Percentage of Canadian women unaware of the importance of folic acid for pregnancy remains unchanged

Approximately one in four women in Canada are unaware of the benefits of taking folic acid before and during pregnancy — a percentage that has not improved in over a decade, say researchers at the University of Toronto and Sinai Health.

In a paper published in the Journal of Obstetrics and Gynaecology Canada, the researchers analyze data from the Canadian Community Health Survey, conducted by Statistics Canada in 2017–18.

“We compare this data to the last national study on prevalence of folic acid supplementation awareness in 2006–2007, which utilized data from the Canadian Maternity Experiences Survey,” says Vrati Mehra, a fourth-year medical student at U of T’s Temerty Faculty of Medicine. “We see almost no change in awareness levels from then till now. The numbers have essentially remained the same.”

Mehra is lead author of the paper along with Professors Ellen Greenblatt, John Snelgrove and Claire Jones, all from the department of obstetrics and gynaecology at Temerty Medicine, and Professor Hala Tamim from York University. Greenblatt, Snelgrove and Jones are also clinicians in the department of obstetrics and gynaecology at Mount Sinai Hospital.

“Vrati had worked on a previous project of ours, a prenatal program design that involved interviewing pregnant participants,” says Jones, who is also the program director for Gynaecologic Reproductive Endocrinology & Infertility residency at U of T. “Hearing many admit they did not know about supplementing with folic acid inspired her to look further into it — a good example of how anecdotal evidence can suggest fruitful research paths.”

In the early 1990s, researchers showed that folic acid could prevent open neural tube defects. The neural tube is formed in the third and fourth weeks of pregnancy and develops into the nervous system: the spinal cord and brain. Defects lead to higher incidence of miscarriages, or debilitating conditions such as spina bifida or anencephaly at birth.

“Although we typically get enough folic acid for daily functioning, the requirement increases significantly during pregnancy to support the development of a growing baby,” says Mehra. “So, in the early 2000s, the government mandated that companies fortify pasta, breads, cereal and other grain foods with folic acid.”

The folic acid fortification came with targeted public ad campaigns, which raised awareness levels among Canadian females from 25–50 per cent in the early 2000s to between 70–75 per cent in 2007.

“However, since then, the public campaigns have become more passive,” says Mehra. “Posters by the Public Health Agency of Canada are available online for those seeking information about folic acid. However, to my knowledge, there are no active campaigns targeting people who might be completely unaware of its importance.”

The study also found that certain socioeconomic patterns had persisted over the decade. People who were younger were more likely to be unaware of folic acid, as were people with lower income or less education. Landed immigrants were three times more likely to be unaware, on average. 

Some of these disparities could be the result of how health information circulates, says Mehra, where access to a regular health-care provider is key. 

“People get info from their family doctors, or from a public campaign poster in a health-care provider’s office. Those who only see a doctor after finding out that they are pregnant, or don’t have regular follow-up, have fewer chances to learn about folic acid.”

She adds, “We are currently experiencing a crisis of family doctors in the country. The shortage makes me worry about what may happen to awareness levels in the coming years.”

Possible solutions include introducing folic acid benefits for pregnancy in the high school sexual health curriculum — which already includes content on contraception and pregnancy — stressing that pregnant people need folic acid, and those planning to become pregnant should take supplements three months in advance and during their pregnancy.

Given the large number of immigrants who come to Canada, another possibility would be to introduce the information during the immigration process.  

“I was once an immigrant,” says Mehra. “I remember accompanying my parents to the Service Ontario Centre to get our health cards. Including a simple line in multiple languages about folic acid, either in the paperwork or displayed on posters, could help. We also visited other public spaces like libraries and community centres, which are ideal for informative posters.

“A collective effort from the government, health-care providers, the education system and the immigration system would make a big difference.”