ASSESSMENT OF KNOWLEDGE AND PRACTICE OF PERICONCEPTIONAL FOLIC ACID SUPPLEMENTATION (PFAS) AMONG CHILDBEARING AGE WOMEN (18-45YEARS) ATTENDING ANTENATAL CLINICS IN ENUGU, NIGERIA.

The nutritional benefits of folic acid were first discovered by LucyWills in 1931 but it was finally synthesized in pure form by Bob Stroksand in 1943.Unambiguous evidence has been avail

CHAPTER ONE1.0 INTRODUCTION

Folic acid (vitamin B9) is important in a vast number of human metabolic pathways.Examples include; interconversion of amino acids serine to glycine, conversion ofhomocysteine to methionine, synthesis of purines and pyrimidines, growth and healthydevelopment of a fetus The nutritional benefits of folic acid were first discovered by LucyWills in 1931 but it was finally synthesized in pure form by Bob Stroksand in 1943.Unambiguous evidence has been available for more than two decades on the effectiveness

of periconceptional folic acid supplementation (PFAS) in preventing neural tube defects(NTDs) However, though this information exists a large population of its target audience(the childbearing age women) remain blissfully unaware of this very important fact

Birth defects are documented as the leading cause of infant mortality worldwide and neuraltube defects are the third leading birth defects (United States Institute of Medicine [USIM],1998) Periconceptional folic acid supplementation, the oral ingestion of folic acidsupplements of not less than 0.4mg per day; from preconception period to 12 weeks postconception has been proven to reduce the risk of occurrence and 4mg per day the risk ofreoccurrence of neural tube defects Neural tube defects are series of congenital anomaliesthat result as a consequence of faulty or aberrant neural tube development, which has beenshown to be linked to less than optimal maternal blood folate concentration The mostcommon NTDs are Spina bifida and anencephaly Spina bifida is the embryologic failure offusion of one or more vertebral arches, sub-types of Spina bifida are based on degree andpattern of deformity Two broad types of Spina bifida are Spina bifida occulta and Spinabifida cystica Basically, the neonate is born with an exposed spinal cord (Pitkin, 2007).Anencephaly on the other hand is a congenital defective development of the brain withabsence of bones of the cranial vault and absent or rudimentary cerebral and cerebellahemispheres, brainstem and basal ganglia This condition is almost invariably fatal

The neural tube is the early spinal cord found in embryo’s which forms within 28 days afterconception Due to the fact that this is very early in pregnancy most NTDs develop beforewomen realize that they are pregnant, therefore too late for them to do anything to avert it.

In developed economies though, there are a number of prenatal tests that are carried out totest for NTDs especially in those perceived to be at risk The most commonly employedtest is alpha fetoprotein (AFP) This is because abnormally high levels are recorded in openNTD cases Other tests include amniocentesis and ultrasonography, though no one testingprocedure is infallible

The link between folate deficiency and NTDs was first suggested by Hibbard (1964).Further research was reported by Smithels (1983) Since then, many other trials using folicacid supplements in pregnant women have been done all over the world The resultsdemonstrated conclusively the link between folate deficiency and increased risk of NTDs(Hoffbrand, 2001) Due to the early development of NTDs in fetuses, it is important thatwomen in childbearing age increase their folate intake prior to conception as well as duringthe first 12 weeks of pregnancy Both the United States Public Health Service and theBritish National Health Service (1992) recommend that women intending to becomepregnant should take folate supplements of 0.4mg per day until the 12th week of pregnancy(Mesereau and Kilker, 2004) Research has shown that a daily folate supplement of 0.4mgreduces the chance of neural tube defects by an estimated 36%; also that 4mg per day has

Culled from Wardlaw (2003)

been estimated to prevent 8 in 10 cases of NTDs provided the supplementation is startedprior to conception (Wald, 2004).

1.1 Statement of the Problem

During pregnancy there is a marked increase in folate utilization This is primarily as aresult of increase in reactions requiring single carbon transfers, rapid rate of cell division inmaternal and fetal tissues also deposition of folate in the fetus Even though the benefits offolate to general health of the population are well documented, the current daily intake offolates among women aged 19-65 years is only 0.292mg (Butriss, 2005) a value well belowthe recommended daily intake (RDI) for pregnant women The recommended daily intakefor pregnant women is 0.6mg this is based on the amount that maintained erythrocyteconcentrations during clinical trials (Allen, 2004)

Randomized clinical trials have shown that folic acid supplements taken prior to conceptionand through approximately the first twelve weeks of pregnancy lowers the risk that agenetically predisposed woman will have a baby with a neural tube defect (Hoffbrand,2004; Taylor and May, 2008) Neural tube defects occur in approximately 0.1% of births inthe United States (King, 2004) It affects 4,500 pregnancies yearly in the European Union(Tita, 2005) and approximately 0.9% of births in other countries Neural tube defects tend

to reoccur in subsequent pregnancies if aggressive periconceptional supplementation is notundertaken Higher intake of dietary folate, and not less than 4mg daily of folic acidsupplements, including higher erythrocyte folate concentrations are inversely related to therisk of neural tube defects (Weller, 1993; Shaw, Schaffer, Verlie, Morland & Haris, 1995).Clinical trials have shown that women with neural tube affected pregnancies absorb 20-25% less folate from either supplements or foods than women in the control group Themechanism by which folate lowers the risk of NTDs is not fully understood Presumably,women at risk have a metabolic defect that hinders folate metabolism This affectsbioavailability and impedes transport of folate and critical metabolites to the rapidlygrowing embryo

Periconceptional folic acid supplementation is both simple and cost effective This isbecause not only does it prevent occurrence and reoccurrence of NTDs it also ensuresoptimal blood folate concentration It prevents hyperhomocystenemia (elevated bloodhomocysteine level) which is associated with a myriad of other health conditions Elevatedblood homocysteine has been associated with greater risk of pre-eclampsia, preterm

delivery and a greater risk of low birth weight infants (Volset, 2000) A rise in incidence of

abrupt placentas, spontaneous abortions and club foot were also documented.Periconceptional folic acid supplementation is very important in the case of adolescentmothers This is because they are still growing and have increased folate needs; they easilydeplete their folate stores placing both themselves and their babies at risk Another point onits scoreboard is the fact that dietary folate is not as easily assimilated as the supplementdue to reduced bioavailability

1.2 Objective of the study

The general objective of the study was to assess knowledge and practice amongchildbearing age women in Enugu metropolis of Enugu State, Nigeria aboutpericonceptional folic acid supplementation (PFAS) and its health implications

1.2.1 Specific objectives

The specific objectives of this study were to:

i assess knowledge, and practice among the target population of the benefits ofpericonceptional folic acid supplementation;

ii assess the level of knowledge amongst the target population about foods rich infolate;

iii evaluate pattern of consumption of such foods using 24 hour dietary recall andfood frequency questionnaire; and

iv correlate evidence between the variables, different antenatal clinics, private versuspublic

1.3 Significance of the study

The result of this study will serve as a guide to health care providers andNutritionists/Dietitians, on the urgent need for concerted effort on educating the targetaudience on the importance of periconceptional folic acid supplementation and the healthimplications of poor supplementation practices The results will also show the vitaminsupplementation habits of the expectant mothers and the implication of their preferredantenatal booking times It will also fill a knowledge gap because there is a dearth of goodquality studies pertaining to knowledge and practice of folate usage in the Nigerian setting.This is compounded with the fact that there is widespread ignorance on the healthimplications of less than optimal blood folate concentration especially during the criticalpericonceptional period

CHAPTER TWO

2.0 LITERATURE REVIEW

Folate is derived from the Latin word folium which means foliage (Wardlaw, 2003; Taylor

and May, 2008) This is because it is found in abundance in many green leafy vegetablesincluding spinach Folate is a collective name for a group of substances with a chemicalstructure related to pteroylmonoglutamic acid (PGA) or folic acid The term folic acidrefers specifically to the fully oxidized monoglutamate form of the vitamin that issynthesized for commercial use in supplements and fortified foods; it rarely occurs innature Basically two forms exist; dietary folate –folate occurring in food and syntheticfolate (folic acid) which is present in dietary supplements (Kromhout, 2008)

2.1 Chemistry

Folic acid is composed of 3 large subunits; a bicyclic nitrogenous compound calledpteridine, a molecule of para-amino benzoic acid and glutamic acid (a non-essential aminoacid) In the course of metabolism, folic acid is converted into dihydrofolic acid (DHFA)then tetrahydrofolic acid THFA (the absorptive form of folate) which polymerizes to formvarious polyglutamates found in living organisms

Folic acid structure (Taylor and May, 2008)

The molecule can vary in structure by reduction of the pteridine moiety to dihydrofolic acid

or tetrahydrofolic acid (THF); elongation of the glutamate chain to form polyglutamatesand substitution of 1-C units at the 5th or 10th positions or both positions Folate co-enzymesare polyglutamyl forms of THF including those with methyl (-CH3-), methylene (-CH2-),methenyl(-CH=), formyl(-CH=O), or formimino(-CH=NH-)

2.2 Folate content of foods

Green leafy vegetables, asparagus, spinach, cabbage, organ meats, okra, wheat germ, bean

sprouts, peanuts, kidney beans, avocado, papaya and black eyed peas are all good folate

sources However the folate content of orange is notably the most bioavailable This islargely due to the stability conferred on it by the ascorbic acid (vitamin C) which isabundantly present in the fruit Food processing and preparation destroy 50-90% of thefolate in foods Folates are very heat labile, therefore to conserve folate in green leafyvegetables, processing methods such as steaming, stir frying and microwaving are advised(Wardlaw, 2003) These methods involve limited contact with water which can leach outwater soluble vitamins

Milk also is a well known folate source It contains up to 7 milligrams per 100grams andfermented milk products are reported to contain even higher amounts (Forssen, Jagerstad,Wigertz & Wittloft, 2000).The high level of folate is the result of additional folateproduction by bacteria Folate producing ability has been reported in some bacterial speciesused as yogurt starter cultures This ability varies greatly even amongst strains of the samespecies Some bacteria are able to synthesize this vitamin (co-factor) by themselves fromsimple precursors, but some autotrophic bacteria have a strict growth requirement for folicacid (Hugenholtz, Hunik, Santos & Smid, 2000).An interesting study by Holasova,

FiedLerova, Roubal & Pechacova (2004) outlines Streptococcus thermophilus as a good

folate producing agent They postulate that by careful selection of microbial strains used asstarter cultures the folate content of fermented milk products can be enhanced naturally.Studies are also ongoing on the ability of healthy adults to increase their vitamin notablyfolate status by consuming vegetables with prebiotic qualities like the commonly consumed

Venonia amygdalina (bitter leaf).

2.3 Physiology and metabolism

When naturally occurring food folate is consumed it must first be converted to themonoglutamate form by the enzyme pteropolyglutamate hydrolase, also referred to asfolate conjugase or glutamate carboxypeptidase II This is located primarily in the jejunalbrush-border membrane (Halsted, 1990) The optimum pH for brush border conjugase is6.5-7.0 After deconjugation to the monoglutamyl form, folate is transported across themembrane by a pH dependent carrier mediated mechanism (Zimmerman and Gilula, 1989).Luminal pH changes with chronic drug use (as in oral contraceptives) or diseases that alterjejunal pH can impair folate absorption (Mason, 1990) Before entry into the portal blood,folic acid undergoes reduction to THF and either methylation or formylation in mucosalcells (Gregory, 1995) The predominant form of folate in plasma is 5-methyl THF, which isprimarily bound loosely to albumin with a smaller percentage bound with high affinity tofolate binding protein (Stokstad, 1990) Folate transport across membranes into cells incertain tissues including kidney, placenta and choroid plexus occurs via membraneassociated folate binding proteins that act as folate receptors and thereby facilitate cellularuptake of folate Once within the cells 5- methyl THF is demethylated and converted to apolyglutamyl form Due to the fact that folate polyglutamates do not cross the cellmembranes as a result of the charge on their side chain, polyglutamylation helps sequesterfolate inside the cell Tissues are limited in their ability to store folate beyond their normalrequirement

Knowledge of in vivo kinetics of a nutrient aids in understanding the requirements of that

nutrient and providing insight into experimental design involving interventions to alternutritional status Priorities in further studies include determining the effects of pregnancyand other conditions of altered physiology, also effects of various disease states and effects

of genetic polymorphism of key enzymes of folate metabolism on whole body folatekinetics

2.4 Bioavailability of folates

Folate occurs naturally in small amounts in foodstuff It is usually bound to glutamic acidchains In the context of folate, bioavailability is most appropriately used to describe the

overall efficiency of utilization, including physiological and biochemical processesinvolved in intestinal absorption, transport, metabolism and excretion Bioavailability offolates from naturally occurring sources is variable and frequently incomplete, manydietary variables, physiological conditions, and pharmaceuticals may affect thebioavailability of folate (Kromhout, 2008) Dietary authorities therefore conservativelyestimate that the absorption of dietary folate is about 50% lower than that of folic acid Theforegoing supports the case for supplementation because to absorb the correct quantity toattain the Recommended Daily Allowance, a pregnant woman would have to eatapproximately five servings of black eyed peas per day (Blade, 1998).

In broad terms, folate bioavailability is measured by intestinal absorption, tissue uptake,enterohepatic circulation and rate of urinary excretion However, intestinal absorption plays

the largest role in influencing folate bioavailability (Mckillop et al., 2006) Analysis of

food folacin content is also complicated This is because there is a variety of naturalvitamin forms, variable gamma glut-amyl polymer lengths and inherent instability of

folates (Eitenmiller and Landen, 2009) Mckillop et al (2006) conducted a research to

determine factors that affect the absorption of food folate with different levels ofglutamylation They used spinach, egg yolk and yeast as sources of folate Their resultsproved conclusively that level of folate conjugation has absolutely no effect onbioavailability

2.5 Biochemical functions of folates

Folate requiring reactions collectively referred to as 1-C metabolism; include thoseinvolved in different phases of amino acid metabolism, purine and pyrimidine synthesis,and the formation of the primary methylating agent, S-adenosylmethionine (SAM) Theproduction of 5-methyl tetrahydrofolicacid (5-methyl THF) by methylene tetrahydrofolatereductase (MTHFR) is necessary for the major reaction that forms methionine fromhomocysteine This remethylation pathway requires the enzyme methionine synthetase andcobalamin (vitamin B12) as well as 5-methyl THF Homocysteine remethylation to producemethionine is the only known reaction for this form of folate A methyl group is removedfrom 5-methyl THF and is sequentially transferred first to the cobalamin coenzyme then to

N H

C H 2

N

N

N H

C H 2 I

C H 2 I S I

Another interesting function of folates is in the degradation of histidine Histidine isdeaminated and hydrolyzed to form N-formiminoglutamate (FIGlu) which donates itsformimino group to THF leaving glutamate

Folate metabolism involves more than 30 genes, enzymes and transporters Future analysis

of genes encoding the various enzymes involved in folate metabolism coupled withcontinued assessment of interaction of polymorphism, nutrition and disease prevalence willgreatly enhance understanding of their metabolic effects

2.6 Folate deficiency

Folate deficiency is a lack of folate in the diet and the signs are often subtle Clinically,chronic severe folate deficiency is associated with megaloblastic anemia Which ischaracterized by large abnormally nucleated erythrocytes that accumulate in the bonemarrow (Lindenbaun and Allen, 1995).There are also decreased numbers of white blood

cells and platelets as a result of general impairment of cell division Also the intestinalmucosa shows pathological signs early during periods of inadequate intake because it isregenerated every three days and therefore has high folate requirements in comparison toother tissues Other symptoms include loss of appetite, weight loss, lethargy, sore throat,headaches, palpitations, irritability, and behavioral disorders

Women with folate deficiency who become pregnant are more likely to give birth to lowbirth weight babies, premature infants and infants with neural tube defects In infants andchildren folate inadequacy can slow growth rate Recent studies have suggested aninvolvement in tumourogenesis (especially in the colon) throughdemethylation/hypomethylation of fast replicating tissues Folate is a coenzyme that is vitalfor the synthesis of DNA and RNA, the metabolism of amino acids and methylationreactions Due to this essential role, relatively large quantities of folate are needed insituations where rapid cell division is taking place, a prime example being in thedevelopment of a fetus

The first effect of an excessively low intake is an inadequate folate status, which if presentaround the time of conception is that it predisposes the woman to having a neural tubedefect affected baby Folic acid is essential for the formation of heme, the iron containingsubstance in hemoglobin which is crucial for oxygen transport Vitamin B9 is involved inthe production of neurotransmitters therefore has been postulated to be effective in thetreatment of anxiety and depression (James, 2009) The importance of folate and B12 indepression is due to their role in transmethylation reactions, which are crucial for theformation of neurotransmitters (serotonin, epinephrine) Low levels of folate or Vitamin B12

can disrupt transmethylation reactions This could lead to accumulation of homocysteineand impaired metabolism of neurotransmitters (especially the hydroxylation of dopamineand serotonin from tyrosine and tryptophan), phospholipids and receptors Increasedhomocysteine levels in the blood could lead to vascular injuries through oxidative stresswhich could contribute to cerebral dysfunction All these can lead to development of

various disorders, including depression (Karakula et al., 2009; Coppen and

Bolander-Gouaille, 2005)

Low plasma B12 and folate have been found in studies of depressive patients, and low folatelevels have also been linked to poor response to antidepressant treatment Not only doesadequate consumption of folate and B12 decrease the risk of developing depression theyalso help in its treatment in association with antidepressants.

2.6.1 Causes of folate deficiency.

A deficiency of folate can occur when the body’s need for folate is increased, dietary intake

is inadequate or when the body looses more folate than usual Aging decreases the body’sability to properly absorb folate Some medications that interfere with the body’s ability touse folate may also increase its need

Situations that increase folate need include;

 pregnancy and lactation

 tobacco smoking/alcoholism

 malabsorption

 kidney dialysis

 liver disease

Medications that can interfere with folate utilization include

 anticonvulsants(phentoin and primidone)

 metformin (used in non insulin dependent diabetes mellitus)

 sulfasalazine (anti-inflammatory used in treatment of rheumatoid arthritis)

 Triamterine (diuretic)

 Methotrexate (anti folate used in cancer treatment) _also used as an

anti-inflammatory agent in Crohn’s disease and ulcerative colitis

Less than optimal blood folate level apart from increasing the risk of a neural tube defectaffected birth, could result in gastrointestinal disorders, Vitamin B12 deficiency, prematuregraying of hair, and overall weakness (Clark, 2008) Long term deficiency leads tomegaloblastic anemia, osteoporosis as well as increased risk of blood and cervical cancers.The most common adverse effect of excessively high levels of folate is that it can mask

vitamin B12 deficiency which can result in neurological damage when left untreated It hasbeen established through various clinical trials that a pregnant woman can take up to 5mg

of folic acid daily without harming the unborn child

2.7 Folates and neural tube defects

A protective effect of folate against the development of neural tube defects specificallySpina bifida and anencephaly is well recognized, having been established by a chain ofclinical research studies over the past half century (Pitkin 2007) Neural tube defectspresent a major public health problem by virtue of their mortality, morbidity, social costand human suffering They have come to the limelight as various factors implicated inneonatal deaths (infections, preterm deliveries etc) are gradually coming under control

The results of various studies carried out in the past few decades led to the followingrecommendations for folic acid supplementation dosages in the United States of Americaand some other countries;

(i) That all women of reproductive age should consume 0.4mg of folic acid daily to

reduce their risk of having a child with Spina bifida or any other neural tube defect

(ii) Also that women at high risk and women with a previous neural tube defect affected

pregnancy should consume 0.4mg of folic acid daily and when actively trying toconceive, at least one month before conception increase their intake to 4mg daily.Through the first three months of pregnancy

These recommendations were endorsed by organizations like; The American Academy ofPediatrics, The Spina bifida Organization among others The recommendations failed toyield the expected results (drastic reduction in NTD incidence) which led to mandatoryfortification of flour and grain products in the United States of America Mandatoryfortification has led to a fall in NTD incidence in the United States of approximately 25%-30% and improved folate indices, though some still argue that the reduction in NTDfrequency could be multi-factorial The folate - neural tube defect relationship represents

the only instance in which a congenital malformation can be prevented simply andconsistently This is very important given the fact that surgery cannot repair the neurologicdeficits associated with neural tube defects.

Some glaring risk factors have been identified for neural tube defects and they include;

(a) Previous neural tube defect affected pregnancy; studies have stipulated that such

women absorb less folate from either supplements or foods due to a metabolicdefect They have a high chance of another neural tube defect affected birth unlessaggressive periconceptional supplementation of 10 times the normal dosage (4mg)

is undertaken

(b) Medically diagnosed obesity

(c) Women on anti-seizure medication like tegretol, carbamazapine and valproic

acid-these it is postulated affect jejunal pH, disrupting folate assimilation leading to itsdeficiency and placing the woman at risk

Other risk factors include race/ethnicity, maternal non-insulin dependent diabetes mellitus,also low socio-economic factors which have in turn been linked to low folate and vitamin Cintake

2.7.1 Prevalence of neural tube defects

The rate of neural tube defects in Nigeria is among the highest reported worldwide

(VanderJagt et al., 2007) even though NTDs are reported as being more common in the

white population (Buccimazza, Molento, Dunne & Viljoen, 1994) A study by Airede in

1992 reports an incidence of 7 per1000 live births in Nigeria He observed that moredefects were evident from parity four and above and that females were mostly affected.India is another country that has a high rate of neural tube defect occurrence A strong linkhas been found between neural tube defects and consanguinity (Mahatdevan and Bhat,2005) which is commonly practiced in India They reported an incidence of 5.7 per 1000births which is still lower than the Nigerian figure Considering the fact that consanguinity

is not commonly practiced in Nigeria, education and fortification would go a long way toreduce the incidence of neural tube defect affected births.

A study by Idowu, Disu, Anga & Fabanwo (2008) reported a need for periconceptionalhealth policy This is because in their study population there was no history ofconsanguinity as a remote cause of the NTD cases he studied, but none also ofpericonceptional folic acid supplementation In the United States, a prevalence of 37.8 per100,000 births was reported prior to 1998 but after mandatory fortification was introduced

it has fallen to 30.5 per 100,000 births This was a significant decrease of 19% which couldwell be multi factorial (Taylor and May, 2008).A prime study by Djientcheua (2008) onNTD management aptly showed that its management is a terrible burden on the affectedfamilies both financially and emotionally Most cases showed little or no developmentalmilestones even at 18 months Another study by Naci Oner (2006) found folate deficiencyhigher in rural areas She pinpointed independent predictors of folic acid deficiency as lowincome, including low folic acid and ascorbate intake Presently, no European Unioncountry has imposed mandatory fortification In Britain, two non-governmentalorganizations, March of Dimes and The Gallup organization undertake yearly surveysregarding maternal knowledge, attitude and practice of folate usage among childbearingage women This they have done since 1995, the number of women that realize theimportance of periconceptional folic acid supplementation rose from 52% in 1995 to 77%

in 2004 The increase was probably due to widespread enlightenment programmes

2.8 Other health implications of less than optimal blood folate concentration

Megaloblastic anemia is the condition which most people associate with low folate level inthe blood Recently research findings have concluded that it has far more serious healthimplications Plasma folate is inversely related to plasma homocysteine (Boddie, Dedlow,and Nackashi, 2000) This simply means that the lower the folate level is, the higher thehomocysteine Increased homocysteine levels have been linked with increasedcardiovascular disease risk (Guelpen, 2007), an increased risk for eclampsia, increasedincidence of placental abruptions and spontaneous abortions A study on pregnant women

in Northern Nigeria (VanderJagt et al., 2007), recorded a mean blood homocysteine level

of 14.1 micro mole per litre.This exceeded the accepted upper limit for their age group (12micro mole per litre) Elevated blood homocysteine level was earmarked as a sensitiveindicator of sub-optimal folacin levels This is because in some cases, high serum folacinlevels exist in situations of low tissue level due to inter conversion of different biologicforms.

Unlike neural tube defects (NTDs) the link between cancer and folic acid is still in infancy.Folate deficiency is postulated to increase the risk of cancers of the brain, cervix, lung andcolon Folate plays an important role in DNA synthesis and it was hypothesized that lack offolate will precipitate strand breakage and mutations in the genetic code initiating cancer(Duthie, 1999) Conversely anti-folates have been used for years as anticancer drugs due totheir stalling effect on the rapidly dividing cancer cells; this aptly demonstrates theconsequence of folate inadequacy in the system (Chabner, Bello and Bertino, 1972)

CHAPTER THREE 3.0 MATERIALS AND METHODS

3.1 Area of the study

The study was conducted in Enugu metropolis, the capital city of Enugu state, Nigeria.Enugu which literally means top of the hill, owes its geographical significance to thediscovery of coal in its environment by British geologists in 1909 In the cosmopolitan city,trading on various levels remains the dominant occupation followed by civil service due tothe large number of both federal government and state owned Parastatals in the town.Banking is another vibrant part of the Enugu economic scene It has a good number of bothold and new generation banks The inhabitants are mainly Christians with a few Muslimsand other religions (Enugu State Nigeria, 2008)

3.2 Research design

This was a prospective questionnaire based study It was aimed at assessing knowledge andpractice among childbearing age women in Enugu metropolis about periconceptional folicacid supplementation and accruing health benefits

3.3 Study population

All pregnant women, attending ante- natal clinics in Enugu metropolis

3.4 Scope of the study

Six ante-natal clinics (3 private, 3 public) were selected based on catchment area andrelative popularity for the study The selection was done from a list of major private andpublic owned ante-natal clinics in Enugu metropolis They include;

 Ntasi obi ndi no n’afufu Specialist Hospital, Transekulu.

 Trans-ekulu, Specialist Hospital

 Enugu State Teaching Hospital, G.R.A

 Niger Foundation Hospital, Independence Layout

 Mbanefo Hospital ,Transekulu

 Merkens Hospital, Achara Layout

 Annunciation Specialist Hospital, Emene

 Ogui Health Centre, New Layout.

 Eastern Nigeria Medical Centre, Uwani

 Mother of Christ Specialist Hospital, Ogui

 Poly Sub-District Hospital, Asata

 Balm of Gilead Hospital, Maryland

 St Patrick’s Hospital, Asata

 University of Nigeria Teaching Hospital, Ituku Ozalla

Three private and three public ante-natal clinics were selected from the above list

The study involved the following;

 The use of questionnaire to gather information on socio-demographic status,

knowledge, and practice of the women concerning periconceptional folic acidsupplementation

 Basic obstetric data was also gotten from the questionnaire which included

information on parity, gravidium and previous incidence of adverse pregnancyoutcome

 Questions were asked to ascertain if they knew the correct dosage and timing for

effective NTD prevention

 Use of a 24 hour dietary recall and food frequency questionnaire to assess

consumption pattern of dietary folate

 Biochemical tests to determine hemoglobin (Hb) level for 10% of the sample size

and investigate presence of nutritional anemia

3.5 Sample size calculation

Sample size for the study was calculated based on the percentage of subjects who presented

with elevated homocysteine level in a study by VanderJagt et al (2007); the figure was

55% The study investigated nutritional factors associated with anemia in pregnant women

in Northern Nigeria The relative contribution of iron, folate and B12 to anemia in pregnantwomen in the study area was investigated

Fifty-five percent of their study population presented with elevated homocysteine level(which is inversely correlated to the level of folate and B12) That is they had a value higherthan 12µmol/L The following formula was used in sample size calculation;

N = 4p (1-p)

Where N = Total number of people required

P = Proportion of people assumed to have subnormal nutritional status

W = required precision level or probability level

For this study W = 0.05(5%) and P = 55%

N = 4 x 0.55(1- 0.55)

(0.05)2

= 2.2 (0.45)

0.0025 = 0.99

0.0025 = 396 subjects

After adding 5% to take care of dropouts, the number was rounded up to 420

3.6 Sampling

In this study, 70 women were randomly selected from each of the six ante-natal clinics (3private, 3 public) slated to participate in the study Respondents were selected randomly byconvenience sampling of patients physically present on each visit to the ante natal clinic.This was done till a sample size of 70 was obtained from each facility Conveniencesampling was based on the respondents consent to participate in the study after the purpose

of the study and their involvement had been explained

The sub-sample for biochemical analysis was selected from respondents who had presentedfor booking, were past the first trimester and had not started folate supplementation

3.7 Methods of data collection

A letter of permission obtained from the Head, Department of Home Science, Nutrition andDietetics, signed by the project supervisor was sent to appropriate authorities in theconcerned facilities This letter introduced the researcher and solicited their co-operation

throughout the study period Copies of this letter were presented during preliminary visits

to all the facilities used where they were also given copies of the research tool andpermission for actual takeoff of the study gotten

Local committee ethical clearance approval for the study was gotten from Enugu StateUniversity Teaching Hospital, Enugu

3.7.1 Questionnaire

A well structured and validated questionnaire was used in data collection Thequestionnaire was validated by staff of the Department of Home Science, Nutrition andDietetics This questionnaire helped in data generation regarding demographics, knowledgeand practice of folate supplementation in pregnancy Also in the evaluation of consumptionpattern of folates using a 24-hour dietary recall and food frequency questionnaire The

questionnaire was pilot tested in Nawfija, Orumba South Local Government Area using

twenty respondents to screen out irrelevant questions

3.7.2 Biochemical investigations

Approximately 2mls of venous blood was collected from 10% of the respondents forhemoglobin determination and investigation of nutritional anemia 4mls of Drabkinsreagent was added to 0.02mls of well mixed whole blood, the resultant mixture was thenincubated at room temperature for 20 minutes The results were read out colourimetrically

at 540nm using Drabkins reagent as the reference solution The results were then calculatedfrom the hemoglobin standard curve

3.8 Data analysis

Data from the questionnaires were keyed into the computer after coding using epi infoversion 3.5 The results were subsequently analyzed using the Statistical Package for SocialSciences (SPSS) version 17 Chi-square test was used to establish relationship betweenobserved frequencies Data were expressed as frequencies and percentages Correlationswere done to establish relationship between age, parity, maternal educational level andknowledge of use and importance of folates in pregnancy

CHAPTER FOUR

4.0 RESULTS

4.1 Personal characteristics of the respondents

Table 1 shows that more than one half (55.5%) of the respondents from both institutionaltypes were between the ages of 25- 31years,and the lowest percentage 1.0% (private) and2.7% (public) were in the 39-45 years group The respondents whose ages were between 32and 38 years had the second highest percentage of 27.5% (private) and 26.9% (public).Therespondents between 18 and 24 years were 16.0%( private) and 18.8% (public)

Table 1 Age (years) distribution of respondents.

Table 2 shows that a majority of the respondents for both private and publicly owned antenatalclinics were married; 95% (private) and 95.8% (public) The unspecified had 3.5% (private) and1.1% (public) The single respondents had 1.5% (private) and 3.2% (public) The values weremuch lower than the married respondents in both facility types.

Table 2 Marital status of the respondents

4.2 Educational, occupational, and income levels of the respondents by

Table 3 Educational status of the respondents

Footnote B.Sc-Bachelor of Science degree

BA-Bachelor of Arts degree

HND-Higher National Diploma

M.Sc-Master of Science

MBA-Masters in Business Administration PhD-Doctor of Philosophy

Table 4 shows occupational spread of the respondents About sixty percent (60%) of therespondents were gainfully employed (civil servants, artisans, coppers and business women) andapproximately forty percent (40%) were unemployed These were housewives, applicants, andstudents Approximately one third of the respondents were civil servants and had the largestpercentage of 33.0% (private) and 41.0 % (public) Table 4 shows that coppers had the leastpercentage at 3.0% (private) and 0.5 %( public).

Table 4 Occupation of the respondents

Frequency Percentage Frequency Percentage

Table 5 shows estimated monthly income of the employed respondents in naira Approximately

60% of the respondents were employed Analysis of their estimated monthly income in nairashowed an almost identical spread in both public and privately owned institutions The highestpercentage of employed respondents at 41.9% (private) and 42.1% (public) earned between 7,500and 45,000 naira monthly Those that earned between 45,000 and 60,000 naira monthly had closevalues of 15.2% (private) and 14.9% (public) respectively

Table 5 Estimated monthly income of the employed respondents by facility type

4.3 Obstetric details of the respondents

Figure 1 shows parity of the respondents The zero parity groups had close values 42.5%(private) and 40.1% (public) These values were much higher than those of other paritygroups The frequency decreased as the parity increased Parity six had the least value at0.5% for each facility type

nta

ge

privatepublic

Table 6 shows the gravidium of the respondents The gravidium of the respondents followed thesame trend as the parity The frequency decreased as the gravidium (number of pregnancies)increased Gravidium 1 had the highest percentage 38.5% (private) and 39.0% (public) whilegravidium 8 had 1.5% (private) and 0.5% (public), respectively.

Table 6 Gravidium of the respondents

Table 7 shows that approximately 16% of the respondents had experienced at least an incident ofadverse pregnancy outcome, 18.2% (private), and 15.0% (public).

Table 7 Incidence of adverse pregnancy outcome among the respondents.

4.4 General health status of the respondents

Figure 2 shows the number of respondents that smoke and the spread in both categories The

respondents that attended private clinics had no smokers (100%) while those that attended public

clinics had 99.5% non-smokers The difference was only 0.5% between public and privateantenatal clinics

100

0

99.5

0.5 0

Fig 2: Cigarette/ Tobacco habit of respondents

Table 8 shows the percentage of respondents that consumed up to 3 servings of alcohol on regularweekly basis The respondents that consumed up to three servings of alcohol weekly were fewer1.0% (private) and 3.2% (public) as against those that did not consume alcohol who had closevalues of 98.9% (private) and 96.8% (public) respectively, in both institutional types.

Table 8 Alcohol consumption pattern of the respondents

Table 9a shows the number of respondents that were on prescription medication A majority of therespondents 85.0% (private) and 78.8% (public) were off prescription compared to those whoindicated that they were on prescription 15.8% (private) and 21.2% (public) Table 9b then showsthe actual prescription drugs that the respondents were currently taking A majority of therespondents (n=70) who indicated that they were on prescription medication 80.0% (private) and90.0% (public) were actually taking routine drugs

Table 9a Percentage of respondents on prescription medication.

Figure 3 shows the number of respondents that had taken oral contraceptives at some point in theirreproductive history A majority of the respondents 93.0% (private) and 92.0% (public) had nevertaken any medication of that sort.

Fig 3: Oral contraceptive intake by the respondents

a - represents those that had taken oral contraceptives at some point in their reproductive history

b - represents those that have never taken any medication of that sort

Table 10 shows the percentage of respondents (n= 28) whose oral contraceptive had been

prescribed by a doctor A majority of respondents (71.0%) in the private institutions indicated thattheir oral contraceptives had been prescribed by a Doctor while a majority (64.0%) of the publicinstitution respondents had self prescribed

Table 10 Respondents source of oral contraceptive prescriptions

Frequency Percentage Frequency Percentage

a - represents those prescribed by a doctor

b - represents those that were self prescribed

Table 11 shows the number of respondents that were epileptic None of the respondents in both

facility types indicated that they were epileptic While only 1.5% of the respondents from theprivate clinics were unspecific

Table 11 Percentage of epileptic respondents by facility type

Frequency Percentage Frequency Percentage

Table 12 shows the number of respondents that were diabetic A small percentage of respondents

in both facility types were diabetic, 0.5% (private) and 1.5% (public) However 1.5% (private) and0.5% (public) respectively were unspecific

Table 12 Percentage of diabetic respondents

Frequency Percentage Frequency Percentage