Knowledge of supplemental folic acid during pregnancy

. A specific instrument was used for data collection. The data were entered into an appropriate spreadsheet and later statistically analyzed. Pearson´s chi-squared test, p <0.15, was used. Results. On average, the interviewed mothers were 25 years old and received less than two minimum wages. Most had prenatal in the first quartile and a mean of seven appointments, starting the use of folic acid from the 7 th to the 9 th week of gestational age. However, when asked about the importance of folic acid and its action, almost the majority was not able to answer. Conclusion. Although daily acid supplementation is recommended in prenatal care, this study found that consumption is inadequate, contributing to the increased risk of fetal malformation. Healthcare professionals, especially nurses, should develop educational activities for women about the use of folic acid in the pre-gestation period and in the first pregnancy trimester.


Introduction
Every woman who desires to have a child needs to pay special care to her diet and lifestyle habits.Caring for pregnancy should start from the moment she decides she wishes to become pregnant, as good planning throughout pregnancy decreases the chances of congenital anomalies in babies.Hence, good prenatal care is fundamental.One such care concerns the use of folic acid, folate or vitamin B9, which is a B-complex water-soluble vitamin.Whereas the term folate encompasses all forms of this vitamin, including both its many naturally-occurring compounds and folic acid, the term folic acid (pteromonoglutamic acid) refers to the synthetic form found in vitamin supplements and fortified food. 1 Folic acid is usually associated with the intracellular vitamin B12, also known as cobalamin, which presents itself in two forms of active coenzymes: methylcobalamin and desoxyadenosylcobalamin. Cobalamin is used to denote the structure of a corrin nucleus; methylcobalamin and adenosylcobalamin act as cofactors in the body, while the others are therapeutic methods of food consumption. 2,3olate interferes with the increased volume of erythrocytes, the enlargement of the uterus, and the growth of the placenta and fetus, as well as with the prevention of respiratory diseases in infancy and Down's syndrome.It acts as a coenzyme in the metabolism of amino acids, and in the synthesis of purines and pyrimidines and of nucleic acids (deoxyribonucleic acid -DNA and Ribonucleic Acid -RNA), which are vital for cell division and protein synthesis, thereby playing a fundamental role in the process of cell multiplication. 4,5lic acid is predominantly found, among other sources, in organ meats, green vegetables, legumes, beans, citrus fruits such as spinach, lentils, chickpeas, asparagus, broccoli, peas, cabbage, corn, peanuts and orange. 5,6Its deficiency is associated with high levels of homocysteine in the serum, can be found associated with hypertensive pregnancy syndrome, recurrent spontaneous abortions, premature births, low birth weight, chronic cardiovascular and vascular brain diseases, dementia, and depression. 7As to congenital anomalies, folic acid replacement prevents open neural tube defects (ONTD).[9] The low consumption in the diet, gene disorders, smoking, chronic use of oral hormonal contraceptives, diabetes, and use of anticonvulsant medications are some factors related to a decreased folic acid serum level. 10n an attempt to reduce the problems caused by deficiency of folic acid in pregnant women, Brazil's National Health Surveillance Agency (ANVISA) made it mandatory for wheat flour and maize sold in the country to be fortified with iron and folic acid by Resolution 344 of December 12,   2002, implemented as of July 2004.ANVISA provides that each 100g of flour and maize be fortified with 0.15 mg of folic acid.Added to food, this has a bioavailability 85-100% , while folate, in its natural form, present in fresh food, has a bioavailability of 50%, and is more susceptible to destruction in the preparation. 11,12A daily dosage of 0.4 mg of folic acid is recommended for all women who plan to become pregnant; for those who have had children with problems or who use medications that interfere with folate levels in the body, such as anticonvulsants, the recommend dose is 4mg. 12For lactating and pregnant women, an additional daily dose of 0.1 mg and 0.2 mg of folic acid is recommended, respectively.The use of folic acid is recommended three months prior to gestation through the 12th week of gestation. 7 our literature review we found that daily supplement doses of 5 mg/day of folic acid reduced by 75-91% the incidence of neural tube defects, compared with a reduction of 23-66% when using 0.4 mg to 0.8 mg daily, allowing us to observe a direct relationship between dose and effect for neural tube defects. 6More than a third of women worldwide are considered to be deficient in folic acid.Its concentration decreases during pregnancy due to plasma volume expansion, when hemodilution occurs. 13One study found folic acid supplementation in 31.8% of women during pregnancy and 4.3% in the preconception period, which further demonstrates the lack of knowledge of the use of folic acid at the right time during pregnancy.Among patients in the 30th week of pregnancy, it was found that 20% used folic acid.This result was influenced by the following factors: low education and socioeconomic status, lower maternal age, absence of a partner, and the lack of pregnancy planning.The lack of knowledge about the essential drugs used in the pregnancy cycle is still significant. 4other factor that increases the use of folic acid is the prenatal medical appointment, according to Brazil's Ministry of Health (MOH); a 5 mg prescription is made from the first prenatal appointment up to 14 weeks of gestation.There is a need for promotion and continuous dissemination of the importance of periconceptional folic acid supplementation among health professionals involved in prenatal care, especially nurses, who in Brazil provide prenatal care to low-risk pregnant women. 14However, because folic acid in doses above 5 mg can mask pernicious anemia and B12 deficiency anemia, it is therefore not recommended for strict vegetarians. 15Excess folic acid intake destabilizes the relationship with vitamin B12 and boosts chromosomal breakage and mitotic disorders, which could account for the high incidence of colon and rectal cancer in these women.Changes in the mammary glands of newborns whose mothers have been exposed to high doses of folic acid also raise doubts.There has also been an association with a slightly increased risk of early respiratory infections in newborns, and the risk is most particularly observed in the first trimester. 16In view of the above, this research aimed to identify the use of folic acid during pregnancy and the knowledge about folic acid among postpartum women.

Methodology
This was a quantitative, descriptive, and exploratory study, carried out in the pediatric outpatient center of Base Hospital, a teaching hospital in the city of São José do Rio Preto, in northwestern São Paulo state, Brazil.Receiving about 300 newborns per month, the outpatient unit performs newborn metabolic screening (Guthrie test or heel pick test), which can be standard, conducting examinations such as TSH, T4, and phenylketonuria and cystic fibrosis; or extended, including examinations such as: G.6P.D Deficiency, aminoacidopathies, congenital toxoplasmosis, biotinidase deficiency, galactosemia, and 17OH.The study's population included 198 mothers who brought their children for neonatal screening at the location described Knowledge of supplemental folic acid during pregnancy above, with their prenatal record card, and agreed to participate by signing the Instrument of Consent, after the needed clarifications were made.Exclusion criteria encompassed those who did not agree to participate.A data collection followed, using a specific instrument containing questions regarding socio-demographic information and gynecological and obstetric data, which were supplemented with prenatal record card data.The data were then transcribed into an spreadsheet in Excel 2010 and statistically analyzed.Initially, an analysis by descriptive statistics was performed for the results obtained from the instrument application.Next, Pearson's chi-square test was used with a significance level of 0.15, with the objective of verifying the possible candidate variables for composing the logistic regression model, which was conducted using the stepwise method to find the best selection of predictor variables.Statistical analysis of the data was performed with the aid of the GraphPad InStat 3.0 and Prism 1. 6

Results
The postpartum women were on average 25 years of age, with a standard deviation of 5.17; 58.08% identified as white; 81.31% had a partner; 56.85% lived in rented accommodations; 65.15% reported a family income below 2 minimum wages; and 52.02% of the pregnant women did not perform paid work.The average schooling duration was 11 years, with a standard deviation of 2.15.Table 1 shows the socioeconomic characteristics of postpartum mothers.According to Table 2, 60.02% of the postpartum mothers had their first sexual intercourse between the ages of 15-16 years, the average being 16 years with a standard deviation of 2.33, while 65.15% indicated that "sometimes I make use of condom," and 55.56% had had more than one partner during their sex life.Obstetric and prenatal care data are described in Table 3.According to the number of pregnancies, 50.51% were primiparous and 81.81% had never had an abortion; 96.46% had prenatal care, and 81.82% started it in the 1 st trimester of pregnancy; 45.96% had 7-8 prenatal appointments, the average being 7 appointments, with a standard deviation of 1.44.Folic acid was prescribed to 81.31% of the pregnant women, but 19.87% of these prescriptions occurred after the 13th week of pregnancy; when added to the 18.69% who had no prescription, it was found that 38.56% had no prescription, or had it after the stage recommended for consumption.It is noteworthy that 24.1% of the women with a prescription for folic acid mentioned not having been counseled on the importance of taking it, and thus didn't.
Out of the 18.69% of women who did not have a prescription, 67.57% reported ignorance about the need for the use of folic acid during pregnancy.None of the interviewees began the use of folic acid before pregnancy.Moreover, 4.55% had a child with malformations.It turned out that 2.00% of the women used folate antagonist, concomitant with folic acid.It draws attention that 6.00% are diabetic, of whom 81.81% are insulin dependent.
As for knowledge, 54.55% of the mothers said they did not know about folic acid, but 94.57% indicated it to be a vitamin B complex.It was found that the mothers did not have the following knowledge: 95.96%, that folic acid is found in foods; 60.29%, that its consumption is related to fetal development, preventing malformation; and 66.16%, that it brings benefits to pregnancy.After applying the statistical tests, we identified significance in relation to the profession (p = 0.08426), i.e. women exercising remunerated activity had greater knowledge; and the type of housing (p <0.0001) of the mother, i.e. women renting their residence had less knowledge.

Discussion
The socioeconomic characteristics were similar to those found in a study about mothers in Romania in 2010, which found that non-use or low use of folic acid was directly related to low socioeconomic condition. 17Researchers reported similar rates in the number of pregnancies, and the predominance of early prenatal care in the first gestational quartile. 18Regarding the number of appointments, all the nutritional care of pregnant women, use of vitamin and mineral supplementation, maternal health, and other important factors to mother's and child's well-being must be employed during the prenatal period.The Health Ministry recommends its beginning in the first trimester, totaling at least six visits by the end of the gestation. 14The average of adequate prenatal appointments or even some with more appointments is not proved to be a quality factor for the proper pre-natal care relative to folic acid supplementation. 18,19It was observed that the use of folic acid occurred between the 7th and 9th week of gestation, as described by other researchers. 18,199][20] In developed countries such as the United States, Canada, the Netherlands, and the United Kingdom, a correlation was shown between women who planned pregnancies and performed appropriate treatment with folic acid. 4[17][18][19][20] Regarding the lack of knowledge about folic acid, there exists a significant number of women who used folic acid without knowing what this vitamin is and its importance, especially in the prevention of neural tube defects, and the appropriate time period for taking it. 4,20Health professionals, especially nurses who have educational practices in their assignments, play an extremely important role in guiding patients and prescribing folic acid in order to achieve better preventive results. 14The professionals, obstetric physicians and midwives, know the role of folic acid in the prevention of neural tube malformation, but do not know the time of use, the start of the supplementation and optimal dosing, which are relevant points in this prevention.Thus, public policies are needed that focus on the training of professionals who work in women's care to minimize the risk of such anomalies. 17though daily supplementation of folic acid is recommended and provided as a public health intervention in Brazil during prenatal care to prevent the occurrence of neural tube closure defects in the fetus, the inadequacy of its use has been proven.The conclusion is that health professionals, especially nurses, should be required to develop educational activities for women, individually or in groups, on the use of folic acid during pre-pregnancy and the first trimester of pregnancy.
software.The Brazilian ethical guidelines for research with human beings, Resolution of the National Council of Health (CNS) / Ministry of Health (MOH) 196/96, in force at the time of approval of the research project, were met, and the study was evaluated by the Research Ethics Committee of the Faculty of Medicine of Sao Jose do Rio Preto [Faculdade de Medicina de São José do Rio Preto), FAMERP, under approval N o 350.287.

Table 1 .
Distribution of the 198 postpartum mothers according to socioeconomic information.Sao Jose do Rio Preto, 2014

Table 2 .
Distribution of 198 postpartum women according to gynecological data.Sao Jose do Rio Preto, 2014

Table 3 .
Distribution of postpartum mothers according to obstetric data.Sao Jose do Rio Preto, 2014

Table 4 .
Distribution of 198 postpartum women according to their knowledge about folic acid.Sao Jose do Rio Preto, 2014