the role of folic acid supplementation in prevention of congenital anomalies. Knowledge about using folic acid before and in the first trimester of pregnancy was highest among university-educated women and those working in professional occupations. Only 18.8% of women reported taking folic acid, and 8.8% had used it before conception. Awareness campaigns are suggested to improve knowledge about folic acid among women in the childbearing period in Egypt. صرم ،ةرهاقلا ،سمش ينع ةعماج ىفشتسم في لماولحا ءاسنلا ىدل لملحاب ةطيحلما ةترفلا في كيلوفلا ضحم مادختساب ةفرعلما قوزرم ءايض ،ليع نحمرلا دبع ،حرف ورمع ،سردلما قئاف ،يزردلا ديلو ةـطيحلما ةرـفلا في كـيلوفلا ضـمحب ةـيليمكتلا ةـلجاعلما نأ فورـعلما نـمو .يـبصعلا بوـبنلأا بوـيعل عـفترم عوـقو رـم في ظـحول :ةـصلالخا ضـ حم مادختـ سا لوـ ح ةـ فرعلما ىوتـ سم ساـ يق لىإ ةضرعتـ سلما ةـ ساردلا هذـ ه تـ فده دـ قو .بوـ يعلا هذـ ه لـ ثم رـ طامخ نـ م لـ لقت لـ ملحاب سمـش نـع ةـعماج ىفـشتسم في ةدلاوـلل ةقباـسلا ةـياعرلا ىـع نددرـي يـئلالا لـماولحا ءاـسنلا ىدـل لـملحاب ةـطيحلما ةرـفلا في كـيلوفلا تاعَلطتـسلما نـم % 62.4 نأ َّنـبتف .لـماح ةأرـما 660 عـم ةيصخـش تلاـباقم للاـخ نـم تانايبتـسا ءلـم مـتف .2012 ماـع في رـم في ةرـهاقلاب .ةـ يقللخا تاذوذـ شلا نـ م ةـ ياقولا في كـ يلوفلا ضـ محب ةـ يليمكتلا ةـ لجاعلما رودـ ب مـ لع ىـ ع نـ هنم % 39.2و ،كـ يلوفلا ضـ محب َنعمـ س دـ ق ًاـيعماج ًاـيلعت نـقلت تياوـللا ءاـسنلا نـب ىـعأ هـنم لىولأا ةـثلاثلا رهـشلأا فيو لـملحا لـبق كـيلوفلا ضـحم مادختـسا نـع ةـفرعلما تـناكو هنمدختـسا دـق َّنـك نـهنم % 8.8و ،كـيلوفلا ضـحم لواـنتب ءاـسنلا نـم طـقف % 18.8 تداـفأ دـقو .ةـ ّيفَرِح نـهم في نـلمعي تياوـللا ءاـسنلاو .رـم في باـجنلإا ةرـف في ّنـه تياوـللا ءاـسنلا ىدـل كـيلوفلا ضـحم نـع ةـفرعلما نـسحتل ةـيعوت تلاـمحب ماـيقلا حارـقا مـتو .لـملحا لـبق Connaissances sur l'utilisation périconceptionnelle de l'acide folique chez des femmes enceintes à l'hôpital universitaire Ain Shams, au Caire (Égypte) RÉSUMÉ En Égypte, l'incidence des malformations du tube neural est élevée. La supplémentation en acide folique durant la période périconceptionnelle est connue pour réduire le risque de telles malformations. La présente étude transversale visait à mesurer le niveau de connaissances sur l'utilisation périconceptionnelle de l'acide folique chez des femmes enceintes consultant à l'hôpital universitaire Ain Shams au Caire (Égypte) pour des soins prénatals en 2012. Des questionnaires ont été remplis pendant des entretiens individuels avec 660 femmes enceintes. Parmi les répondantes, 62,4 % avaient entendu parler de l'acide folique et 39,2 % connaissaient le rôle de la supplémentation en acide folique dans la prévention des anomalies congénitales. Les femmes ayant fait des études universitaires et celles exerçant une activité professionnelle possédaient les connaissances les plus élevées sur l'utilisation de l'acide folique avant et pendant le premier trimestre de grossesse. Seules 18,8 % des femmes ont déclaré prendre de l'acide folique, et 8,8 % y avaient eu recours avant la conception. Des campagnes de sensibilisation sont suggérées pour améliorer les connaissances sur l'acide folique chez les femmes en âge de procréer en Égypte. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 562 Introduction Neural tube defects (NTDs) are birth defects of the brain and spinal cord that can cause death, or permanent damage to the nervous system (1). The most frequent forms of NTDs are spina bifida and anencephaly (2). Such defects are among the most common birth defects worldwide (3), occurring in an estimat- ed 300 000 newborns each year (2,4). Evidence of the relationship between insufficient intake of maternal folic acid and the risk of NTDs led to the United States Public Health Service recom- mendation in 1992 that women with the capacity to become pregnant need to consume 400 µg folic acid on a daily basis (5). The incidence of NTDs falls by 50%–80% when women consume folic acid supplements daily, and there is now a consensus that supplementation should begin not only during the first trimester but also earlier, before concep- tion (6–8); this was supported by a cohort study in 1999 by Berry et al. (9). In view of the benefits of consuming folic acid for women in the childbearing years, several studies have been con- ducted in different parts of the world to assess women’s awareness of the role of folic acid in fetal development. In the United States of America (USA), there has been an increasing trend in the percentage of women who are aware of the benefits of folic acid, up to 85% (10), whereas in Qatar 53.7% of women had heard about folic acid and only 15% of them knew its role in preventing birth defects (11). With regard to preconcep- tional use of folic acid, a study conduct- ed in Taipei among pregnant women showed that only 15.6% of them had taken folic acid before conception (12). In Egypt, neurological disorders are the most common birth defects, with NTDs forming 10.2% of neurological disorders (13). One study found the incidence of NTDs in Egypt to be 1.38% (14), which is high compared with other parts of the world, where the reported incidence ranges from 0.05% to 0.36% (2,15). To date, there had been very little evidence in the literature about knowledge and prac- tice of folic acid use among pregnant women in Egypt. The aim of this study was to measure the level of knowledge about periconceptional use of folic acid among pregnant women at Ain Shams University hospital, Cairo, Egypt. The current study will provide a baseline description about folic acid knowledge which can be used to assess the need for awareness campaigns. Methods Study design and sample This cross-sectional, observational study was conducted in the antenatal care (ANC) clinic at Ain Shams Uni- versity Hospital, Cairo, Egypt. This is considered one of the main hospitals in north-east Cairo, receiving a variety of patients from different regions of Cairo and even from other governorates. Any pregnant women aged 18–45 years who sought medical consultation at the ANC clinic were included. The diagnosis of pregnancy was confirmed by viewing patients’ files, previous his- tory, examination and investigations [previous urine beta-human chorionic gonadotropin (βHCG), blood βHCG or ultrasound]. Pregnant woman who were younger than 18 or older than 45 years were excluded. Data were collect- ed by questionnaires from 670 pregnant women during the period from June to August 2012; 10 pregnant women did not give consent for participation in the study, giving a response rate of 98.2%. Data collection An anonymous, standardized question- naire was filled through an interpersonal interview. This included 15 questions about the following: sociodemographic data (age, residency, occupation, educa- tional level); obstetric history (gravid- ity, previous ANC; number of ANC visits; gestational age); and folic acid knowledge and use (ever heard about folic acid before, from where she heard about it, recommended period of intake according to her knowledge, whether she took folic acid in the current preg- nancy and if so when, benefits of folic acid intake, and different food sources of folic acid). The number of ANC visits in the current pregnancy was classified as sufficient or insufficient, according the recommendations of the Royal Col- lege of Obstetricians and Gynaecolo- gists (16). The validity of the questionnaire was tested by translating a pre-existing questionnaire (17) to Arabic language and comparing the findings of both questionnaires. The reliability of the questionnaire was evaluated by inter- viewing 20 patients from the inpatient clinic twice with different interviewers and separated by 5 days. The findings of both interviews were compared. Af- ter the pilot study, the questions were rearranged, modified by adding more choices or substituting open questions. The questionnaire was written in the common Egyptian Arabic dialect and each interviewer followed the ques- tion structure strictly with agreed-upon alternative explanations. Each interview was conducted by one of the trained authors. The pregnant women were interviewed while they were waiting for their ANC visit, in a separate area from the other participants to ensure privacy and confidentiality. Participants who agreed to participate were interviewed regardless of whether if was their first or follow-up visit. The interviewers visited the ANC clinic 4 times per week for a 9-week period. Verbal consent was taken from each participant (n = 660) before filling the questionnaire. The study protocol has been approved by the ethics committee of Ain Shams University. The question- naire was developed by the authors of this study in consultation with the com- munity department at Ain Shams Uni- versity. Then it received ethical approval from 2 different faculty staff members. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 563 Data analysis The collected data were revised, coded and tabulated using SPSS, version 15.0.1 for Windows. Quantitative continuous variables are expressed as mean and standard deviation (SD). Qualitative variables are expressed as frequencies and percentages. Student t-test was used to compare continuous vari- ables between the 2 study groups. Chi- squared and Fisher exact tests were used to examine the relationship between categorical variables. Both univariate and multivariate logistic regression analyses were done to examine the as- sociation of awareness and intake of folic acid supplements with selected sociodemographic and obstetric char- acteristics of the studied women. P < 0.05 was considered as the cut-off value for significance. Results Sociodemographic characteristics and folic acid knowledge Table 1 shows the sociodemographic characteristics of all the pregnant women in the study and of the women who had heard about folic acid before. From the total sample of 660 women, 412 (62.4%) had heard about folic acid. Only 79 (12.0%) women knew it was important to take folic acid before pregnancy and 53 (8.2%) knew about taking it in both the preconception and 1st trimester periods. Out of the whole sample of women, 259 (39.2%) mentioned its role in prevention of birth defects. Out of the total sample of respond- ents, 124 (18.8%) reported taking folic acid in the current pregnancy; 58 (8.8%) had taken it before pregnancy and 80 (12.1%) took it in the 1st trimester. For the women who had heard about folic acid their main source of knowledge was the physician, reported by 92.0%; other sources of knowledge were the family, nurses, pharmacists, media, books and the Internet (8.0%). The highest knowledge rates about folic acid were found among women working in professional jobs (90.9%). Women with university education (88.3%) and of women with history of ≥ 6 pregnancies (84.4%) were the most aware about folic acid. The lowest knowledge rates were among illiterate women and those with only primary school educational (25.0% and 35.6% respectively). When the participants who reported knowing about folic acid were asked about sources of folic acid, 92.0% reported folic acid supplements, 2.9% fish, 1.1% liver and 4.0% green vegetables The relationship between the so- ciodemographic characteristics of the pregnant women and their knowledge about the use of folic acid was analysed for 3 groups: those who knew about preconceptional use of folic acid (n = 79), those who knew about 1st trimes- ter use of folic acid (n = 324) and those who knew the recommended period of intake of folic acid, i.e. knew about folic acid intake during both the preconcep- tional and 1st trimester periods (n = 54) (Table 2). Highly significant relation- ships between the educational level of pregnant women and their knowledge about folic acid intake were seen in all 3 groups (P < 0.01). Occupational status and number of previous pregnancies were significantly related to women’s awareness of folic acid utilization pre- conception (P = 0.011 and P = 0.0001 respectively) and in both recommend- ed intake periods (P = 0.004 and P = 0.046 respectively). Having a sufficient number of ANC visits for the current Table 1 Sociodemographic characteristics and obstetric history of the study women in relation to their general awareness of folic acid Variable All women Heard about folic acid No. % No. % Total 660 100.0 412 62.4 Age group (years) 18–24 209 31.7 111 53.1 25–29 359 54.4 238 66.3 30–34 74 11.2 51 68.9 35–45 18 2.7 12 66.7 Education Illiterate 116 17.6 29 25.0 Primary school 45 6.8 16 35.6 Preparatory school 106 16.1 56 52.8 Secondary school 299 45.3 228 76.3 University 94 14.2 83 88.3 Job Not working 600 90.9 360 60.0 Skilled work 27 4.1 22 81.5 Professional 33 5.0 30 90.9 Gravidity (no.) ≤ 2 432 65.5 266 61.6 3–5 196 29.7 119 60.7 ≥ 6 32 4.8 27 84.4 ANC visits in current pregnancy Insufficient 99 15.0 43 43.4 Sufficient 561 85.0 369 65.8 n/a = not applicable; ANC = antenatal care. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 564 pregnancy was significantly related to knowledge of folic acid intake during the 1st trimester (P = 0.029). Univariate analysis Table 3 shows the univariate analysis of sociodemographic characteristics of the study women and their knowl- edge about folic acid intake. Knowl- edge about folic acid intake during the preconceptional period showed significant relationships with age group (25–29 years), university education level, professional occupation and his- tory of ≥ 2 pregnancies. Women with university education level were about 13-fold more aware about folic acid than illiterate women (OR = 12.8, 95% CI: 1.65–99.0), while specialist working women were 3-fold more aware about folic acid than non-working women (OR = 3.14, 95% CI: 1.44–6.85). Women who had a pregnancy history of ≥ 3 were 1.8–4.6 times more aware than women with history of ≤ 2 pregnancies. Secondary school/diploma and university levels of education were high- ly significantly associated with knowl- edge about folic acid intake during the 1st trimester. Women with secondary school and university educational level were more than 4-fold (OR = 4.52, 95% CI: 2.02–10.1) and 6-fold (OR = 6.11, 95% CI: 2.33–16.1) more aware than illiterate women respectively. Suf- ficient ANC visits during the current pregnancy was significantly related to knowledge about folic acid, as women who had sufficient ANC visits during their current pregnancy were twice as aware about folic acid than those who had insufficient ANC visits (OR = 2.09, 95% CI: 1.07–4.10). The relationship of sociodemo- graphic characteristics of the women with their knowledge about the both periods of folic acid intake showed very similar results as for knowledge about folic acid during the preconceptional period. Multivariate analysis The multivariate analysis of sociode- mographic characteristics is shown in Table 4. The relationships between the women’s knowledge of folic acid and their sociodemographic characteristics Table 2 Relationship between women’s sociodemographic and obstetric characteristics and their knowledge about folic acid supplementation in different stages of pregnancy Variable Knew about folic acid supplementation during: Preconception (n = 79) 1st trimester (n = 324) Both periods (n = 54) No. %a P-value No. %a P-value No. %a P-value Age (years) 18–24 15 13.5 0.098 87 78.4 0.694 9 8.1 0.190 25–29 53 22.3 187 78.6 38 16.0 30–34 7 13.7 42 82.4 5 9.8 35–45 4 33.3 8 66.7 2 16.7 Education Illiterate 1 3.4 0.002 15 51.7 < 0.001 0 0.0 < 0.001 Primary school 1 6.3 12 75.0 1 6.3 Preparatory school 6 10.7 36 64.3 1 1.8 Secondary school 45 19.7 189 82.9 29 12.7 University 26 31.3 72 86.7 23 27.7 Occupation Not working 63 17.5 0.011 280 77.8 0.486 40 11.1 0.004 Skilled work 4 18.2 18 81.8 4 18.2 Professional 12 40.0 26 86.7 10 33.3 Gravidity (no.) ≤ 2 39 14.7 < 0.001 206 77.4 0.101 27 10.2 0.046 3–5 28 23.5 100 84.0 21 17.6 ≥ 6 12 44.4 18 66.7 6 22.2 ANC visits in current pregnancy Insufficient 5 11.4 0.164 29 65.9 0.029 3 6.8 0.191 Sufficient 74 20.1 295 80.2 51 13.9 aPercentage of women in each sociodemographic and obstetric category who had heard about folic acid. ANC = antenatal care. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 565 in the multivariate analysis were similar to those in the univariate analysis, ex- cept for occupational status which was not significant in multivariate analysis. Discussion The impact of NTDs is considered a global health-care issue affecting huge number of newborns each year (4). Fortunately, the risks of NTDs can be reduced by using folic acid before and during the 1st trimester of pregnancy (6,8,9). In Egypt, the high incidence of NTDs (14) points to a need for preven- tion by increasing women’s awareness of periconceptional use of folic acid. The present study at a tertiary care clinic in Cairo, Egypt showed that 62.4% of the pregnant women surveyed knew about folic acid in pregnancy. Looking at differ- ent studies conducted in the Middle East, the level of awareness ranged from 46.6% to 85% (11,18,19). In Taiwan the aware- ness rate among pregnant women was 89.1% (12). In a study in Kansas, USA, the level of general awareness about folic acid was 88% among women of child- bearing ages (20). A small percentage of women in the present study had some university education (14.2%) whereas in the Kansas study 65.6% of women had some college education or were college graduates (20), which might explain their higher general awareness level. The present study demonstrated that the proportion of all participants who knew about the benefits of folic acid in prevention of birth defects was 39.2%. This percentage is higher than in other nearby countries in the Middle East (8.7%–14%) (11,18,21), but lower than in Israel and Abu Dhabi, United Arab Emirates (UAE) (46.6%–77.7%) (19,22), which shows that there is room for improvement. When compared with Israel our women’s knowledge about taking folic acid both preconception and in the 1st trimester was considerably lower (Egypt: 8.2%, Israel: 77.7%) (19). Although in the present study the nature of the women’s occupation af- fected their knowledge about use of folic acid before conception, it was sig- nificant in univariate analysis but not in multivariate analysis, which suggests Table 3 Univariate analysis of association of women’s sociodemographic and obstetric characteristics with their knowledge about folic acid supplementation in different stages of pregnancy Variable Knew about folic acid supplementation during: Preconception 1st trimester Both periods Crude OR (95% CI) P-value Crude OR (95% CI) P-value Crude OR (95% CI) P-value Age (years) 18–24 (Ref.) 25–29 1.83 (0.98–3.42) 0.057 1.01 (0.59–1.75) 0.967 2.15 (1.00–4.63) 0.049 30–34 1.02 (0.39–2.67) 0.971 1.29 (0.55–3.01) 0.560 1.51 (0.51–4.50) 0.458 35–45 3.20 (0.86–12.0) 0.084 0.55 (0.15–1.99) 0.363 2.27 (0.43–12.0) 0.335 Education Illiterate (Ref.) Primary school 1.87 (0.11–32.0) 0.667 2.80 (0.73–10.8) 0.134 1.87 (0.11–32.0) 0.667 Preparatory school 3.36 (0.39–29.3) 0.273 1.68 (0.68–4.18) 0.264 0.51 (0.03–8.45) 0.638 Secondary school 6.89 (0.91–52.0) 0.061 4.52 (2.02–10.1) < 0.001 4.08 (0.54–31.1) 0.175 University 12.8 (1.65–99.0) 0.015 6.11 (2.33–16.1) < 0.001 10.7 (1.38–83.5) 0.023 Occupation Not working (Ref.) Skilled work 1.05 (0.34–3.20) 0.935 1.29 (0.42–3.91) 0.658 1.73 (0.56–5.36) 0.343 Professional 3.14 (1.44–6.85) 0.004 1.86 (0.63–5.48) 0.262 3.89 (1.70–8.88) < 0.001 Gravidity (no.) ≤ 2 (Ref.) 3–5 1.79 (1.04–3.08) 0.035 1.53 (0.87–2.71) 0.141 1.90 (1.02–3.52) 0.042 ≥ 6 4.66 (2.03–10.7) < 0.001 0.59 (0.25–1.37) 0.213 3.10 (1.20–8.00) 0.019 ANC visits in current pregnancy Insufficient (Ref.) Sufficient 1.96 (0.75–5.16) 0.171 2.09 (1.07–4.10) 0.032 2.25 (0.67–7.53) 0.189 OR = odds ratio; CI = confidence interval; ANC = antenatal care; (Ref.) = reference category. EMHJ  •  Vol. 20  No. 9  •  2014 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 566 that as a variable it has less influence than educational level or number of pregnancies. Knowledge about the use of folic acid during both the preconcep- tional and 1st trimester periods was very high among women with university education, and increased significantly with the number of pregnancies. In the present study 18.8% of the pregnant women reported consuming folic acid during the current pregnancy. In the UAE the percentage was much higher, at 68% (18,22), which may be due to the fact that the UAE govern- ment ANC facilities provided folic acid free of charge. Supplying folic acid supplements for all visitors to ANC clinics is likely to raise the percent- age of females using them and hence decrease the incidence of NTDs. This is an important consideration for policy-makers. Besides the emotional, psychological and physical effects of spina bifida, the total cost of lifetime management of the cases who survive is high and causes a huge burden on the community (23). Further studies should be done to study the cost–ben- efit of providing folic acid free of charge in Egypt. A study in Qatar demonstrated that the physician was the main source of women’s knowledge about folic acid (63.4%) (11), although in Taipei the percentage was 44.4% (12). Other sources of knowledge in those studies included newspapers, books, nurses, pharmacists and the family. Our study revealed that 92.0% of women knew about folic acid from the physician. This finding should be considered in folic acid promotion campaigns. Amtai et al. suggested that every family planning consultation and every child vaccina- tion should be used as an opportunity to promote folic acid use (19). This is also applicable in Egypt, especially during visits for obligatory childhood immuni- zations. Another method of spreading folic acid awareness is through aware- ness campaigns, which could include posters, announcements in the media and sessions for high-school or even university students. These campaigns should educate women about foods that are rich in folic acid, in addition to encouraging the consumption of the Table 4 Multivariate analysis of association of women’s sociodemographic and obstetric characteristics and their knowledge about folic acid supplementation in different stages of pregnancy Variable Knew about folic acid supplementation during: Preconception 1st trimester Both periods Adjusted OR (95% CI) P-value Adjusted OR (95% CI) P-value Adjusted OR (95% CI) P-value Age (years) 18–24 (Ref.) 25–29. 1.42 (0.72–2.81) 0.313 1.04 (0.57–1.88) 0.906 1.69 (0.73–3.87) 0.218 30–34 0.71 (0.24–2.11) 0.536 1.44 (0.55–3.77) 0.461 0.99 (0.28–3.45) 0.983 35–45 2.07 (0.46–9.38) 0.343 0.68 (0.17–2.77) 0.589 1.58 (0.25–9.96) 0.628 Education Illiterate (Ref.) Primary school 1.94 (0.11–35.0) 0.653 2.66 (0.66–10.8) 0.171 1.85 (0.10–33.4) 0.676 Preparatory school 3.00 (0.33–27.2) 0.329 2.11 (0.82–5.44) 0.124 0.47 (0.03–8.12) 0.605 Secondary school 7.65 (1.00–58.7) 0.050 5.67 (2.44–13.2) < 0.001 4.62 (0.60–35.8) 0.143 University 15.33 (1.88–124) 0.011 7.23 (2.52–20.7) < 0.001 13.1 (1.59–108) 0.017 Occupation Not working (Ref.) Skilled work 0.77 (0.23–2.54) 0.666 1.07 (0.33–3.48) 0.906 1.11 (0.33–3.75) 0.865 Professional 1.53 (0.61–3.84) 0.370 1.03 (0.31–3.47) 0.959 1.40 (0.53–3.74) 0.499 Gravidity (no.) ≤ 2 (Ref.) 3–5 2.17 (1.18–4.00) 0.013 1.73 (0.93–3.23) 0.083 2.30 (1.13–4.67) 0.021 ≥ 6 6.23 (2.37–16.4) < 0.001 0.61 (0.24–1.57) 0.307 4.83 (1.59–14.7) 0.006 ANC visits in current pregnancy Insufficient (Ref.) Sufficient 1.90 (0.68–5.29) 0.220 2.21 (1.08–4.52) 0.030 2.01 (0.57–7.10) 0.281 OR = odds ratio; CI = confidence interval; ANC = antenatal care; (Ref.) = reference category. طسوتلما قشرل ةيحصلا ةلجلمانوشرعلا دلجلما عساتلا ددعلا 567 recommended daily dose of folic acid supplements or as part of multivitamin tablets. Fortification of foods with folic acid is another strategy for decreasing NTDs. Data has revealed an association between folic acid fortification and a decrease in the risk of NTDs (24). It is noteworthy that the fortification of some foods, including enriching cereals and grains with folic acid, was mandated in the USA since 1998 (25). After folic acid fortification was implemented the reduction in the prevalence of NTDs in the country was 23% (26). There were some limitations that may have affected the study findings. First, the study may have been subjected to population bias, as the data were collected from only one health-care centre in Cairo, Egypt. Secondly, the study women were attending a tertiary health-care facility and they may not have had the same level of knowledge as women attending for ANC in pri- mary or secondary health-care facilities. Thirdly, women below age 18 years and older than 45 years were not included in our sample and therefore our results might not accurately reflect the level of knowledge about folic acid in all women of childbearing ages. Finally, women were included regardless their previous number of ANC visits. In conclusion, there is room for im- provement regarding the knowledge about folic acid among women in the childbearing years in Egypt. The present study revealed that a small propor- tion of women were aware about the importance of preconceptional folic acid, and even fewer had consumed fo- lic acid in the preconceptional period. Knowledge about folic acid intake was significantly higher among women with university education and high gravid- ity. 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