Women’s awareness and periconceptional use of folic acid: data from a large European survey

Figures & data

Table 1 Proportion of women included and excluded from the sample in each country

Country	Enrolled, n	Excluded, n (%)	Final sample, n
Austria	1099	104 (9)	995
Czech Republic	1111	48 (4)	1063
Denmark	1215	147 (12)	1068
France	2088	63 (3)	2025
Germany	2189	211 (10)	1978
Greece	506	6 (1)	500
Italy	2083	68 (3)	2015
Netherlands	1098	85 (8)	1013
Norway	1116	97 (9)	1019
Poland	1041	0 (0)	1041
Portugal	1028	24 (2)	1004
Russia	1044	27 (3)	1017
Spain	2111	123 (6)	1988
Sweden	1060	48 (5)	1012
Switzerland	1223	130 (11)	1093
Turkey	1035	24 (2)	1011
Ukraine	1022	6 (1)	1016
United Kingdom	2252	185 (8)	2067
Total Europe	24,321	1396 (6)	22,925

Table 2 Patient sociodemographic characteristics

Characteristic	Unweighted sample (n = 22,925)	Weighted sample (n = 22,925)
Age (years), mean (95% CI)	33 (33.0–33.2)	33 (32.4–32.6)
Biological children
Yes, %	54	58
Number, mean (95% CI)	1.8 (1.78–1.81)	1.7 (1.72–1.75)
Height (m), mean (95% CI)	1.65 (1.653–1.657)	1.65 (1.650–1.654)
Weight (kg), mean (95% CI)	67 (66.4–67.0)	66 (65.3–65.9)
Employment status, %
Part-time/full-time employed	63.3	61.1
Staying at home/unemployed	23.4	27.3
Student	13.2	11.6
Marital status, %
Married/living with partner	61.3	64.2
Steady relationship, not living together	15.3	15.1
Single/without a steady relationship or other	23.5	20.6

Abbreviations: n, number; CI, confidence interval.

Figure 1 The proportion of European women with at least one biological child who answered “yes” to the question, “Now please think of the pregnancy with your first child, was this a planned or unplanned pregnancy?”.

Notes: European aggregated data are based on weighted samples (unweighted n number shown in brackets). Data for the individual countries are based on unweighted samples.
Abbreviations: EU, total Europe; AT, Austria; CZ, Czech Republic; DK, Denmark; FR, France; DE, Germany; GR, Greece; IT, Italy; NL, Netherlands; NO, Norway; PL, Poland; PT, Portugal; RU, Russia; ES, Spain; SE, Sweden; CH, Switzerland; TR, Turkey; UA, Ukraine; UK, United Kingdom; n, number.

Figure 2 Among European women with biological children and who planned their first pregnancy, responses to the question, “When you were making plans to become pregnant with your first child, which of the following did you do?”.

Notes: European aggregated data are based on weighted samples (unweighted n number shown in brackets). Data for the individual countries are based on unweighted samples.
Abbreviations: EU, total Europe; AT, Austria; CZ, Czech Republic; DK, Denmark; FR, France; DE, Germany; GR, Greece; IT, Italy; NL, Netherlands; NO, Norway; PL, Poland; PT, Portugal; RU, Russia; ES, Spain; SE, Sweden; CH, Switzerland; TR, Turkey; UA, Ukraine; UK, United Kingdom; n, number.

Figure 3 The proportion of European women who answered “yes” to the questions, “Have you heard of folic acid?” and “Do you know what the benefits of folic acid are?” and the proportion of women who identified neural tube defects/spina bifida when asked, “Which of the following diseases/birth defects can folic acid protect against?”.

Notes: The following answers were possible: anemia, autism, cystic fibrosis, Down syndrome, neural tube defects/spina bifida, thrombosis, cardiovascular disease/cardiovascular health, and “I don’t know.” More than one answer could be chosen. Data are shown by country. European aggregated data are based on weighted samples (unweighted n number shown in brackets). Data for the individual countries are based on unweighted samples.
Abbreviations: EU, total Europe; AT, Austria; CZ, Czech Republic; DK, Denmark; FR, France; DE, Germany; GR, Greece; IT, Italy; NL, Netherlands; NO, Norway; PL, Poland; PT, Portugal; RU, Russia; ES, Spain; SE, Sweden; CH, Switzerland; TR, Turkey; UA, Ukraine; UK, United Kingdom; n, number.

Figure 4 The proportion of European women who answered “yes” to the questions, “Have you ever heard of folic acid?” and “Do you know what the benefits of folic acid are?” and the proportion of women who identified neural tube defects/spina bifida when asked, “Which of the following diseases/birth defects can folic acid protect against?”.

Notes: The following answers were possible: anemia; autism; cystic fibrosis; Down syndrome; neural tube defects/spina bifida; thrombosis; cardiovascular disease/cardiovascular health; I don’t know. More than one answer could be chosen. Data are shown by age and for women with and without children. European aggregated data are based on weighted samples (unweighted n number shown in brackets).
Abbreviation: n, number.

Figure 5 The proportion of European women taking folic acid at the time of the survey.

Note: European aggregated data are based on weighted samples (unweighted n number shown in brackets).
Abbreviation: n, number.

Figure 6 The proportion of European women with biological children and aware of FA who answered “yes” to the question, “Did you receive any advice/information to take folic acid either whilst you were pregnant or when you were thinking of becoming pregnant?” and “Again thinking of the pregnancy with your first child, did you take a folic acid supplement whilst you were pregnant or when you were trying to become pregnant for the first time?”

Note: European aggregated data are based on weighted samples (unweighted n number shown in brackets).
Abbreviations: FA, folic acid; n, number.

Table S1 Questionnaire

G1. Have you ever heard of folic acid?
Yes	□ 1 Go to G2
No	□ 2 Go to H1
The next series of questions will ask about if and why you have taken folic acid. In these questions, we are interested in occasions when you deliberately took a supplement of folic acid.
G2. Have you ever taken a folic acid supplement?
Yes	□ 1 Go to G3a
No	□ 2 Go to G5a
G3a. Do you currently take a folic acid supplement?
Yes	□ 1 Go to G3c
No	□ 2 Go to G4
G3b. deleted
G3c. Is the folic acid supplement you are currently taking a prescription product or a nonprescription product (over-the-counter product)?
Prescription product	□ 1
Nonprescription product (over the counter)	□ 2
Don’t know	□ 99
G3d. Is the folic acid supplement you are currently taking a multivitamin product or a single vitamin supplement?
Prenatal multivitamin product	□ 1
Other multivitamin product	□ 2
Single vitamin supplement, containing only folic acid	□ 3
Don’t know	□ 99
G3e. How frequently are you supposed to take your folic acid supplement?
Every day	□ 1
5–6 times a week	□ 2
3–4 times a week	□ 3
2–3 times a week	□ 4
Once a week	□ 5
Less frequently than once a week	□ 6
Don’t know	□ 99
G3f. In an average week, how many times have you forgotten or have you chosen not to take your folic acid tablet?
Never	□ 1
1 day out of 7	□ 2
2 days out of 7	□ 3
3 days out of 7	□ 4
4 days out of 7	□ 5
5 days out of 7	□ 6
6 days out of 7	□ 7
7 days out of 7	□ 8
G4. What are the reasons why you are currently taking or have been taking a folic acid supplement before?
Please tick all that apply.
A doctor/health care professional advised it	□ 1
A friend/relative advised me to take it	□ 2
Because I am anemic	□ 3
Because I am planning to become pregnant	□ 4
Because I am pregnant	□ 5
Because it has general health benefits	□ 6
I read about it and heard it was good for me	□ 7
Because it is in my multivitamins	□ 8
Because I have a folic acid deficiency	□ 9
Because I might not be getting enough folic acid in my normal diet	□ 10
Because I am breast feeding	□ 11
Because I had premenstrual symptoms	□ 12
Because I had problems with my menstrual bleeding	□ 13
Other (please specify): _________________________________________	□ 14
No specific reasons	□ 15
G5a. Do you know what the benefits of folic acid are?
Yes, I know what the benefits of folic acid are	□ 1 Go to G5b
No, I don’t know what the benefits of folic acid are	□ 2 Go to G6
G5b. Which of the following diseases/birth defects can folic acid protect against?
Please tick all that apply.
Anemia	□ 1
Autism	□ 2
Cystic fibrosis	□ 3
Down syndrome	□ 4
Neural tube defects/spina bifida	□ 5
Thrombosis	□ 6
Cardiovascular disease/cardiovascular health	□ 7
I don’t know	□ 99
G6. Now please think of the pregnancy with your first child, was this a planned or an unplanned pregnancy?
Planned	□ 1 Go to G7
Unplanned	□ 2 Go to G8
G7. When you were making plans to become pregnant with your first child, which of the following did you do?
I stopped using my birth control without consulting my doctor or another health care professional first	□ 1
I consulted my doctor or another health care professional before stopping my birth control	□ 2
I had not used a contraceptive before	□ 3
Other (please specify): _________________________	□ 4
I don’t remember	□ 99
G8. After you personally found out about the pregnancy with your first child (for example by using a pregnancy test), approximately how much time passed by until you went to see your gynecologist or another health care professional?
1 week or less	□ 1
2 weeks	□ 2
3 weeks	□ 3
4 weeks	□ 4
5 weeks or more	□ 5
I don’t remember	□ 99
G9. Did you know about the benefits of folic acid related to birth defects at any of the following points in time?
Tick all that apply.
At the time I was thinking of becoming pregnant for the first time	□ 1
At the time I stopped using contraception and tried to become pregnant	□ 2
At the time I was pregnant with my first child	□ 3
I didn’t know about the benefits of folic acid at any of the abovementioned time points	□ 4
G10. Did you receive any advice/information to take folic acid either whilst you were pregnant or when you were thinking of becoming pregnant?
Yes	□ 1 Go to G11
No	□ 2 Go to G12
G11. Which sources of information made you aware to take folic acid whilst you were pregnant or when you were thinking of becoming pregnant?
Please tick all that apply.
Gynecologist	□ 1
Primary care physician/general practitioner	□ 2
Other kind of doctor	□ 3
Midwife	□ 4
Nurse	□ 5
Pharmacist	□ 6
Friends	□ 7
Partner/husband	□ 8
Parents	□ 9
Siblings	□ 10
I already knew I should take folic acid	□ 11
I read about it in a magazine/newspaper	□ 12
I read about it in an information leaflet provided in a waiting room	□ 13
I read about it in an information leaflet provided in a pharmacy	□ 14
I saw something on the internet	□ 15
I saw something on TV	□ 16
I can’t remember	□ 17
G12. Again thinking of the pregnancy with your first child, did you take a folic acid supplement whilst you were pregnant or when you were trying to become pregnant for the first time?
Yes	□ 1 Go to G13a
No	□ 2 Go to G14
G13a. At which time point did you start to take folic acid?
Before I found out about my pregnancy	□ 1 Go to G13b
After I found out about my pregnancy	□ 2 Go to G13b
I don’t remember	□ 99 Go to G14
G13b. How many months [before you found out about your pregnancy]/[after you found out about your pregnancy] did you start to take folic acid ?
Number of months:	□ □
If, less than a month, please enter days
Number of days:	□ □
If, more than a year please enter years
Number of years:	□ □
G14. What is the reason why you didn’t take folic acid when you were pregnant for the first time or when you were trying to become pregnant for the first time?
Please tick all that apply.
I didn’t think it was important/necessary/didn’t know about	□ 1
the benefits of folic acid
I didn’t know about folic acid	□ 2
There was enough folic acid in my diet	□ 3
No one advised me to take it	□ 4
I forgot to take it regularly	□ 5
I thought it might have a negative effect	□ 6
Vitamins can cause digestive problems	□ 7
I felt too sick to take it	□ 8
I don’t like to take pills every day	□ 9
Because of the costs	□ 10
Other (please specify):_________________________________	□ 11
There is no particular reason	□ 12
Folic acid is a vitamin B and important for women across all ages and life stages. It is difficult to gain sufficient levels of folic acid from a normal diet. Particularly women in the fertile age range tend not to have sufficient levels of this vitamin. This vitamin is even more important for women who wish to become pregnant at some stage of their life, because folic acid is needed for the healthy development of an unborn baby. Sufficient levels of folic acid are needed right from the moment of conception, even before the pregnancy is known about.
Suppose there were an oral contraceptive that is additionally supplemented with folic acid and so combines a birth control pill and folic acid in just one small pill. This means the pill would prevent you from getting pregnant and improve the folic acid level in your body. This pill would not lead to any additional side effects or health related problems than the current 1-month pill.
G15. How likely are you to consider using this pill?
Not likely at all	□ 1
Not very likely	□ 2
Neutral	□ 3
Somewhat likely	□ 4
Very likely	□ 5