Maltese women shun vitamin that helps prevent birth defects

An extensive study has found that just one-quarter of Maltese women who delivered a baby as recently as 2015 had reported taking folic acids before pregnancy

Just one-quarter of Maltese women who delivered a baby as recently as 2015, had reported taking folic acids before pregnancy – a supplement which significantly reduces neurological diseases like Spina Bifida.

An extensive study of 4,385 women who delivered a baby in 2015 found that just 25% (1,125) reported taking their folic acid, a supplement strongly recommended by doctors and gynaecologists before and during pregnancy.

Moreover, only 7% of mothers aged under 25 reported taking folic acids, the study published in the Malta Medical Gazette found.

And in an indication of health inequalities, the least likely to have taken folic acids were people with lower educational levels and migrants from outside the European Union. Mothers are advised to take 400 micrograms of folic acid each day – from before they are pregnant until they are 12 weeks pregnant.

Folic acid is a man-made form of a B vitamin called folate, and plays an important role in the production of red blood cells to help a baby’s neural tube develop into her brain and spinal cord. Birth defects occur within the first 3-4 weeks of pregnancy, so having folate during those early stages when the baby’s brain and spinal cord are developing is important to prevent neural tube abnormalities that can lead to the occurrence of anencephaly and spina bifida. Folate is found naturally in dark green vegetables and citrus fruits but to be effective, folic acids have to be taken in the right dosage before conception.

The prevalence of neural tube defects in Malta is 10 for every 10,000 births. Yet according to the Malta Medical Gazette study this rate can be halved if more women take folic acids before conception.

To reduce the risk of these diseases a number of countries, including the USA and Canada, have introduced mandatory food fortification of flour with folic acid, to ensure that women are already taking the required amounts of folic acid before and during the early weeks of conception. These initiatives have translated into a significant decrease in neural tube defects in those countries.

Women in Malta are routinely asked during the first antenatal clinic visit at hospital whether they have been taking folic acid supplements and whether they started them before pregnancy.

However, the authors acknowledged that women generally present at the obstetricians’ clinics following conception, “at a time too late for prevention of potentially avoidable NTDs.”

Results showed that women having had a planned pregnancy were the most likely to take folic acid before becoming pregnant.

The study showed Gozitan women reported taking significantly less folic acid before pregnancy than women residing in other areas.

Young women were found to be the least likely to take folic acid supplementation before becoming pregnant, with only 7% of mothers in Malta aged less than 25 years taking preconception folic acid.

Mothers of African or European non-EU origin were associated with the lowest rates of perireconception folic acid intake.

“This highlights the possibility of existent health inequalities,” the study said, and issues with health promotion messages and recommendations reaching foreign mothers and mothers of minority ethnic groups.

Moreover, a number of family doctors are themselves not fully aware of the benefits and correct timing and dosage of folic acid intake.

“Women’s knowledge and intake of folic acid supplements is influenced significantly by health care professionals’ advice, namely general practitioners, obstetricians, paediatricians and pharmacists,” the authors said.

“General practitioners have an important role in increasing awareness and improving pre-conceptional folic acid intake. It is important that they are aware of this and give appropriate advice to all women of childbearing age even when they are attending clinics for other reasons.

“Unfortunately, it has been documented that a number of family doctors are themselves not fully aware of the benefits and correct timing and dosage of peri-conceptional folic acid intake. Although obstetricians are fully aware and do provide folic acid supplementation advice, women generally present at the obstetricians’ clinics following conception, at a time too late for prevention of potentially avoidable NTDs.”

‘Preconception clinics’ are considered as the ideal venues that may educate and encourage women to take preconception folic acid supplements. However, such clinics are not available in Malta.

“In the absence of mandatory food fortification, countries must be innovative and pro-active in undertaking initiatives to improve women’s folic acid uptake with the aim of avoiding potentially preventable devastating birth defects as are neural tube defects. This is an area which undisputedly offers great public health potential. It is important to ensure that any initiatives undertaken reach all maternal categories including the more vulnerable women,” the doctors said, calling for more research in determining women’s views of what encourages or stops them from having better preconception care.

The study was authored by doctors Miriam Gatt and Marika Borg, researcher Elaine Grech Mercieca and Prof Neville Calleja.

Percentage of women who took folic acid before pregnancy

Went to university 35.5%
Other post-secondary education 26.6%
Stopped at secondary 17.2%
Aged under 25 7%
25-35 29%
Over 35 27.8%
From western region 25.87%
From northern region 30.2%
From south-east region 29.8%
From north harbour 23%
From Gozo 21.9%
From south harbour 18.4%
Maltese-born 28.2%
Other EU country 20.7%
Other European countries 19.8%
Africa and Middle East 4.3%