Evaluation of the knowledge and practices of pregnant Yemeni Women regarding teratogens

Purpose: To investigate the knowledge and practice of pregnant women with regards to teratogens. Methods: A month-long cross-sectional study was carried out among 150 pregnant women selected from four Motherhood and Child Healthcare Centers (MCHCs) in Mukalla District of Yemen. Data collection was conducted during face-to-face interviews using a questionnaire. Descriptive and simple regression analyses were used. Results: Of the 150 pregnant women who participated in the study, 95.3 % of the pregnant women were < 36 years old, 7.4 % had children with congenital malformations, 62 % indicated that they had heard about folic acid; however, only 16.6 % knew the significance of folic acid. Regarding toxoplasmosis, 94.7 % indicated that they had heard about toxoplasmosis, and 76 % knew about the serious consequences of the disease (congenital malformation and abortion) during pregnancy. Based on simple regression analysis, the results indicate that education and parity, irrespective of age or income level, were the major factors determining better knowledge and practices in pregnancy with regards to toxoplasmosis. Conclusion: Knowledge of folic acid deficiency among pregnant women in Mukalla District of Yemen is relatively low. Furthermore, preventive practices to avoid folic acid deficiency are minimal.


INTRODUCTION
Congenital abnormalities are the root cause of neonatal death in 11 % of Yemeni infants [1]. The annual mortality rate of neural tube defects (NTD) is approximately 2.5 per 100,000 infants in Yemen [2]. Further, the seroprevalence of T.gondii, the causative agent in toxoplasmosis infections, was found in approximately 45 % of women in Sana'a, Yemen [3]. Although Yemen does not have any official recommendations regarding folic acid supplementation, the World Health Organization recommends daily folic acid supplementation with 400 µg (0.4 mg) folic acid. Supplementation should be commenced as early as possible to prevent neural tube defects [4]. In addition, toxoplasmosis screening is not routinely tested in Yemeni women despite its high seroprevalence [3,[5][6][7].
A teratogen is an agent to which exposure during pregnancy can cause a harmful effect on the fetus. This teratogen can induce or increase the incidence of congenital malformation [8]. Folate deficiency is one of the most common vitamin deficiencies in women. Women who consume a low level of folate during pregnancy are at risk for poor pregnancy outcomes, including NTDs [9,10]. Several studies have shown that periconceptional use of folic acid has an effective role in the prevention of NTDs [10][11][12][13]. Czeizel and colleagues in a cohort-controlled trail in Hungary reported that periconceptional multivitamin supplementation causes a reduction in certain congenital abnormalities, including NTDs [11]. Wilson and colleagues showed the efficacy of supplementary folic acid in the prevention of NTDs [12]. Bower and colleagues showed that periconceptional folic acid supplementation in Western Australia since 1996 has reduced anencephaly by 32 %, spina bifida by 23 % and encephalcoele by 34 % [13]. Berry and colleagues reported that periconceptional folic acid supplementation reduced the rate of NTDs in China [14]. Studies have also shown that 50-80 % NTDs can be prevented if a woman consumes sufficient amounts of folic acid daily before conception and throughout the first trimester of her pregnancy [11][12][13][14].
Based on the authors' knowledge, there is no study has been conducted on this Toxoplasmosis issue in the Mukalla District of Yemen, and hence, this study has been addressed in this research. The aim of this study was to determine the level of knowledge and identify the practices of Yemeni women regarding folic acid supplementation.

METHODS Pretest
A pilot survey was conducted among 15 pregnant women in the Mukalla District of Yemen. The sample of pregnant women used in this analysis was not included in the study. The questionnaire was pretested to determine the length of the interview, question sequence, and the identification of difficult questions.

Ethical consideration
Ethical approval was obtained from Hadramout University College of Medicine (HUCOM), Department of Community Medicine (11 /2012).

Study design
A cross-sectional study was conducted and the data was collected by a group of 3rd year medical students to assess the knowledge and practices among pregnant women regarding folic acid deficiency and toxoplasmosis.

Study setting
The study was conducted among pregnant women who attended the one of four local Motherhood and Child Healthcare Centers ( All pregnant women in the selected MCHCs were included in our study. The sample size was distributed proportionally among all the MCHCs according to the total number of pregnant women visits to each MCHC ( Table 1). The convenient sample applied to select pregnant women from each MCHC. If one pregnant woman could not participate for any reason, another one would be chosen.

Data collection
The data was collected by face-to-face interviews using the adopted questionnaire. It contained open-and closed-ended questions and was divided into: (a) Personal data and sociodemographic characteristics of the pregnant women such as income and educational level; (b) the personal profile of the pregnant women such as age, address, number of pregnancies, number of abortions, number of living offspring, number of children with anomalies and the kind of anomalies -if found; and (c) questions relating to the knowledge and practice of the pregnant women towards teratogens (i.e., folic acid deficiency and toxoplasmosis infection).

Statistical analysis
The data was checked for accuracy and completeness, then coded, and finally entered into the computer using statistical package for social science (SPSS) version 19. The obtained data was analyzed using descriptive statics (frequencies and percentages). Simple regression analysis was also used (p = 0.05). Data presented in the tables were arranged using computer applications (Word® and Photoshop®).

RESULTS
A total of 150 pregnant women participated in the study. In terms of age, 35.3% were 26-30 years old and 32.7% were between 21 -25 years old. Regarding the income level of the families of the pregnant women, 85.3% indicated that their income only meets their family's needs and 5.4% stated that their income exceeds their needs. Twenty-six percent of interviewed women were illiterate, whereas the rest completed the following levels of education: 54% primary, 12% secondary, and 8% university degrees or higher. Approximately 84.7% of women had between 1 -5 pregnancies and only 0.7% had more than 10 pregnancies. Abortion history was negative for 68 % of pregnant women and positive for 29 % of pregnant women. About 7.4 % of pregnant women declared that they had children with congenital anomalies, and brain defects were the most common anomalies (Table 2).
When women were asked whether they heard about folic acid or not, 62 % said yes, and although 79.6 % of those who said yes stated that they knew the importance of folic acid, only 33.8 % gave the correct answer about its significance. Around 55 % knew the proper time for folic acid supplementation, 38.7 % gave incorrect answers, and 6.4 % didn't know the proper time for folic acid supplementation. When asked whether they heard about neural tube defects, most of them, 76.7 %, responded no, and out of those who had heard about neural tube defects, 65.7 % said that there is relationship between neural tube defects and folic acid deficiency (Table 3).
When those who heard about folic acid were asked whether they had taken folic acid supplementation before, 80.6 % responded that they took folic acid supplementation and 19.4 % responded that they didn't take folic acid supplementation (Table 3). When pregnant women were asked whether they ate green leafy vegetables during their pregnancy, 74 % responded with yes, 25.3 % said not too much, and only 0.7 % said no.  The positive responders were also asked if toxoplasmosis can be transmitted through external touch to cat hair. Nearly 39 % responded yes, 28.9 % responded no, and 32.4 % declared they did not know. Furthermore, they were asked whether toxoplasmosis could be transmitted when you work in the garden without gloves, and 40.1% said yes, 16.9% said no, and 43% said they did not know. When asked if they did an investigation for toxoplasmosis, 45.1 % said no and 54.9 % said yes, and out of those who have been tested, 41% claimed that they tested positive (Table 4). All 150 pregnant women were asked if they wash their fruits and vegetables before eating, and 93.3 % responded with always, 6% responded with sometimes, and 0.7% responded with never. The detailed information about the knowledge and practices of pregnant women towards toxoplasmosis were given in Table 4.
Using simple regression analysis, there was no significant association between knowledge and the practice of pregnant women about the significance of folic acid and age, income, and educational level (Table 5). Eighty percent of those with university degrees or higher knew the correct answer as opposed to 45.4 % of those with secondary education, 30 % of women with primary education, and 22.2 % of illiterate women (Table 6).  Table 4). Knowledge of pregnant women about the serious consequences of toxoplasmosis exposure to pregnant women was analyzed with age, education, income level, and parity using simple regression analysis, and there was a significant difference with education level (p ≤ 0.025) ( Table  7).
Practice of pregnant women was analyzed with age, education, income level, and parity using simple regression analysis, and there was a significant difference with parity level (p ≤ 0.011) ( Table 7). The women who knew the correct answers were 100 % with university degrees or higher, 82.3 % of those with secondary education, 82 % of women with primary education, and 68.5 % of illiterate women ( Table  8). All (100 %) of women with parity between 11-15 pregnancies were tested for toxoplasmosis, 76 % of women with parity between 6 and 10 pregnancies, and 50 % of women with parity between 1 -5 pregnancies (Table 9).       studies, such as Kondo and colleagues reported that less than 15 % of Japanese women were aware of a link between folic acid and NTDs [17].

DISCUSSION
In addition, a study in the United States revealed that 13 % of all women surveyed knew that folic acid helps prevent birth defects [18]; however, an UAE study reported lower rates, 69.7 % [16]. Using simple regression analysis, our study showed that education was the most important significant factor influencing pregnant womens' knowledge regarding the importance of folic acid in pregnancy. This was similar to the study conducted in United Arab Emirates [16]. Out of those who interacted with cats, 64.5 % washed their hands after dealing with the cats. Jones and colleagues [19] reported that 80 % of pregnant women washed their hands after dealing with cats. Regarding raw meat, 32.6 % of our study population ate raw meat whereas in the study by Jones and colleagues [19], only 6 % of pregnant women ate raw meat. The reason behind this difference could be due to the high emphasis on good hygiene in the American population.

CONCLUSION
The results of this study suggest that more professional education is needed by healthcare providers to increase the awareness of pregnant women about the importance of folate supplementation in pregnancy. Yemen does not have any official guidelines on folic acid periconceptional use; therefore, a specific policy should be established to promote folic acid intake in the periconceptional period in order to reduce the risk of congenital abnormalities. More health education programs addressing the methods of transmission of toxoplasmosis and its prevention should be conducted. Further studies are required to determine the prevalence of congenital anomalies and to assess the knowledge of pregnant women regarding other teratogens.